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THE 


Monthly  Cyclopedia 


OF 


PRACTICAL   MEDICINE 


CHARLES  E.  DE  M.  SAJOUS,  M.D. 

EDITOR 

J.  MADISON  TAYLOR,  A.B.,  M.D. 

ASSOCIATE  EDITOR 


Vol.  X7K/bld  Series.    Vol.  VIII,  New  Series 


1 


PHILADELPHIA  : 

V.   A.    DAVIS  COMPANY,   PUBLISHERS. 
1905. 


THE   MONTHLY   CYCLOPAEDIA 

OF 

PRACTICAL   MEDICINE 


(Published  the  Last  of  Each  Month) 


Vol.  XVIII. 
Old  Series. 


PHILADELPHIA,  JANUARY,  1905. 


Vol.  VIII,  No.  1. 

New  Series. 


PAGE 

ANNOUNCEMENT > 

EDITORIALS 

THI  TRAINING  OF  THE  MOD- 
ERN 8URGEON.     N.  Senn 2 

THE  QUESTION  OF  POSTURE  IN 
CARDIO-VASOULAR  DISEASE. 

Alien  J.  Smith 4 

DIGITALINE  IN  THE  TREATMENT 
OF  NUTRITIONAL  DISOR- 
DERS.    Henry  Beates,  Jr 7 

THE  ROLE  OF  ADRENOXIN  (OXI- 
DASE) IN  PATHOLOGY. 
Charles  E.  de  M.  Sajous 10 

CYCLOPAEDIA    OF   CURRENT 
LITERATURE 

ACID     INTOXICATIONS.       "  Medical 

News  " 13 

ALBUMINURIA.    "  Journal  American 

Medical  Association" 14 

ARTERIES,  THE   EFFECT    OF   COLD 

ON.     M.  Herz IS 

ASTHMA,   NASAL  TREATMENT  OF. 

Alexander  Francis 16 

ATROPINE,    ACTION    OF,    ON    THE 

INTESTINE.     N    E.  Riedel 16 

BARIUM     CHLORIDE.     MEDICINAL 

VALUE  OF.    Ernesta  Pesci 17 

BLOOD     PLATELETS,     ORIGIN     OF. 

K.  Priesich  and  P.  Heini 18 

BLOOD   POISONING,    PERCHLORIDE 

OF  IRON  IN.  P.  W.  Latham....  18 
BRAIN  TUMOR   AND   TRAUMA.     E. 

W.  Holmes 18 

BURSITIS,     TREATMENT     OF 

CHRONIC.     P.  Hoffmann 19 

CALOMEL     AS    A     POISON.      T.    L. 

Bunting 19 

OANCER  AND  TUBERCUL08I8,  THE 

ASSOCIATION    OF.     W.  A. 

Bastedo 20 

CARBOHYDRATE  METABOLISM. 

F.  A.  Rhodes 20 

CATARACT,  IMMATURE.  ARTI- 
FICIAL MATURATION  OF.     M. 

M.  McHardy 21 

CHILDREN,  DIAGNOSIS  OF  DISEASE 

IN.    J.  Madison  Taylor 21 

CONSTIPATION,  DIETETICS  IN  THE 

TREATMENT  OF.    Sigismund 

Cohen 23 

CORNEAL  THERAPEUTICS.      A.  Mc- 

Gillivray 24 


TABLE  OF  CONTENTS. 

PAGE 

DIAPHORESIS  IN  OPHTHALMOL- 
OGY.    Hiram  Woods 24 

DIPHTHERIA,    LESI0N8     OF    THE 

KIDNEY  IN.     Mario  Flamini 24 

DUODENAL  ULCER  AND  ITS  TREAT- 
MENT.    D'Arcy  Power 26 

DYSPEPSIA,  CHRONIC,  SURGICAL 
CURE  OF  CERTAIN  CASES  OF 
BO-CALLED.     C.  A.  L.  Heed 26 

EMBOLISM  FOLLOWING  OPERA- 
TION.    S.  S.  Dearborn 27 

ENDOCARDITIS,     INFECTIVE, 

COURSE  OF.     Herbert  French....    27 

ENTERITIS,  TRAUMATIC.    Vinay....     27 

EPILEPSY,    DENTITION    IN.     W.   P. 

Sjiratling 28 

EPILEPSY,  TREATMENT  OF,  IN 
CONNECTION  WITH  AUTO- 
AND  HETEROTOXI8.  A.  McL. 
Hamilton 23 

EPILEPSY,  TREATMENT  OF.WllH- 

OUT  DRUGS.     A.  L.  Kanuey 28 

GASTRO-ENTERITIS,   BC1TERMI1K 

IN.     Decherf 30 

GOUT,  ETIOLOGY  AND  PATHOLOGY 

OF.     T.  B.  Futeher 30 

IMMUNITY,  INHERITED,  INSTEAD 
OF  INHERITED  PREDISPOSI- 
TION.    O.  Effertz 30 

INTERMITTENT     CLAUDICATION. 

A.  J.  Paiek 31 

INTERNAL    HAEMORRHAGE.    T.  L. 

Coley 31 

IRON.  THERAPEUTIC  VIRTUES  CF. 
John  Knott 32 

LEU000YTE8,     THE     DIAGNOSTIC 

VALUE  OF.     G.  W.  MtCaskey....     33 

LEUKAEMIA,  ROENTGEN  RAYS  IN 
THE  TREATMENT  OF.  George 
Dock 33 

MAMMARY     GLAND,     CARCINOMA 

OF   THE.     W.  h.  Rodman 34 

METABOLISM,  DISEASES  OF  THE 
SKIN  CONNECTED  WITH  ER- 
RORS OF.     L.  D.  Bulkley 35 

MILK  DIET,  INFLUENCE  OF,  ON 
THE  CIRCULATION.  Carlo 
Colombo 36 

MYOCARDIUM,  DEGENERATIVE 
CHANGES  IN  THE.  Raymond 
Clark m     36 

NERVOUS  THROAT  PAIN.  Boenning- 
h  a  ii.i 


36 
OBESITY.     Leven 37 


PAGE 

OVARIES,  CONSERVATIVE  OPERA- 
TIONS ON  THE.  J.  W.  Coken- 
ower 37 

PAROTITIS  FOLLOWING  INJURY 
OR  DISEASE  OF  THE  ABDOM- 
INAL AND  PELVIC  VISCERA. 
Brenn  n  Dyball 37 

PNEUMONIA,  ACUTE  LOBAR, 
TREATMENT  OF.  Beverley  Rob- 
inson      38 

PNEUMONIA  OF  ADULTS,  TREAT- 
MENT OF.     M.  Manges 38 

PNEUMONIA,    SERUM    TREATMENT 

OF.    J.  M.  Anders 39 

RABIES,  NEGRI'S  BODIES  AND 
THEIR  SIGNIFICANCE  IN. 
Luigi   D'Amato 39 

RADIOTHERAPEUTIC     TECHNIQUE. 

VARIATIONS  OF.     R.  H.  Boggs.    40 

REFRACTION  IN  CHILDREN,  NER- 
VOUS SYMPTOMS  PRODUCED 
BY.     J.  H.  Claib.rne 40 

RHEUMATIC  AFFECTIONS,  1N1FA- 
VENOUS INJECTIONS  OF  SALI- 
CYLATES  FOR.     Behr 40 

SIGMOID,   SURGICAL    DISEASES  OF 

THE.     II.  D.  Niles 41 

SKULL  AND  BRAIN,  EFFECT  OF  DI- 
RECT AND  INDIRECT  VIO- 
LENCE UPON  THE.    A.  E.  Sterne    41 

SKULL,  BIRTH-FRACTURE  OF  THE. 

James  H.  Nicoll 42 

SPINA    BIFIDA,     OPERATIVE 

TREATMENT  OF.     E.  R.  Secord..    42 

STOMACH,     MOTOR     INSUFFIENCY 

OF  THE.     E.  O.  Adams 43 

BYPHILIB,    PROGNOSIS   OF.      N.   E. 

Aronstam 43 

TUBERCULIN  TEST,  THE  VALUE  OF 

THE.     I.  H.  Neff. 43 

TUBERCULOSIS  OF  THE  MIDDLE 
EAR,  BILATERAL.  Dunbar 
Roy 44 

TUBERCULOSIS,  PULMONARY, 
METHODS  OF  INFECTION  IN. 
J.  O.  Cobb 44 

TYPHOID    FEVER,  TREATMENT  OF. 

F.  F    Caiger 45 

ULCER    OF   THE   STOMACH    AND 

DUODENUM.     C.  P.  Howard 46 

VOMITING  OF    PREGNANCY.      J.  M. 

H.  Martin 46 

DR.  FRANK  P.  FOSTER 47 

BOOKS  AND  MONOGRAPHS  RE- 
CEIVED      47 


ANNOUNCEMENT. 


The  Nobel  prize  in  Medicine  and  Physiology  was  awarded  this  year  to  Professor 
J.  P.  Pawlow,  of  the  Military  Academy  of  Medicine  of  St.  Petersburg.  The  medical 
world  cannot  but  applaud  this  selection;  the  honor  has  never  been  conferred  upon 
a  man  more  worthy  of  it. 

That  Professor  Pawlow's  main  work  was  in  connection  with  the  digestive  organs 
is  well  known,  but  a  feature  of  his  investigations  which  has  not  been  sufficiently 
appreciated,  is  that  their  practical  value  is  principally  due  to  the  broad  field  covered 


2  ANNOUNCEMENT. 

by  them.  Though  a  physiologist,  he  has  always  emphasized  the  need  of  seeking  in 
pathological  states,  as  well  as  in  the  laboratory,  the  solution  of  physiological  problems. 
"The  question  as  to  whether  the  gastric  glands  have  likewise  a  special  secretory 
innervation,"  wrote  Professor  Pawlow  some  years  ago,  "is  now  a  very  old  one  and 
has  had  an  interesting  career.  In  this  matter  physiology  stood  for  a  long  time  in 
sharp  conflict  with  practical  medicine.  Physicians  bringing  forward  their  observa- 
tions in  proof,  had  long  answered  the  question  in  the  affirmative,  and  looked  upon 
the  existence  of  secretory  nerves  to  the  stomach  as  undoubted.  They  had  even  come 
to  recognize  different  morbid  conditions  of  the  innervation  apparatus.  Physiologists, 
on  the  other  hand,  had  fruitlessly  endeavored  for  decades  to  arrive  at  definite  results 
upon  this  question.  This  is  a  striking,  but  by  no  means  isolated,  instance  where  the 
physician  gives  a  more  correct  verdict  concerning  physiological  processes  than  the 
physiologist  himself ;  nor  is  it  indeed  strange.  The  world  of  pathological  phenomena 
is  nothing  but  an  endless  series  of  the  most  different  and  unusual  combinations  of 
physiological  occurrences  which  never  make  their  appearance  in  the  normal  course 
of  life.  It  is  a  series  of  physiological  experiments  which  nature  and  life  institute, 
often  with  such  an  interlinking  of  events  as  could  never  enter  into  the  mind  of  the 
present-day  physiologist,  and  which  could  scarcely  be  called  into  existence  by  means 
of  the  technical  resources  at  his  command.  Clinical  observation  will  consequently 
always  remain  a  rich  mine  of  physiological  facts.  It  is  therefore  only  perfectly 
natural  that  the  physiologist  should  endeavor  to  maintain  a  close  connection  between 
his  science  and  that  of  medicine." 

The  readers  of  the  Monthly  Cyclopedia  have  doubtless  recognized  that  this 
thought  has  inspired  much  of  the  work  submitted  in  its  columns.  So  clearly  does  it 
meet  the  needs  of  the  moment,  that  it  has  been  determined  to  increase  the  size  of  the 
journal  in  order  to  develop  its  field  of  usefulness  in  this  direction.  Beginning  with 
this  month's  issue,  therefore,  the  Monthly  Cyclopedia  will  contain  editorials  by 
leading  clinicians,  pathologists,  physiologists,  surgeons,  etc.,  in  which  the  practical 
and  experimental  branches  of  medicine  will  be  jointly  analyzed.  That  such  distin- 
guished members  of  the  profession  as  Nicholas  Senn,  Allen  J.  Smith,  Henry  Beates, 
Jr.,  James  Tyson,  Joseph  Collins,  C  A.  Oliver  (whose  papers  appear  in  this  and 
the  next  issue)  should,  from  the  start,  give  the  plan  their  active  support,  is  sug- 
gestive.   It  is  hoped  that  it  will  meet  with  the  approval  of  our  readers. 

The  editor's  labors  being  such  as  to  prohibit  his  assuming  additional  duties,  he 
was  able,  through  the  kindness  of  his  publishers,  to  obtain  the  valued  co-operation  of 
his  friend,  Dr.  J.  Madison  Taylor,  whose  scholarly  attainments  and  scientific 
knowledge  are  well  known,  and  who  will  have  charge  of  the  new  department. 


Editorials. 


THE  TRAINING  OF  THE  MODERN  SURGEON. 
There  is  no  country  in  the  world  where  surgery  has  received  more  attention 
than  in  the  United  States.     This  fact  becomes  very  apparent  in  all  of  our  many 
medical  schools,  the  transactions  of  our  medical  societies,  and  in  the  current  med- 
ical literature.    Much  of  the  progress  and  advancement  of  surgery  during  the  last 


THE  TRAINING  OF  THE  MODERN  SURGEON.  3 

quarter  of  a  century  is  the  outcome  of  the  work  of  a  large  number  of  our  inde- 
fatigable surgeons.  It  is  very  apparent  everywhere  that  the  American  doctors  have 
a  special  predilection  for  the  mechanical  part  of  the  healing  art.  It  is  not  saying 
too  much  when  I  make  the  statement  that  this  tendency  has  grown  beyond  the  limits 
of  normal  requirements.  The  great  field  of  the  practice  of  internal  medicine  does 
not  appear  to  offer  the  same  attractions  to  our  young  graduates  as  the  operating 
room.  American  medicine  is  becoming  more  and  more  surgical,  and  this  change 
has  not  always  been  for  the  benefit  of  patients  nor  for  the  betterment  of  the  science 
and  art  of  medicine. 

The  surgeon  is  not  made  in  medical  colleges.  The  function  of  the  medical 
colleges  consists  in  qualifying  their  students  for  general  practice.  The  student  who 
in  the  day  of  his  graduation  decides  to  devote  himself  exclusively  to  surgical  prac- 
tice makes  a  great  mistake.  The  scientific,  successful  surgeon  must  be  a  good  phy- 
sician. He  must  be  thoroughly  grounded  in  the  fundamentals  of  medicine,  anatomy, 
physiology,  chemistry,  bacteriology,  and  pathology.  These  primary  studies  consti- 
tute the  foundation  upon  which  scientific  surgery  rests.  Without  such  a  firm  founda- 
tion surgery  is  reduced  to  the  level  of  a  menial  trade.  The  elementary  branches 
must  be  mastered  in  college.  The  students  who  devote  their  energies  and  a  liberal 
share  of  their  time  to  the  elementary  branches  and  know  how  to  apply  them  in 
practice  will  experience  no  difficulty  in  grasping  the  teachings  of  the  practical  chairs. 

How  many  physicians  and  surgeons  study  the  elementary  branches  after  grad- 
uation? Very  few,  indeed.  They  spend  their  leisure  time  in  keeping  pace  with 
the  rapid  advances  of  the  practical  part  of  their  profession;  hence  the  great  neces- 
sity of  giving  the  elementary  branches  the  importance  and  attention  they  deserve  on 
the  part  of  teachers  and  students.  The  surgeon  must  be  a  good  diagnostician,  and 
this  he  cannot  be  unless  he  is  a  competent  physician.  I  have  often  been  amused  and 
instructed  in  looking  over  the  libraries  of  surgeons.  Only  too  often  have  I  found 
them  made  up  of  books  and  journals  devoted  exclusively  to  surgery.  Frequently 
the  only  works  on  internal  medicine  were  the  well-worn  text-books  used  in  college. 
This  is  a  great  mistake.  The  moment  the  surgeon  loses  interest  in  general  medicine, 
from  that  moment  he  neglects  the  scientific  part  of  his  work  and  gradually  drifts 
into  a  routine  practice.     Surgery  should  be  the  outgrowth  of  a  general  practice. 

After  the  young  physician  has  practiced  general  medicine  for  five  or  six  years 
and  finds  that  he  is  in  possession  of  an  aptitude  for  surgery,  then  is  the  proper  time 
to  lay  out  his  plans  for  the  future.  The  experience  gained  during  several  years  of 
general  practice  will  be  invaluable  to  him  in  his  subsequent  surgical  career.  He  is 
then  not  as  confident  as  he  was  immediately  after  graduation.  If  lie  is  honest  with 
himself  he  has  discovered  defects  in  his  professional  education  which  must  be  reme- 
died.    He  is  then  well  prepared  to  perfect  himself  for  his  new  career  by  further 


4  THE  QUESTION  OE  POSTURE  IN  CARDIO- VASCULAR  DISEASE. 

laboratory  work  and  clinical  instruction.  Only  too  many  have  been  laboring  under 
the  wrong  impression  that  all  that  is  necessary  is  to  attend  one  of  our  numerous 
post-graduate  schools  or  visit  a  famous  clinic  for  the  same  length  of  time.  This  is 
a  great  fallacy.  The  young  physician  in  quest  of  surgical  knowledge  must  spend 
one  or,  still  better,  two,  years  in  the  further  study  of  surgical  anatomy  and  surgical 
pathology  and  reap  the  benefits  of  clinical  instruction  not  only  of  one,  but  of  a 
number  of  operators  with  a  well-earned  reputation.  An  observing  student  will  soon 
become  familiar  with  the  methods  and  technique  of  an  operator  and  each  surgeon 
has  some  branch  of  surgery  in  which  he  is  more  proficient  than  others.  It  is  no 
longer  necessary  to  make  pilgrimages  to  foreign  countries  for  post-graduate  instruc- 
tion in  surgery.  There  are  many  excellent  institutions  in  this  country  that  can  fur- 
nish the  necessary  laboratory  facilities  and  many  surgeons  whose  work  has  earned 
for  them  more  than  a  national  reputation.  A  visit  abroad  for  six  months  or  a  year 
is  to  be  recommended,  especially  if  the  student  is  familiar  with  the  German  or  French 
language.  A  scientific  tour  through  a  foreign  country  without  a  knowledge  of  the 
language  is  most  unprofitable  and  should  not  be  encouraged. 

To  sum  up  the  training  of  a  surgeon:  master  the  elementary  branches  in  col- 
lege, do  general  practice  for  several  years,  return  to  laboratory  work  and  surgical 
anatomy,  attend  the  clinics  of  different  operators,  and  never  cease  to  be  a  physician. 
If  this  advice  is  followed  there  will  be  less  unnecessary  operating  done  in  the  future 

than  has  been  the  case  in  the  past. 

N.  Senn.* 

Chicago. 

THE  QUESTION  OF   POSTUEE  IN  CABDIO-VASCULAB  DISEASE. 

In  normal  states  of  the  circulatory  apparatus  the  various  factors  combined  in 
maintenance  of  an  even  progression  of  the  blood  are  so  co-ordinated  that  their  indi- 
vidual contributions  to  the  accomplishment  of  the  work  in  hand  can  only  with 
special  care  be  demonstrated,  although  easily  appreciable  in  theory;  but  in  states 
of  difficulty  of  circulation  each  factor  in  its  inco-ordination  may  come  to  be  in  part 
or  solely  responsible  for  important  phenomena  in  the  symptomatology  of  the  case. 
Posture,  with  its  inseparable  feature  of  blood  gravitation,  is  in  health  appreciable 
only  by  theory  or  special  experimental  effort;  yet  in  conditions  of  difficult  circula- 
tion it  becomes  a  factor  of  ranking  importance,  favorable  attitudes  of  the  body  or  of 
special  parts  being  unwittingly,  but  certainly,  sought  by  the  sufferer  and  often 
acquiring  valuable  significance  to  the  objective  observer.  The  well-known  advice  to 
change  the  patient  from  side  to  side  and  to  limit  the  periods  of  dorsi-posture  in 
cases  of  impeded  pulmonary  circulation  in  pneumonia  and  hypostasis  of  the  lungs, 
the  common  practice  of  depressing  the  head  and  upper  part  of  the  trunk  in  anoes- 

*  Professor  of  Surgery,  Rush  Medical  College. 


THE  QUESTION  OF  POSTURE  IN  CARDIO-VASCULAR  DISEASE.  5 

thetic  shock,  and  the  somewhat  similar  posture  assumed  by  every  individual  in  any 
similar  state  of  faintness  are  examples  in  point.  Whatever  the  nature  of  the  fault 
of  equilibrium  between  the  pressure  of  the  circulating  fluid  and  its  containing  walls, 
whether  a  fault  of  bulk  content  (and  in  some  measure  of  the  blood  character),  a 
nervous  atony  of  the  walls,  or  a  definite  structural  inability  of  the  heart  or  vessels 
or  both,  the  same  factor  of  posture  is  certain  to  manifest  itself  in  a  more  or  less 
prominent  measure  as  the  fault  passes  the  bounds  of  endurance.  In  consequence  a 
variety  of  physical  peculiarities  become  apparent  and  may  proceed  to  troublesome 
grades.  As  illustrative  of  this  group  of  phenomena  depending  more  or  less  upon 
such  mechanical  variations,  several  may  be  presented,  as  often  noted  in  the  course  of 
cardio-vascular  disease. 

What  explanation  may  be  given  of  the  nocturnal  polyuria  of  such  cases?  The 
polyuria  of  chronic  cardio-vascular  cases  is  commonly  referred  to  the  renal  or- 
gans themselves,  and  accepted  as  a  symptom  of  fibrosed  kidneys,  typically  in  the 
so-called  "red,  granular  kidney,"  but  also  in  the  "fatty  and  contracted"  state  of 
these  parts ;  yet  this  is  probably  quite  as  incorrect  as  the  old  classification  of  diabetes 
mellitus  as  a  form  of  renal  disease.  The  urinary  function  may  tentatively  be  looked 
upon  as  twofold :  filtrative  and  secretory.  The  latter  of  these,  for  the  sake  of  the 
argument,  may  be  placed  aside  as  nonessential  to  the  question  in  hand.  In  large 
part,  from  the  structural  analogy  of  these  parts  to  filters,  the  filtrative  process  may 
be  attributed  to  the  Malpighian  tufts  and  their  inclosures ;  and  the  degree  of  filtra- 
tion, importantly  influencing  the  total  quantity  of  urine,  must  depend  largely  on 
questions  of  degree  of  vascular  pressure  in  these  structures — always  in  correlation 
with  regularity  of  circulation  in  the  organ.  Excess  of  pressure  associated  with  ap- 
preciable degree  of  stagnation  or  passive  hyperemia  in  the  kidney  cannot,  save  at 
the  very  start  of  the  condition,  lead  to  increased  filtration  from  mechanical  reasons 
(which  may  here  be  neglected  to  avoid  digression),  but  must  lead  to  diminution  of 
the  filtrative  output;  and  so,  too,  diminution  of  pressure  with  or  without  a  tendency 
to  renal  stagnation  must  constitute  an  unfavorable  state  for  the  filtrative  process. 
In  the  type  of  cases  in  hand  two  factors  may  be  thought  of  as  increasing  intravas- 
cular tension,  aside  from  such  as  operate  upon  the  venous  side  of  the  circulation, 
the  fibrosis  of  the  vessel  walls  and  the  cardiac  hypertrophy.  The  former  of  these 
might  well  be  corrected  by  variation  of  the  bulk  of  the  contained  blood;  to  both, 
but  especially  the  second,  must  be  attributed  the  increase  of  tension  induced  by  the 
increased  cardiac  force  and  its  distribution  to  the  smaller  streams;  and  at  least 
in  some  measure  this  increase  of  tension  must,  so  far  as  the  kidney  is  concerned,  be 
regarded  as  contributory  to  filtration  through  the  tuft  walls  and  therefore  to  increase 
in  urinary  production.  In  the  production  of  the  increased  output  of  night,  so  com- 
mon in  such  cases,  the  question  of  body  posture  is,  to  the  writer's  mind,  an  impor- 

3 


6  THE  QUESTION  OF  POSTURE  IN  CARDIOVASCULAR  DISEASE. 

lant  element,  even  though  it  be  not  the  sole  element  of  difference  in  the  diurnal  and 
nocturnal  life  of  the  individual.  Of  course,  in  all  cases  the  regularity  of  circulatory 
flow  depends  in  an  enormous  degree  on  the  relative  integrity  of  the  venous  return; 
and  this  can  never  he  disregarded  in  contemplation  of  any  individual  case.  But, 
supposing  other  factors  to  be  negligible  for  the  present  (the  absence  of  distinct 
obstruction,  fair  respiratory  movement,  a  competent  heart,  etc.),  it  may  be  presumed 
that  venous  return  from  the  bulk  of  the  body-mass  will  be  more  easy  in  the  recum- 
bent posture  than  when  operating  against  gravity  in  the  erect  attitude,  and  that 
under  such  circumstances  general  circulatory  progression  will  be  favored.  On  the 
other  hand,  presuming  that  in  the  presence  of  a  diffuse  arteriosclerosis  the  vascular 
caliber  will  be  much  the  same  in  the  arterial  tree  at  all  hours,  the  heart  should  find, 
in  forcing  the  blood  through  the  recumbent  body,  a  greater  difficulty  than  when  the 
individual  is  erect,  because  of  the  elimination  of  an  important  force:  the  weight 
of  the  blood  column  beyond  the  arch  of  the  aorta.  The  work  of  the  heart  in  the 
changed  posture  as  compared  with  that  in  the  erect  position  (disregarding  the  cir- 
culation in  the  head  and  neck  for  the  time,  but  accepting  it  as  a  modifying  influence 
of  secondary  importance)  is  that  of  pulsing  forward  over  a  wide,  but  relatively  flat, 
area  the  weight  of  the  arterial  column  as  compared  to  the  lifting  of  the  same  weight 
perpendicularly  over  the  short  interval  between  the  ventricular  level  and  the  level 
of  the  aortic  arch.  Or,  in  a  homely  simile,  the  work  would  differ  between  the  trans- 
ference of  a  ton  of  coal,  shovel  by  shovel,  to  a  new  heap,  say,  fifty  feet  distant  on  a 
level,  and  the  heaving  of  the  same  weight,  shovel  by  shovel,  over  a  barrier  of  two  or 
three  feet  in  height  and  allowing  it  to  fall  on  a  new  heap  fifty  feet  below.  The  dif- 
ference is  appreciable.  This  should  mean,  the  work  of  the  heart  being  more  diffi- 
cult in  the  recumbent  position,  it  should  beat  with  greater  force,  and  that  the  in- 
crease of  force  of  each  wave  should  be  felt  by  the  renal  arteries  and  capillaries  in 
the  tufts  in  an  increased  tension,  and  that  filtration  should  thus  be  augmented.  The 
difference  between  tension  in  the  tufts  at  such  a  time  and  that  of  the  diurnal  erect 
position,  in  which  the  weight  of  the  arterial  column  enters,  may  be  little, — but  an 
important  feature  enters  in  that  it  is  applied  at  a  time  more  favorable  for  constant 
interchange  of  blood  in  the  organ  (the  recumbent  posture  favoring  venous  return), 
the  amount  of  filtration  depending  not  only  on  the  actual  pressure  in  the  kidney, 
but  upon  the  volume  of  blood  passing  through  it  as  well  (the  watery  elements  of 
the  blood  approaching  the  glomerules  being  proportionately  greater  and  more  favor- 
able for  filtration  than  that  which  has  been  relatively  stationary  in  the  same  position 
and  robbed  of  more  or  less  of  its  filterable  material). 

The  same  principle  applied  to  the  question  of  why  a  cardiac  case,  passed  to  the 
stage  of  cardiac  weakness  and  degeneration,  should  require  a  higher  and  higher 
pillow  and  eventually  find  relative  comfort  only  'in  the  sitting  posture.     The  work 


DIGITALINE  IN  THE  TREATMENT  OF  NUTRITIONAL  DISORDERS.  7 

of  propelling  the  blood  over  a  wide,  flat  area  (recumbent  posture)  is  found  pro- 
gressively preponderating  over  the  face  of  the  heart,  and  the  recumbent  position 
tends  to  interfere  with  what  is  now  perhaps  the  most  active  of  the  influences  in 
venous  progression, — respiratory  movement.  The  erect  posture  in  extreme  cases 
adds  to  venous  movement  by  the  height  of  the  venous  column  and  demands  mus- 
cular effort  for  its  maintenance.  The  intermediate  sitting  posture  hence  comes  to 
be  insistently  demanded  as  presenting  less  difficulty  in  either  direction.  The  heart 
may  be  of  sufficient  power  to  accomplish  the  elevation  of  the  arterial  stream  over 
the  arch  of  the  aorta,  largely  leaving  to  gravity  the  distribution  of  the  fluid  in  the 
trunk  and  extremities;  but  the  least  depression  to  a  lying  posture  is  quickly  marked 
by  cardiac  labor  and  the  oncome  of  cyanosis.  The  difference  in  the  perpendicular 
lift  of  the  venous  stream  between  standing  and  sitting  is  roughly  represented  by 
the  column  of  blood  in  the  femoral  vein,  or  if  the  lower  extremity  be  elevated  by 
the  venous  column  in  the  entire  limb,  whence  a  very  real  aid  in  removal  of  gravita- 
tion is  to  be  recognized ;  and  little  wonder  can  be  felt  that  at  times  in  the  moribund 
state  sudden  assumption  of  erect  or  semi-erect  posture  should  entirely  overpower 
the  right  heart  and  death  should  follow. 

So,  too,  identical  lines  of  explanation  are  applicable  in  questions  of  distribution 
of  cardio-vascular  oedema,  typically  met  in  the  feet  and  hands,  in  the  distribution 
of  terminal  cardiac  purpura,  and  of  cyanosis,  as  well  as  a  number  of  other  of  the 
well-recognized  symptoms  of  such  disease.  Of  course,  the  presentation  of  this  one 
factor  is  not  to  be  interpreted  as  an  idea  of  its  sole  importance  in  determining  the 
semeiology  of  such  cases  or  as  operative  without  important  reactive  influences  aris- 
ing in  connection  with  the  other  forces  of  circulation;  but  in  its  part  as  one  among  a 
number,  as  an  important  part  of  disordered  mechanism,  it  has  here  been  presented 
in  this  mode  of  casual  discussion  by  invitation  of  the  editor. 

Allen  J.  Smith.* 

Philadelphia. 

DIGITALINE  IN  THE  TREATMENT  OF  NUTRITIONAL  DISORDERS. 

The  scope  of  digitaline  (Merck's  German)  in  the  treatment  of  nutritional 
diseases,  is  shown  to  have  a  wider  and  deeper  application  as  we  examine  into  the 
physiological  laws  justifying  its  administration.  Clinicians  regard  this  remedy 
too  exclusively  as  applicable  only  to  diseases  of  the  heart.  In  reality,  cardiac  affec- 
tions constitute  but  a  narrow  field  for  this  exceedingly  valuable  agent. 

When  the  physiological  principles  underlying  metabolism  and  nutrition  are 
called  to  mind,  the  truth  and  forcefulness  of  this  assertion  becomes  apparent.  In 
considering  this  subject  it  must  be  remembered  that  cellular  function  depends  upon 

•Professor  of  Pathology,  University  of  Pennsylvania. 


g  DIGITALINE  IN  THE  TREATMENT  OF  NUTRITIONAL  DISORDERS. 

the  blood-plasma — derived  from  the  terminals  of  the  arterial  side  of  the  circulation 
surrounding  the  cellular  elements.  This  fluid  provides  the  cells  with  the  principles 
necessary  for  their  life,  as  well  as  those  which  are  essential  to  the  performance  of 
the  special  functions  with  which  they  are  endowed.  It  is  also  necessary  to  bear 
in  mind  that,  its  origin  being  from  the  arterial  side  of  the  blood-stream,  normal 
cell-action  must  necessarily  depend  upon  normality,  quantitative  and  qualitative,  of 
the  plasma  fluid.  We  are  thus  confronted  with  vast  physiological  problems  as- 
sociated with  the  circulation. 

This  intercellular  blood-plasma,  it  must  be  emphasized,  is  a  totally  different 
factor  in  vital  phenomena  from  that  lymph  contained  in  the  lymphatic  system 
proper.  Indeed,  lymphatic  system  lymph  is  the  remains,  so  to  speak,  of  inter- 
cellular lymph,  which  has  already  performed  its  chief  functions.  It  occupies  rela- 
tively a  position  of  minor  importance,  in  so  far  as  metabolism  and  nutrition  are 
concerned.  Again,  as  is  well  known,  the  normality  of  the  oxygen-bearing  inter- 
cellular plasma  depends  upon  the  mean  pressure  existing  between  the  arterial  and 
venous  sides  of  the  circulation.  Any  condition,  therefore,  local  or  central,  which 
disturbs  this  equilibrium,  or  mean  pressure,  must  necessarily  greatly  modify  its 
value  in  function. 

That  local  morbid  processes  do  exist  in  a  system  such  as  the  circulatory,  seems 
to  have  attracted  too  little  attention.  The  physiology  of  a  system  such  as  this 
must,  in  a  sense,  involve  its  entirety,  and  yet  the  morbid  process  may  show  itself 
altogether  locally.  It  may  as  reasonably  be  expected,  therefore,  that  remedial 
measures  affecting  a  system  as  a  whole  can  correct  the  local  defect. 

The  problem  of  maintaining  the  circulatory  equilibrium  is  chiefly  solved  by  the 
function  of  the  arteries,  and  that  property,  hitherto  not  sufficiently  recognized,  the 
regulation  of  propulsion.  The  propelling  power  of  the  arteries  is,  obviously,  a 
most  important  factor,  when  taken  in  connection  with  nutritional  diseases.  This 
property  of  the  arterial  system  has  been  shown  by  Sajous,  who  has,  in  addition  to 
his  personal  researches,  studied  the  investigations  of  physiologists,  physiological 
chemists  and  histologists,  to  be  largely  governed  by  the  adrenal  system. 

Whether,  in  the  treatment  of  this  vast  field  of  nutritional  disorders,  a  remedy 
excites  the  normal  physiological  activity  of  the  adrenal  system  or  acts  directly  upon 
the  structures  involved,  the  terminal  process  is  explainable  in  the  same  way.  The 
direction  of  the  plasmatic  circulation  is  from  the  arterial  terminals  toward  the  radi- 
cals of  the  venous  system.  The  pressure  is  greatest  in  the  intercellular  spaces  and 
steadily  diminishes  until  a  state  of  negative  pressure  prevails  in  the  venous  channels. 

Tbe  relation  of  the  negative  pressure  to  coronary  circulation  and  cardiac  func- 
tion is  too  large  a  subject  to  be  here  discussed,  but  the  simple  fact  that,  as  the 
myocardial  function   (owing  to  reduced  efficiency  of  the  plasma)    loses  some  of 


DIGITALINE  IN  THE  TREATMENT  OF  NUTRITIONAL  DISORDERS.  9 

its  functional  activity,  the  contents  of  the  coronary  arteries  become  proportionately 
reduced,  and  the  output  of  the  left  ventricle,  at  each  pulsation,  is  diminished  both 
in  volume  and  strength,  points  to  its  importance.  The  degrees  of  these  serious 
disturbances  vary  with  the  intensity  of  forces  in  operation  and  other  factors  involved. 

The  maintenance  of  cardiac  action,  under  conditions  of  coronary  disease  and 
myocardial  degeneration,  therefore,  depends  upon  the  intelligent,  and  what,  for 
self-evident  reasons,  must  be  called  the  bold,  administration  of  digitaline  (Germanic, 
Merck.)  This  particular  preparation,  digitaline,  is  specifically  mentioned  because  it 
has  proven  to  be  the  one  remedy  possessing,  pre-eminently,  this  power. 

In  the  range  of  disturbed  metabolism  and  nutritional  disorders  can  be  included 
all  of  those  senile  alterations  of  function  dependent  upon  changes  in  the  arterial 
system.  Because  of  their  interference,  locally,  with  circulatory  equilibrium,  there 
occurs  surcharging  of  the  dendrites  with  intercellular  plasma  of  an  abnormal  or 
hypo-  or  hyper-  tonic  quality.  This  in  turn  results  in  interference  with  the  chemical 
and  physiological  processes  through  which  nervous  energy  is  developed.  The  manner 
in  which  the  nerve-energy  is  evolved  has  been  ascribed  by  Sajous  to  a  reaction 
between  the  phosphorus  of  the  myelin  (highly  organized  so-called  fat,  really  alcohols) 
of  the  nervous  elements  and  oxygen  in  the  axis-cylinder, — i.e.,  the  oxygen  of  the 
blood-plasma,  which  also  travels,  in  his  opinion,  through  nervous  elements.  This 
clearly  accounts  for  the  benefit  obtained  from  agents  which  enhance  oxygenation, — 
i.e.,  functional  activity. 

Failure  of  memory,  forgetfulness  of  recent  events,  nocturnal  insomnia,  drowsi- 
ness through  the  day,  and,  in  further  advanced  cases,  the  clinical  picture  of 
apparent  cerebral  softening,  are  frequently  nothing  more  than  inhibitions  of  cell 
function.  By  the  bold  use  of  digitaline,  employed  with  a  view  to  bringing  about 
a  restoration  of  lost  circulatory  equilibrium,  these  symptoms  can  be  overcome,  and 
the  associated  nutritional  defects  removed,  so  that  such  a  brain  may  be  restored  to 
its  proper  relationship  with  the  life  unit  of  the  individual. 

The  same  principle  is  applicable  to  parallel  processes  in  any  structure  what- 
soever, whether  it  be  in  the  subcutaneous  cellular  tissue,  as  in  ulceration  accom- 
panying varicose  veins ;  in  the  disturbance  of  the  mucous  membrane  of  the  bronchial 
system  so  common  after  prolonged  bronchitis;  in  the  albuminuria  of  cyanotic  kid- 
ney, and  even  in  many  forms  of  pain  included  in  the  term  "neuralgia." 

Indeed,  if  the  clinician  will  carefully  apply  his  knowledge  of  the  physiology 
of  metabolism  to  any  organ  of  the  body,  when  contemplating  the  treatment  of 
nutritional  diseases  dependent  upon  the  qualitative  disturbances  of  the  intercellular 
blood-plasma,  he  will  meet  with  gratifying  results.  The  digitaline  referred  to,  in 
association  with  such  other  remedies  as  any  concomitant  and  associated  conditions 
may  demand,  has  been  especially  effective  in  the  writer's  hands  when  employed 


10  THE  ROLE  OF  ADRENOXIN  (OXIDASE)  IN  PATHOLOGY. 

with  this  aim  in  view.     Its  action  deals  with  cellular  nutrition,  regeneration,  and 

growth,  and  its  administration,  therefore,  must  be  continued  at  times  for  months 

or  even  years,  as  the  conditions  determine. 

Henry  Beates,  Jr.* 

Philadelphia. 

THE  EOLB  OP  ADRENOXIN"  (OXIDASE)   IN  PATHOLOGY. 

In  the  April  (190-1)  issue  of  this  journal  I  commented  upon  remarks  made  by- 
Prof.  A.  E.  Wright,  March  9,  1904,  before  the  Chelsea  (England)  Clinical  Society, 
in  which  this  distinguished  pathologist  referred  to  substances  that  "were  present  in 
considerable  quantities  in  the  blood."  He  characterized  them  as  "protective  sub- 
stances which  were  involved  in  the  cure  of  disease,"  and  concluded  that  "they  were 
to  be  regarded  as  produced  by  internal  secretion."  He  added,  however,  that  he 
"did  not  know  where  they  were  produced  in  the  body." 

My  commentary  included  the  following  lines :  "Excepting  the  implied  multi- 
plicity of  sera,  Professor  Wright  strikingly  confirms,  it  seems  to  me,  the  con- 
ception I  have  submitted  of  the  means  through  which  the  body  protects  itself  against 
pathogenic  elements,  poisons,  etc.,  by  means  of  its  internal  secretions.  The  'laws' 
which  underlie  the  production  of  these  substances,  a  knowledge  of  which  he  craves, 
are,  I  may  add,  embodied  in  the  functions  of  the  ductless  glands  which  produce  tryp- 
sin, adrenoxin,  and  fibrinogen,  the  two  latter  serving  jointly  to  insure  the  efficiency 
of  the  first,  the  body's  main  resource  against  pathogenic  elements.  Prominent 
among  these  laws  is  the  following:  'The  power  of  the  organism  to  antagonize  the 
constitutional  effects  of  pathogenic  germs,  their  toxins,  and  other  poisons  is  directly 
proportionate,  all  else  being  equal,  to  the  functional  efficiency  of  the  adrenal  system.' 
Moreover,  Professor  Wright's  remarks  are  of  great  value  in  that  they  emphasize — as 
I  have  done  ('Internal  Secretions,'  etc.,  vol.  i,  pp.  609-6G6  and  728-751) — the 
dependence  of  the  immunizing  process,  now  being  studied  in  every  laboratory,  upon 
the  internal  secretions.  The  general  law  of  the  production  of  immunity  under 
these  'protective  substances'  may,  perhaps,  as  Professor  Wright  says,  'be  taken  as 
well  established,'  but  the  admission  that  the  source  of  the  protective  substances  is  un- 
known obviously  weakens  this  assertion.  In  fact,  I  do  not  hesitate  to  state  that 
pathologists  will  continue  to  work  in  the  dark,  as  they  have  now  been  doing  several 
years,  until  they  realize  that  the  very  few  substances, -to  which  various  names  have 
been  given :  Buchner's  alexins,  Ehrlich's  complement,  Metchnikoff's  cytase,  Ehrlich's 
intermediary  body  or  amboceptor,  Bordet's  sensitizing  substance,  etc.,  are  internal 
secretions  in  the  true  sense  of  the  word :  i.  e.,  products  of  ductless  glands." 

Suggestive  in  this  connection  is  the  following  editorial  in  the  Medical  News 
of  December  24,  1904:    "'Life  is  a  series  of  oxidations,'  has  become  an  important 


h  President  of  the  State  Board  of  Health,  Philadelphia,  Pa. 


THE  ROLE  OF  ADRENOXIN  (OXIDASE)  IN  PATHOLOGY.  11 

formula  of  modern  physiology.  The  manifestation  of  heat  and  visible  motion,  in 
which  respects  alone  life  reveals  itself  to  physicist  and  chemist,  has  been  amply 
explained  in  the  basis  of  an  oxidation  of  the  complex  organic  compounds  out  of 
which  the  tissues  are  built. 

"Not  content,  however,  with  this  conclusion,  physiologists  have  probed  more 
deeply  into  the  mechanism  of  vital  oxidations,  and  discovered  that  these  processes 
are  brought  about  by  certain  unorganized  ferments  present  in  the  tissues,  and  called 
oxidases.  The  discovery  of  these  substances  has  opened  up  a  glittering  world  of 
possibilities  to  the  investigator. 

"The  oxidases  are  catalytic  agents  possessing  the  property  of  uniting  with 
molecular  oxygen  and  delivering  it  in  its  atomic  or  active  form  of  the  tissues.  These 
enzymes  are  present  in  all  parts  of  the  body  and  have  been  discovered  even  in  the 
milk  and  urine.  They  have  not  been  isolated  in  their  pure  state,  but  their  presence 
has  been  definitely  demonstrated  by  a  variety  of  well-known  tests. 

"The  practical  importance  of  investigation  on  the  nature  of  the  oxidases  and 
their  mode  of  operation  cannot  be  overestimated.  It  is  not  entirely  poetic  imagina- 
tion that  inspired  Jacques  Loeb  to  predict  that  through  the  oxidases  one  may  in 
time  be  able  to  control  life  as  the  artist  governs  the  keys  of  the  piano.  Not  merely 
the  normal  course  of  life,  but  also  that  vast  gamut  of  diseases  characterized  by 
metabolic  derangements,  might  be  controlled  if  we  only  knew  how  to  favor  or  re- 
tard the  action  of  the  oxidases. 

"Becent  researches  in  this  domain,  valuable  in  themselves,  are  still  more  valuable 
as  an  earnest  of  the  rich  harvest  which  the  future  holds.  L.  Liebermann  has 
pointed  out  a  close  analogy  between  colloidal  platinum  and  the  oxidases.  The 
former,  which  has  for  a  long  time  been  known  to  act  as  a  catalytic  agent  in  the  de- 
composition of  peroxide  of  hydrogen,  owes  this  power  to  the  active  oxygen  which 
it  contains.  The  colloidal  solutions  of  platinum  possess  the  capacity  of  activating 
molecular  oxygen.  In  this  process  loose  compounds  of  platinum  and  oxygen  are 
formed.  The  catalytic  power  of  colloidal  platinum  is  increased  by  the  passage 
through  it  of  some  inert  gas,  such  as  hydrogen  or  nitrogen,  which  action  is  at- 
tributed to  the  mechanical  agitation  produced  by  the  streaming  gas  which,  by 
breaking  up  large  particles  of  the  platinum,  renders  this  capable  of  uniting  with 
a  large  amount  of  oxygen.  The  surface  attraction  of  the  large  extent  of  surface 
represented  in  the  very  fine  particles  present  in  solution  is  capable  of  tearing  asunder 
the  constituents  of  the  inactive  oxygen  molecule. 

"The  experiments  of  L.  Liebermann  on  colloidal  platinum  also  open  up  a  vast 
field  of  possibility  in  the  domain  of  pathology.  This  observer  states  that  the 
mechanism  of  the  oxidative  reaction  helps  to  explain  certain  phenomena  connected 
with  the  destruction  of  foreign  and  toxic  bodies  in  the  organism.     Certain  patho- 


12  THE  ROLE  OF  ADRENOXIN  (OXIDASE)  IN  PATHOLOGY. 

genie  bacteria  are  rendered  innocuous  by  uniting  with  protective  bodies  normally 
present  in  the  organism,  the  complements  of  Ehrlich.  But  these  act  so  slowly  that 
they  cannot  fortify  the  organism  against  an  intoxication.  On  this  account  another 
body  is  necessary,  the  amboceptor  (immune  body),  which  will  unfold  the  activity 
of  the  complement.  The  analogy  to  the  phenomena  of  the  oxidative  reaction  is 
as  follows :  The  pathogenic  agent  corresponds  to  the  tissue,  the  complement  to  the 
active  oxygen,  and  the  amboceptor  to  the  oxidase.  The  amboceptor  is  thus  nothing 
more  than  a  catalyzer. 

"That  catalytic  agents  akin  to  the  oxidases  play  an  eminent  role  in  subduing 
septic  processes  in  the  organism  is  indicated  by  the  recent  researches  of  M.  J.  Hek- 
man  and  H.  J.  Hamburger.  These  observers  sought  an  experimental  demonstra- 
tion of  the  clinical  experience  that  colloidal  silver  has  a  favorable  effect  in  various 
forms  of  bacterial  invasion.  They  found  that,  while  solutions  of  collargolum  of 
a  low  concentration  increase  the  hemolytic  power  of  staphylotoxin,  solutions  of  a 
higher  concentration  entirely  inhabit  hemolysis.  The  authors  attribute  the  in- 
hibitory action  of  colloidal  silver  to  some  catalytic  effect.  In  view  of  Lieber- 
mann's  experiments  on  colloidal  platinum,  this  conclusion  is  probably  correct." 

That  Liebermann's  conclusions  only  confirm  those  submitted  by  myself  two 
years  ago  in  the  first  volume  of  my  work  on  the  "Internal  Secretions,"  etc.,  is  obvious. 
The  most  casual  perusal  of  this  volume  will  show  that  the  800  pages  it  contains 
serve  mainly  to  emphasize  the  overwhelming  importance,  in  physiology,  pathology, 
and  therapeutics,  of  the  oxidizing  substance,  the  so-called  "oxidases,"  of  the  blood. 
Not  only  is  their  role  in  each  organ,  including  the  nervous  system,  defined,  but 
their  identity  (the  secretion  of  the  adrenals,  which  by  taking  up  oxygen  in 
the  lungs  becomes  my  "adrenoxin")  is  also  given.  The  complement  of  Ehrlich 
is  assimilated  therein,  owing  to  its  physico-chemical  attributes,  to  a  trypsin\l\ke 
body  in  the  blood-stream.  This  body,  in  order  to  become  effectively  bactericidal 
or  antitoxic,  is  stated  by  me  to  require  the  aid  of  adrenoxin — also  said,  owing  to  its 
properties,  to  correspond  with  Ehrlich's  amboceptor  or  immune  body.  I  likewise 
specify  that  adrenoxin  only  produces  its  effects  indirectly,  i.e.,  by  catalysis,  its 
role  being  to  transfer  its  oxygen  to  a  third  body,  fibrinogen,  to  raise,  through  the 
effects  of  an  exothermic  reaction,  the  proteolytic  activity  of  the  trypsin,  which,  as 
is  well  known,  steadily  increases  under  the  influence  of  heat  up  to  a  given  limit. 

That  Liebermann's  labors  are  valuable  as  confirmatory  evidence,  but  as  such 
only,  will  be  recognized  by  our  readers. 

Even  the  control  of  oxidations,  "as  the  artist  governs  the  keys  of  the  piano," 
as  Jacques  Loeb  expresses  it,  is  a  subject  treated  at  length  in  "Internal  Secretions," 
the  keyboard  being  located  in  the  pituitary  body. 

Charles  E.  de  M.  Sajotjs, 


Cyclopaedia  of  Current  feiteratur?. 


ACID   INTOXICATIONS. 

By  slow  degrees  and  with  much  travail 
is  nature  delivering  up  the  mysteries  of 
her  more  involved  chemical  processes. 
While  for  many  years  we  have  written 
exhaustively  on  the  oxidations  and  re- 
ductions that  take  place  in  the  human 
body  and  of  their  relation  to  diseased 
states,  it  may  be  said  that  we  are  as  yet 
only  in  touch  with  the  earliest  stages  of 
the  birth  of  correct  ideas  concerning 
these  processes. 

One  type  of  perverted  chemisms  has 
been  termed  the  acidoses,  or  acid  intoxi- 
cations, and  the  researches  of  Magnus 
Levy,  Herter,  von  Mering,  Minkowski, 
and  others  have  advanced  to  such  a  stage 
that  tbe>  offer  practical  guides  to  treat- 
ment, particularly  for  the  more  fragrant 
or  pronounced  states  of  these  forms  of 
slow  poisoning. 

It  is  recognized  that  two  important 
factors  enter  into  the  acid  intoxications. 
Such  acids  may,  in  small  part,  be  ab- 
sorbed from  the  stomach  from  foods,  etc., 
but  these  are  of  much  less  moment  than 
the  organic  acids  that  are  formed  as  the 
result  of  damage  to  the  cells  of  the 
body  whereby  the  ordinary  products  of 
metabolism  are  not  properly  oxidized. 
These  oxidations,  it  is  well  established, 
are  carried  on  particularly  in  the  liver 
cells  and  in  the  muscles,  but  when  these 
cells  fail  in  their  full  duty  organic  acids, 
particularly  diacetic  and  oxybutyric,  are 
formed  in  comparatively  large  quanti- 
ties, and  as  a  result  of  their  noncombus- 
tion  they  eagerly  seize  upon  the  alkalies 
of  the  body  cells,  and,  withdrawing  these 
from  the  metabolic  activities,  set  up  a 
vicious  cycle,  whereby  cell  respiration  is 
very  much  hampered.    For,  as  it  is  well 


recognized,  it  is  necessary  for  the  blood 
to  utilize  the  sodium  of  the  body  in  com- 
bination with  C02  to  carry  on  its  oxida- 
tion functions  in  the  lungs.  The  sodium, 
having  been  largely  seized  upon  by  the 
organic  acids,  is  not  available  for  this 
most  important  work,  and  Pel  ion  is 
heaped  on  Ossa  to  the  ultimate  causation 
of  disease. 

It  is  gradually  becoming  apparent  that 
a  number  of  causes  bring  about  the  pri- 
mary increase  in  the  formation  of  these 
acids,  and  an  increasing  number  of  affec- 
tions of  a  milder  or  severer  grade  are  be- 
ing recognized  as  following  in  the  train 
of  these  sulfoxidations. 

As  for  internal  metabolic  causes,  we 
are  not  yet  in  a  position  to  assert  just 
what  are  the  starting  points.  Intense  in- 
testinal putrefaction  is  known  to  set  free 
a  series  of  bodies  which  cause  an  increase 
in  the  acetone  bodies  in  the  system,  but 
those  most  open  for  research  are  found 
in  drugs.  Thus,  carbon  monoxide  is 
known  to  increase  the  acetone  bodies,  so 
also  phloridzin,  which  drug  induces  a 
type  of  glycosuria  of  more  than  passing 
experimental  interest.  From  another 
viewpoint  adrenalin  brings  about  a  glyco- 
suria, as  do  also  chloroform,  ether,  anti- 
pyrin,  morphine,  atropine,  and  others. 

The  exact  steps  in  the  process  of  acid 
formations  by  these  bodies  is  not  yet  out- 
lined, but  they  each  and  all  are  opening 
up  new  lines  of  approach  to  the  solution 
of  the  first  cause. 

The  results  of  these  intoxications  we 
have  always  with  us.  Some,  like  arthri- 
tis deformans  of  the  noninfectious  type, 
defy  all  efforts  at  analysis,  and  we  are 
compelled  to  fall  back  on  an  hereditary 
nervous  defect,  which  is  the  hair  trigger, 

(13) 


14 


ACID  INTOXICATIONS. 


ALBUMINURIA. 


as  it  were,  to  this  type  of  acid  intoxica- 
tion, to  account  for  the  trophic  disturb- 
ances in  the  joints. 

It  seems  not  improbable,  from  gen- 
eral research,  that  the  cyclical  vomiting 
of  children,  the  vomiting  of  pregnancy, 
and  eclampsia  have  as  one  of  their  etio- 
logical factors  at  least  the  overproduc- 
tion of  these  organic  acids,  while  in  dia- 
betes the  classical  extreme  of  complete 
acid  intoxication  is  met  with. 

While  the  general  procedures  of  the 
therapeusis  of  these  conditions  are  only 
vaguely  outlined  by  the  slow  accumula- 
tion of  a  rational  understanding  of  the 
morbid  processes  themselves,  it  is  not  too 
visionary  to  hope  for  much  relief  in  the 
near  future. 

For  the  most  pronounced  of  these  dis- 
eases, diabetes,  the  general  rationale  is 
now  fairly  clearly  perceived;  but  it  be- 
gins unfortunately  only  after  the  disease 
has  become  established.  The  knowledge 
that  will  lead  to  the  possible  prevention 
of  diabetes  still  is  hidden. 

Alkalies,  to  replace  the  used  sodium 
bases;  careful  intestinal  hygiene,  par- 
ticularly limiting  excessive  putrefaction ; 
a  diet  not  too  restricted,  especially  not  as 
to  water,  but  one  sparing  in  fats  and  car- 
bohydrates; a  partial  removal  of  the  ban 
on  proteids,  and  an  annihilation  of  the 
doctrines  founded  on  the  fancied  differ- 
ences in  red  meats  and  white  meats,— 
these,  combined  with  an  open-air  occu- 
pation, involving  mild  exercise  in  a  care- 
fully selected  equable  climate,  are  the 
main  features  of  the  therapeusis  not  only 
for  diabetes  mellitus,  but  for  practically 
all  of  the  acidoses.  Editorial  (Medical 
News,  December  17,  1904). 

ALBUMINURIA. 

Nothing  is  simpler  in  the  routine  work 
of  the  clinician  than  the  detection  of  al- 
bumin in  the  urine  when  it  is  present  in 


considerable  quantities.  Every  physi- 
cian, however,  sees  cases  in  which  only 
traces  of  albumin  are  present  or  in  which 
the  reactions  obtained  are  atypical ;  it  is 
then  that  he  often  hesitates  to  trust  his 
own  results,  and  prefers  to  send  the  speci- 
men to  an  expert  physiological  chemist 
for  a  definite  opinion.  So  many  differ- 
ent tests  have  from  time  to  time  been 
recommended  for  the  detection  of  mi- 
nute traces  of  albumin,  and  so  many 
warnings  regarding  fallacies  have  been 
made,  that  it  is  but  little  wonder  that 
the  physician  who  lacks  time  to  follow 
the  advances  in  analytical  chemistry 
should  sometimes  become  confused.  It 
would  be  helpful  if  some  chemist  in 
whom  the  profession  has  confidence 
would  at  intervals  "take  stock,"  so  to 
speak,  of  the  various  practically  impor- 
tant urinary  tests,  sift  out  the  less  essen- 
tial reactions,  and  present  to  practition- 
ers, as  the  result  of  the  application  of  his 
critical  judgment,  a  few  simple  and  re- 
liable methods  of  procedure. 

Out  of  the  host  of  tests  for  albumin 
in  the  urine,  a  satisfactory  selection  for 
the  average  practitioner  might  be  made 
somewhat  as  follows:  In  the  first  place, 
a  very  delicate  test  might  be  applied,  like 
that  of  Spiegler  as  modified  by  Jolles, 
which,  when  applied  as  a  ring  test,  will 
demonstrate  the  presence  of  as  little  al- 
bumin as  0.002  gram  in  a  liter.  If  with 
this  very  sharp  test  a  negative  result  is 
obtained,  the  urine  may  at  once  be  pro- 
nounced absolutely  free  from  albumin; 
if  a  positive  result  be  yielded,  confirma- 
tory tests  should  be  made  with  less  deli- 
cate reagents — the  heat  and  nitric-acid 
test,  Heller's  test,  and  the  test  with  fer- 
rocyanide  of  potassium  and  acetic  acid. 
If  all  are  positive  the.  presence  of  albu- 
min in  pathological  quantity  may  be 
safely  diagnosed. 

Albumin  being  present,  it  is  desirable 


ALBUMINURIA. 


ARTERIES,  EFFECT  OF  COLD  ON. 


15 


to  determine  if  it  be  serum-albumin  or 
globulin,  or  both.  For  clinical  purposes 
the  presence  or  absence  of  globulin  can 
be  ascertained  by  simply  diluting  the 
urine,  making  sure  that  it  is  acid  in  re- 
action. Globulin  is  soluble  in  salt  solu- 
tions of  the  concentration  of  ordinary 
urine,  but  is  insoluble  in  very  dilute  salt 
solutions;  it  falls  out  as  a  flocculent 
precipitate  if  the  urine  be  well  diluted 
with  distilled  water.  Thus,  if  50  cubic 
centimeters  of  filtered  urine  be  diluted 
with  500  cubic  centimeters  of  distilled 
water,  and  1  or  2  drops  of  dilute  acetic 
acid  be  added,  the  urine  will  remain 
clear  if  globulin  be  absent,  but  will  show 
flocculi  if  it  be  present. 

Whether  albumin  be  present  or  absent, 
the  urine  should  next  be  tested  for  the 
presence  or  absence  of  albumoses.  In 
ordinary  practice,  as  safe  a  method  as 
any  recommended  for  the  purpose  is  to 
add  5  drops  of  dilute  acetic  acid  and  2 
cubic  centimeters  of  saturated  solution 
of  common  salt  to  10  cubic  centimeters 
of  urine;  boil  and  filter  while  hot;  if 
the  filtrate  on  cooling  becomes  turbid, 
albumoses  are  almost  certainly  present. 
The  delicate  reagent  of  Spiegler,  as 
modified  by  Jolles  and  recommended 
above,  is  not  nearly  so  well  known  as  it 
should  be.  The  test  fluid  consists  of  10 
grams  of  corrosive  sublimate,  20  grams 
of  succinic  acid,  20  grams  of  sodium 
chlorid,  and  500  cubic  centimeters  of  dis- 
tilled water.  To  5  cubic  centimeters  of 
filtered  urine  is  added  1  cubic  centimeter 
of  dilute  acetic  acid,  and  this  mixture  is, 
by  means  of  a  pipette,  gently  and  grad- 
ually passed  clown  the  side  of  an  obliquely 
held  test-tube  containing  4  or  5  cubic 
centimeters  of  Spiegler's  reagent,  so.  that 
the  acidified  urine  forms  a  layer  on  the 
surface  of  the  reagent  without  mixing 
with  it ;  if  albumin  be  present,  a  sharp 
white  ring  appears  immediately,  and  the 


precipitate  will  not  disappear  on  warm- 
ing. 

There  has  been  much  demand  among 
physicians  for  a  safe  and  practical  test 
for  albumin  in  the  urine,  applicable  at 
the  bedside,  or,  at  any  rate,  at  the  pa- 
tient's home.  For  this  purpose  there  is 
nothing  better  than  the  sulphosalicylic- 
acid  reaction;  the  physician  may  carry 
in  his  pocket  or  medical  case  a  small 
phial  of  dry  crystals  of  this  acid.  To 
apply  the  test  one  simply  drops  a  few 
crystals  of  the  acid  into  a  little  fresh 
acid  urine  and  shakes;  if  albumin  be 
present,  a  precipitate  will  be  formed  or 
the  urine  will  become  turbid;  even  if 
only  a  trace  exists,  the  urine  will  grad- 
ually become  opalescent.  This  reaction, 
though  very  simple,  is  delicate  enough; 
if  the  test  yield  a  negative  result  the 
urine  may  be  assumed  to  be  free  from 
albumin ;  if  a  positive  result  be  obtained, 
the  urine  contains  albumin,  and  a  speci- 
men should  be  taken  to  the  physician's 
office  laboratory  and  examined  accord- 
ing to  the  outline  given  above.  Editorial 
(Journal  of  the  American  Medical  Asso- 
ciation, December  3,  1901). 

ARTERIES,  THE  EFFECT  OF  COLD  ON. 

It  is  almost  universally  believed  that 
the  first  effect  of  cold  is  to  contract  the 
arteries,  and  that  of  moderate  warmth  to 
relax  them,  but  this  has  never  been  di- 
rectly proven.  Another  point  which  has 
not  been  solved  is :  what  is  the  condition 
of  the  vessels  on  cither  side  of  the  part 
to  which  the  stimulus  is  applied?  An 
investigation  of  this  cbaractor  has  been 
instituted  by  the  writer  with  Gartner's 
method  of  recording  the  pulse.  The 
lever  of  the  instrument  was  adjusted  to 
the  middle  of  the  forearm,  and  then  cold 
applied  either  above  or  below  this  point 
in  the  form  of  an  ether  spray.  The  re- 
sults failed  to  support  one  of  the  most 


16 


ASTHMA,  NASAL  TREATMENT  OF. 


ATROPINE. 


accepted  tenets  of  hydrotherapy,  as  it 
was  found  that  the  large  artery  which 
carries  the  blood  from  the  place  where 
the  irritant  was  applied  to  the  point 
under  observation  the  sphymograph 
failed  to  contract  under  the  influence  of 
cold.  The  pressure  in  the  small  arteries 
distal  to  the  point  where  the  cold  is  ap- 
plied rises,  because  these  vessels  retract 
in  the  tissues  supplied  by  them.  On  the 
other  hand,  the  tension  decreases  in  the 
small  arterial  twigs,  central  to  the  same 
point,  because  these  vessels  dilate.  When 
warmth  was  used  instead  of  cold,  the  re- 
sults were  so  inconstant  that  no  conclu- 
sion could  be  formulated.  The  results 
of  these  investigations  are  summarized 
as  follows :  The  application  of  cold  does 
not  influence  the  diameter  of  a  large 
arterial  branch.  The  tension  in  the  mi- 
nute branches  peripherally  situated  is  in- 
creased by  the  contraction  of  the  capil- 
laries, while  in  the  centrally  disposed 
set  of  vessels  the  tension  is  dimin- 
ished, because  of  the  dilatation  of  the 
corresponding  set  of  capillaries.  M. 
Herz  (Berliner  klinische  Wochenschrift, 
November  7,  1904). 

ASTHMA,  NASAL  TREATMENT  OF. 

An  experience  obtained  from  treating 
over  400  cases  of  various  kinds  of  asthma 
is  responsible  for  the  opinion  expressed 
by  the  author  that  it  is  those  asthmatics 
who  present  no  gross  nasal  lesions  and 
no  subjective  nasal  symptoms,  that  give 
the  best  hope  of  affording  relief  by  in- 
tranasal treatment.  Of  402  recorded 
cases  only  14  obtained  no  relief,  and  of 
these  3  suffered  from  polypi  and  2  from 
such  pronounced  deflections  of  the  sep- 
tum that  it  was  impossible  to  apply  the 
galvanocautery  without  doing  operations 
which  were  declined.  Only  8  cases  that 
presented  no  gross  nasal  lesions,  out  of 
346  cases  treated,  obtained  no  relief,  and 


of  these  3  were  seen  by  the  author  only 
three  times  and  1  four  times.  Of  the 
remaining  4  cases,  one  was  a  pronounced 
morphino-maniac.  In  addition  to  these 
14  known  failures  there  are  17  cases 
where  it  was  not  possible  to  obtain  any 
record  of  the  result,  and  a  number  of 
others  that  were  completely  relieved  or 
greatly  improved  when  lost  sight  of. 

From  the  experience  obtained  in  treat- 
ing these  cases  the  writer  concludes  that 
asthma  is  due  to  reflex  spasm  of  the 
bronchial  tubes.  The  irritation  may 
originate  in  the  nose,  as  may  be  inferred 
from  (a)  the  intimate  association  be- 
tween hay  fever  and  asthma;  (b)  the 
very  common  record  of  excessive  sneez- 
ing at  some  period  in  the  previous  his- 
tory of  an  asthmatic  patient;  (c)  the 
not  infrequent  alteration  between  asthma 
and  sneezing. 

Asthma  is  not  directly  due  to  any  me- 
chanical obstruction  of  the  nasal  pas- 
sages, and  is  not  commonly  caused  by 
any  gross  nasal  lesions.  Some  part  of 
the  nasal  apparatus  has  a  controlling  in- 
fluence on  the  respiratory  center;  or 
there  is  in  the  nose,  as  it  were,  an  agency 
through  which  the  afferent  impulses 
must  pass.  Alexander  Francis  (Journal 
of  the  Eoyal  Army  Medical  Corps,  No- 
vember, 1904). 

ATROPINE,  ACTION  OF,  ON  THE  INTES- 
TINE. 
The  writer  reports'  in  a  preliminary 
communication  the  result  of  his  experi- 
ments on  the  intestines  of  rabbits  and 
cats,  in  which  he  tested  the  action  of 
atropine.  The  intestines  were  isolated 
in  the  manner  now  employed  by  physi- 
ologists, and  placed  in  an  appropriate 
bath,  which  kept  up  their  living  prop- 
erties. In  other  animals  he  performed 
laparotomies  and  immersed  the  abdo- 
men in  appropriate  baths,  watching  the 


BARIUM  CHLORIDE,  MEDICINAL  VALUE  OE. 


17 


actions  of  the  intestines  under  the  influ- 
ence of  atropine.  His  conclusions  were 
as  follows :  Atropine,  either  in  weak  or 
in  strong  solutions,  stimulates  and  regu- 
lates the  contractions  of  the  intestines. 
Weak  solutions  act  chiefly  on  the  longi- 
tudinal muscle  fibers  of  the  intestines, 
while  stronger  solutions  act  chiefly  on 
the  circular  fibers.  Very  strong  solutions 
of  atropine  produce  a  tetanic  state  in  the 
intestines.  Even  saturated  solutions  of 
atropine  do  not  paralyze  the  isolated  in- 
testine. The  irritability  of  the  muscle 
tissue  of  the  isolated  intestine  is  in- 
creased by  atropine.  As  the  result  of 
these  observations,  there  is  reason  to  be- 
lieve that  the  drug  in  question  stimu- 
lates the  motor  ganglia  of  the  intestine, 
first  producing  a  contraction  of  the 
longitudinal  fibers  and  then  of  the  cir- 
cular fibers.  Atropine  does  not  act  on 
the  empty  intestine,  but  if  injected  into 
the  veins  of  an  animal  with  full  intes- 
tines it  promotes  peristalsis.  Paralysis 
of  the  intestines  from  atropine  occurs 
very  rarely  in  living  animals,  even  after 
poisonous  doses,  and  is  then  intimately 
connected  with  the  paralysis  of  the  heart 
and  respiration.  The  mode  of  action 
of  atropine  on  the  intestine,  which  was 
hitherto  unknown,  is  probably  through 
its  influence  on  the  motor  nervous  mech- 
anism of  the  guts  (Auerbach's  plexus), 
and  through  a  rise  in  the  irritability  of 
the  muscle  fibers.  The  longitudinal 
fibers  are  excited  first;  then  the  others. 
N.  E.  Riedel  (Roussky  Vratch,  October 
16,  1904,  from  New  York  Medical  Jour- 
nal and  Philadelphia  Medical  Journal, 
December  3,  1904). 

BARIUM   CHLORIDE,    MEDICINAL  VALUE 
OF. 

The  author  confirms  the  experiments 
of  Schedel,  and  others,  who  employed 


barium  chloride  as  a  cardiac  stimulant, 
and  for  other  therapeutical  purposes. 
He  found  that  barium  chloride  acts 
favorably  upon  each  of  the  following 
symptoms  independently  of  one  another : 
The  lowered  blood  pressure,  the  pulse, 
the  anuria,  the  dyspnoea,  the  cyanosis, 
and  the  cedemas.  It  is  a  question  how 
barium  chloride  produces  these  effects. 
Certainly  not  through  a  direct  influence 
upon  the  heart,  for  this  may  be  excluded 
from  the  irregular  manner  in  which  it 
acts  on  the  pulse  itself.  On  the  other 
hand,  the  addition  of  barium  chloride  to 
other  true  heart  stimulants  exalts  the 
effects  of  the  latter.  The  German  au- 
thors believe  that  the  essential  effect  of 
barium  chloride  is  to  raise  the  maximum 
blood  pressure.  On  the  other  hand,  the 
present  author  thinks  that  this  effect  is 
exercised  indirectly  through  raising  the 
arterial  tone,  and  thus  increasing  the 
medium  pressure.  Clinically  he  gives 
the  following  indications  for  its  use:  1. 
In  old  or  acute  pleuritic  effusions,  as  an 
excellent  diuretic.  The  results  are 
prompt  and  constant,  and  are  superior 
to  those  obtained  with  any  other  diu- 
retic. 2.  In  the  first  period  of  loss  of 
compensation  in  valvular  disease  of  the 
heart.  It  stimulates  the  arterial  coats 
of  these  cases,  and  thus  enhances  the 
work  of  the  weakened  ventricle.  3.  In 
infectious  diseases  in  which  the  pulse 
tends  to  become  dicrotic,  owing  to  the 
relaxation  of  the  arterial  walls,  and  to 
the  weakening  of  the  poisoned  myocar- 
dium. 4.  The  remedy  is  contra-indi- 
cated in  all  cases  in  which  the  arterial 
pressure  is  very  high  and  the  force  of  the 
heart  very  weak.  Ernesto  Pesci  (Ri- 
forma  Medica,  November  9,  1904,  from 
New  York  Medical  Journal  and  Phila- 
delphia Medical  Journal,  December  24, 
1904). 


18 


BLOOD  PLATELETS. 


BLOOD  POISONING. 


BRAIN  TUMOR. 


BLOOD  PLATELETS,  ORIGIN  OF. 

By  means  of  a  special  combination  of 
eosin  and  methylene  blue  the  authors 
were  able  to  detect  in  blood  platelets  a 
ground  substance,  filled  with  red  gran- 
ules and  a  surrounding  rim  of  proto- 
plasm which  stains  like  the  red  cells. 
The  red  cells,  and  less  often  the  large 
mononuclear  leucocytes,  contain  blood 
platelets  inclosed  in  their  protoplasm. 
There  are,  however,  distinct  differences 
in  staining  between  these  included  ele- 
ments and  the  nuclei  of  the  red  cells. 
The  position  in  centric  or  eccentric  and 
sometimes  the  various  stages  of  extru- 
sion may  be  observed.  Various  experi- 
ments made  to  determine  the  nature  of 
the  substance  of  which  the  platelets  were 
made  up,  proved  that  this  was  chiefly 
nuclei n.  If  two  ligatures  are  applied  to 
a  large  vessel  and  the  stagnating  blood 
be  examined  after  a  certain  time,  the 
bodies  are  not  increased  in  number; 
hence  they  probably  occur  as  such  in  the 
circulating  blood  and  do  not  precipitate 
out  when  the  blood  is  at  rest,  as  has  been 
stated.  Great  importance  has  been  at- 
tributed to  the  fact  that  if  sublimate  is 
allowed  to  act  upon  blood,  structures  re- 
sembling platelets  are  formed  in  great 
number  from  the  red  cells.  These  are 
not,  however,  true  platelets,  for  they  can 
also  be  obtained  from  the  blood  of  chick- 
ens, which  never  contains  platelets.  The 
above  facts,  together  with  the  observa- 
tion that  animals  whose  red  cells  are 
normally  nucleated  do  not  possess  plate- 
lets, makes  it  very  probable  that  the 
latter  are  merely  the  degenerated  and  ex- 
truded nuclei.  When  the  bone  marrow 
of  young  animals  was  examined,  many 
nucleated  red  cells  were  found,  but 
among  these  was  a  large  number  whose 
nuclei  stained  like  the  platelets  nor- 
mally do,  so  that  the  various  transition 
stages  between  both  could  be  well  studied. 


Both  red  cells  and  platelets  are  de- 
stroyed in  the  spleen,  for  if  this  organ 
be  examined,  large  conglomerations  can 
generally  be  discovered.  The  platelets 
are  not  indispensable  for  the  clotting  of 
blood,  but,  as  they  are  degenerated  struc- 
tures, they  are  the  first  to  show  those 
chemical  changes  which  are  necessary 
for  the  production  of  clotting.  K. 
Priesich  and  P.  Heim  (Virchow's 
Archiv,  vol.  clxxviii,  No.  1,  from  Med- 
ical News,  November  26,  1904). 

BLOOD     POISONING,      PERCHLORIDE     OF 
IRON  IN. 

The  writer  calls  attention  to  the  effi- 
ciency of  the  tincture  of  the  perchloride 
of  iron  and  chlorine  in  the  treatment  of 
various  forms  of  blood  poisoning.  The 
most  judicious  plan  is  to  give  moderate 
doses,  cautiously  watching  their  effect 
and  administering  them  more  frequently 
if  the  patient  will  bear  them.  If  not, 
moderate  doses  should  be  continued,  and, 
if  further  antiseptic  action  is  required, 
chlorine  water  or  euchlorin  internally 
should  be  given,  alternately  with  or  in 
the  intervals  between  the  doses  of  iron. 
The  chlorine  water  is  prepared  by  add- 
ing 20  grains  of  powdered  chlorate  of 
potassium  and  1  drachm  of  strong  hy- 
drochloric acid  to  20  ounces  of  water. 
P.  W.  Latham  (Lancet,  November  19, 
1904). 

BRAIN  TUMOR  AND  TRAUMA. 

The  pathology  of  a  traumatic  brain 
growth  is  not  different  from  that  of  a 
tumor  elsewhere.  The  upright  posture 
renders  the  cranium  more  liable  to  in- 
jury, and  in  severe  traumatism  the  dif- 
fusion of  the  force  increases  the  dangers 
to  the  brain.  The  direct  influence  of  the 
blow  is  shown  by  the  tumor  appearing  at 
the  seat  of  injury,  the  cortex  and  the 
cerebellum,  therefore,  being  the  parts  of 


BURSITIS,  TREATMENT  OF  CHRONIC. 


CALOMEL  AS  A  POISON. 


19 


the  encephalon  most  vulnerable  and  most 
liable  to  tumor;  but,  by  reason  of  con- 
cussion and  contrecoup,  deeper  parts  and 
parts  at  a  distance  may  be  affected,  as 
proved  by  the  clinical  evidence  of  tumor. 
The  fact  that  the  brain  is  so  well  pro- 
tected from  infection  from  without,  so 
long  as  its  outworks — the  scalp,  the  skull, 
and  the  meninges — are  intact,  militates 
against  the  bacterial  origin  of  tumor, 
and  favors  the  belief  in  the  cellular,  nu- 
tritional, and  formative  element  as  eausa- 
tives  of  new  growth.  The  same  variety 
of  tumor  is  found  here  as  elsewhere, 
though  from  traumatic  causes  (except- 
ing cysts)  sarcoma  and  gumma  would 
seem  to  bear  the  greater  proportion.  The 
time  of  the  appearance  is  without  limit, 
in  brevity  or  in  duration.  A  completely 
kept  history  of  the  individual  is  of  the 
greatest  importance  in  the  making  of  a 
diagnosis  at  the  very  onset  of  the  disease, 
or  by  exclusion  in  the  more  neutral  areas 
of  the  brain.  E.  W.  Holmes  (American 
Medicine,  December  10,  1904). 

BURSITIS,   TREATMENT   OF  CHRONIC. 

The  operation  advocated  by  the  writer 
consists  of  puncturing  the  bursa,  thor- 
oughly scarifying  its  walls,  expressing 
its  fluid  contents,  bringing  its  walls  in 
contact,  and  holding  them  so  by  means 
of  a  compress  until  their  raw  surfaces 
have  grown  together  and  have  thus  ob- 
literated the  cavity.  It  is  especially 
adapted  to  the  treatment  of  the  condition 
known  as  housemaid's  knee.  An  ordi- 
nary tenotome,  having  a  long  shank,  or 
an  especially  devised  instrument,  is 
passed  into  the  distended  bursa  at  its 
base.  With  the  sharp  edge,  its  entire 
inner  surface  is  marked  with  many  fine 
cuts,  after  which  the  instrument  is  with- 
drawn and  the  bursa  evacuated  of  its 
fluid  contents  through  the  small  skin  in- 
cision.    A  thick,  wide  pad  of  gauze  is 


placed  over  the  bursa  and  firmly  bound 
down  with  strips  of  adhesive  plaster  over- 
lapping one  another  and  completely  en- 
circling the  limb  from  an  inch  or  two 
above  the  upper  margin  to  the  same  dis- 
tance below  the  lower  margin  of  the 
bursa.  Over  this  a  muslin  and  a  crino- 
line bandage  are  applied.  A  pad  of  cot- 
ton should  be  placed  within  the  popliteal 
space  beneath  the  plaster,  to  protect  the 
prominent  hamstring  and  overlying  skin 
from  undue  pressure.  The  raw  bursal 
surfaces  should  be  kept  in  contact  until 
firm  union  has  occurred.  Two  weeks  are 
sufficient.  The  adhesive  plaster  strips 
should  be  renewed  or  re-enforced  when- 
ever they  appear  loose;  as  a  rule,  every 
two  or  three  days.  No  anaesthetic  need 
be  given,  nor  need  the  patient  be  con- 
fined to  bed  or  even  use  crutches  during 
the  after-treatment.  In  the  past  nine 
years  the  writer  has  operated  on  104 
cases  of  housemaid's  knee.  In  2  the  op- 
eration had  to  be  performed  twice,  and 
in  4  three  times,  while  in  98  it  was 
primarily  successful.  The  scarification 
must  be  thorough,  the  withdrawal  of 
synovial  fluid  complete,  and  the  Compres- 
sion quite  firm  to  assure  success.  P. 
Hoffmann  (American  Journal  of  Ortho- 
paedic Surgery,  October,  1904). 

CALOMEL  AS  A  POISON. 

The  writer  states  that  calomel  is  very 
inconstant  in  its  action  as  a  poison. 
Guy  states  that  6  grains  have  proved 
fatal,  while  an  ounce  has  been  taken  with 
impunity.  Rungberg  records  a  case  in 
which  three  injections  of  1  1/2  grains 
each,  given  within  a  month,  proved  fatal. 
and  mentions  other  similar  fatal  casr-s 
after  subcutaneous  injections  of  small 
doses.  The  author  appears  to  favor  the 
theory,  rejected  by  Guy,  that  calomel  acts 
as  a  poison  only  by  its  partial  conversion 
into  perchloride  of  mercury  by  the  free 


20 


CANCER  AND  TUBERCULOSIS. 


CARBOHYDRATE  METABOLISM. 


hydrochloric  acid  of  the  gastric  juice. 
On  this  supposition  the  very  small  fatal 
doses  could  be  explained  on  the  theory 
that  hyperacidity  of  the  gastric  juice 
converts  the  calomel  into  perchloride 
more  rapidly  than  usual,  though  he 
deems  it  more  likely  that  an  impurity 
(probably  perchloride  of  mercury)  was 
originally  present  in  the  fatal  cases.  On 
the  theory  that  it  acts  only  by  conver- 
sion into  perchloride  of  mercury,  the 
relative  impunity  of  large  doses  is  ex- 
plained by  the  supposition  that  so  soon 
as  sufficient  conversion  has  taken  place, 
purgation  supervenes  and  the  remainder 
of  the  calomel  is  expelled  unchanged. 
Calomel  injected  subcutaneously  accord- 
ing to  the  theory  would  be  converted 
into  perchloride  by  the  chlorides  of  the 
blood;  but  in  this  case  the  action  of  a 
small  quantity  could  not  cause  expul- 
sion of  the  remainder,  hence  the  fatal 
results  from  small  subcutaneous  doses. 
Though  appearing  to  have  some  faith  in 
the  perchloride  theory,  the  author,  how- 
ever, states  that  little  is  to  be  feared 
when  pure  calomel  is  used  in  modera- 
tion, however  the  method  of  administra- 
tion. T.  L.  Bunting  (Lancet,  Novem- 
ber 26,  1904). 

CANCER  AND  TUBERCULOSIS,  THE  ASSO- 
CIATION OF. 

Cancer  and  tuberculosis  not  infre- 
quently occur  together  in  an  active  state, 
and  may  be  intimately  associated  in  the 
same  tissue.  There  is  probably  neither 
specific  favoritism  nor  specific  antagon- 
ism between  the  two  types  of  disease. 
There  are  a  few  reported  cases  in  which 
one  of  the  affections  seems  to  have  ex- 
erted a  modifying  influence  on  the  course 
of  the  other.  Lupus  favors  the  develop- 
ment of  epithelioma.  Cancer  is  more 
common  among  those  with  latent  tuber- 
culosis than  among  others  at  the  cancer 


period  of  life.  The  common  age  for  can- 
cer is  not  the  common  age  for  active 
tuberculosis  ( Cruveilhier,  1828).  The 
common  sites  of  cancerous  involvement 
are  chiefly  not  those  of  tuberculous  in- 
volvement and  vice  versa  (Rokitansky, 
1838). 

A  family  history  of  tuberculosis  is 
more  frequent  in  the  cancerous  than  in 
the  general  community,  and  there  may 
be  some  hereditary  relation  between  the 
two.  A  latent  tuberculous  process  in  a 
lymph  node  may  become  active  when  a 
cancer  develops  in  the  neighborhood. 
Lymph  node  enlargement  in  the  vicinity 
of  a  cancer  is  not  always  cancerous 
(Claude,  1899),  and  may  be  solely  tuber- 
culous. W.  A.  Bastedo  (Medical  News, 
December  17,  1904). 

CARBOHYDRATE  METABOLISM. 

From  the  work  done  to  date,  the  au- 
thor finds,  like  Arnheim  and  Eosenbaum, 
that  all  the  organs  contain  enzymes, 
which  may  be  extracted  and  cause  the 
destruction  of  grape  sugar.  The  pan- 
creas shows  the  action  more  positively 
than  any  other  organ.  The  variable  re- 
sults are  due  to  many  conditions  work- 
ing together  for  a  decided  action.  In 
unfavorable  conditions  the  results  may 
be  negative,  although  the  enzymes  are 
present  in  abundance.  The  extract 
which  has  been  found  to  give  the  best 
results  is  the  one  made  by  using  glycerin 
and  alcohol.  The  glycerin-alcohol  ex- 
tract of  all  organs  used  shows  by  experi- 
ment the  presence  of  pronounced  dia- 
static  enzymes  as  well  as  the  glycolytic. 
Clinically,  results  are  good  by  the  admin- 
istration of  the  glycerin-alcohol  extracts, 
pancreas,  spleen,  and  muscle.  The  best 
results  were  by  hypodermic  injections  of 
combined  pancreas  and  muscle.  The 
peculiar  action  at  times  in  the  different 
experiments  makes  it  quite  possible  that 


CATARACT,  IMMATURE. 


CHILDREN,  DIAGNOSIS  OF  DISEASE  IN.         21 


there  is  more  than  one  enzyme  concerned 
in  the  sugar  destruction,  and  that  at 
times  other  enzymes  interfere  with  the 
glycolytic  action.  F.  A.  Rhodes  (Amer- 
ican Medicine,  December  10,  1904). 

CATARACT,  IMMATURE,  ARTIFICIAL  MA- 
TURATION  OF. 

Complete  ripening  of  immature  senile 
cataracts  may  be  safely  and  almost  cer- 
tainly secured  in  from  three  days  to  eight 
weeks  by  preliminary  iridectomy,  with 
trituration  of  the  lens  through  the  cornea 
and  pupil,  if  it  is  done  with  judgment, 
experience,  and  care.  The  ultimate  re- 
sults, surgical  and  visual,  of  extraction 
operations  in  such  cases  are  quite  equal 
to  the  results  of  similar  operations  for 
senile  cataracts  which  have  been  allowed 
to  fully  mature  spontaneously.  Further, 
the  removal  of  such  artificially  matured 
cataracts  is  entirely  free  from  those  risks, 
drawbacks,  and  often  impaired  ultimate 
results  which  follow  from  the  removal 
of  immature  senile  cataracts.  The  pro- 
cedure was  originated  by  Foerster.  The 
writer  has  practiced  it  for  about  twenty 
years  with  the  most  satisfactory  results. 
The  method  is  as  follows :  The  pupil  is 
widely  dilated  with  a  4  grain  to  the 
ounce  solution  of  sulphate  of  atropine, 
applied  twice  in  the  preceding  twelve 
hours.  Cocaine  is  used  for  anaesthesia. 
The  writer  usually  does  a  preliminary 
iridectomy  on  both  eyes,  triturating  only 
one.  Having  done  a  preliminary  iridec- 
tomy, he  lets  the  aqueous  humor  escape 
from  the  wound  by  depressing  its  poste- 
rior lip  with  the  edge  of  a  spoon,  and 
then,  wetting  the  back  of  the  shell  or 
silver  spoon  with  the  patient's  tears,  ap- 
plies its  convex  surface  to  the  center  of 
the  cornea,  stroking  the  cornea  in  a 
radiating  direction,  at  first  very  care- 
fully, observing  that  the  iris  always  slips 
away  in  front  of  each  stroke  of  the  spoon. 


That  is  to  say,  as  the  cornea  goes  down 
against  the  lens,  the  iris  recedes  from 
the  center  toward  the  periphery,  before 
the  pressure  of  the  spoon.  A  nipping 
of  the  iris  between  the  lens  and  the  cor- 
nea often  is  followed  by  iritis.  It  is  to 
be  remembered  that  one  may  do  an  enor- 
mous amount  of  rubbing  on  the  front  of 
the  cornea,  but  without  ripening  the 
cataract — if  there  be  a  fair  quantity  of 
aqueous  humor  in  the  chamber.  The 
amount  of  trituration  to  be  done  de- 
pends: (1)  on  the  amount  of  cortex 
that  requires  to  be  rendered  opaque;  (2) 
on  the  character  of  the  cornea.  If  the 
cornea  is  one  of  those  nice-looking, 
stand-up  cornea,  a  good  deal  of  tritura- 
tion is  required;  if  not,  exceedingly 
little  trituration  is  sufficient.  After  the 
trituration  atropine  is  to  be  used  within 
thirty-six  hours  to  keep  the  pupil  widely 
dilated.  This  method  renders  it  impor- 
tant that  the  patient  should  be  very  ac- 
cessible. The  writer  makes  use  of  it  in 
all  cases  of  immature  senile  cataract  with 
greatly  hampered  vision,  and  with  uni- 
formly successful  results.  M.  M.  Mc- 
Hardy  (British  Medical  Journal,  No- 
vember 12,  1904). 

CHILDREN,    DIAGNOSIS    OF    DISEASE    IN. 

The  author  makes  a  series  of  observa- 
tions upon  the  principles  of  diagnosis  of 
disease  in  children,  giving  his  opinion  as 
to  some  points  not  usually  emphasized, 
and  also  calls  attention  to  certain  factors 
in  semeiology,  to  which  he  advises  atten- 
tion to  be  directed  more  generally.  He 
claims  that  we  have  not  as  yet  taught 
the  undergraduate  student  how  to  apply 
the  fundamental  principles  of  physiology 
to  his  working  knowledge  of  the  phe- 
nomena and  the  natural  history  of  dis- 
ease, and  particularly  urges  that  this 
should  include  many  points  in  embry- 


22 


CHILDREN,  DIAGNOSIS  OF  DISEASE  IN. 


ology  which  ought  to  serve  in  drawing 
analogies  of  the  differences  between 
childhood  physiology  and  the  processes 
of  the  adult.  We  want  not  so  much  new 
facts  as  a  better  correlation  of  those  al- 
ready established.  Many  valuable  truths 
are  scattered  and  unrelated,  and  thus 
their  utility  is  often  obscured  by  being 
placed  in  large  treatises  and  hence  rarely 
consulted.  These  data  should  be  so  ar- 
ranged that  they  shall  not  be  omitted  in 
estimating  the  foundations  of  reasoning 
in  clinical  medicine.  Students  should 
have  no  fascinating  theories  taught  them, 
only  facts,  truths,  and  laws.  We  need 
teachers  who  shall  glean  the  best  conclu- 
sions and  observations  of  research  work- 
ers and  present  these  to  the  undergrad- 
uate in  a  systematic  fashion  and  in  ten- 
able formulations,  unmarred  by  brilliant 
theories. 

A  constantly  recurring  error  is  a  tend- 
ency to  assume  one  or  more  symptoms  as 
pathognomonic,  and  lose  sight  of  the 
symptom  complex.  A  single  obvious 
symptom  may  predominate  in  a  well- 
defined  disease,  but  it  may  also  be  an 
expression,  or  feature,  of  many  patho- 
logical processes;  at  other  times  it  may 
be  the  result  of  previous  degenerative 
changes,  a  psychosis  or  expression  of 
metabolic  disability,  or  the  result  of  neu- 
rotic disturbance. 

Teaching  should  be  from  fundamen- 
tal principles  of  growth  toward  earliest 
evidence  of  change  from  the  normal 
process.  The  governing  innervation, 
direct  and  vasomotor,  should  be  ex- 
plained step  by  step;  hence  the  normal 
variations  in  the  blood  supply,  lymph 
circulation,  cellular  equipoise,  and  the 
slightest  evidences  of  divergences  from 
this  may  go  so  far  as  to  merge  into  ab- 
normalities, producing  changes  recog- 
nizable as  disorder,  thence  passing  on  to 
structural  alterations  sufficiently  exten- 


sive to  be  regarded  as  pathological,  and 
finally  into  lesions. 

When  more  students  are  trained  to 
proceed  inductively  along  the  foundation 
levels  of  biology,  embryology,  and  physi- 
ology, and  thence  ascend  to  pathological 
planes,  more  light  will  be  afforded  by 
which  to  apply  therapeutic  principles. 
More  must  be  known  of  normal  growth 
and  the  phenomena  of  development.  He 
tells  how  those  of  rapid  growth  often  fail 
of  systematic  development  in  several 
directions.  Disease  processes,  infections, 
accidents  of  nutrition,  environmental  in- 
fluences, all  tend  to  initiate  and  empha- 
size minor  departures  from  health.  It 
is  important  to  recognize  the  onset  of 
functional  derangement,  and  we  must 
also  always  direct  our  attention  to  the 
even  higher  duty  of  noting  morbid  phe- 
nomena of  the  mind  and  morals. 

It  should  be  the  aim  of  the  clinical 
teacher  to  emphasize  the  urgency  of  ob- 
taining the  earliest  possible  indications 
or  preomens  of  departures  from  normal 
functionations,  especially  in  children. 
The  phenomena  of  onset  are  too  little 
understood  or  appreciated. 

During  the  period  of  plasticity  nu- 
merous influences  prevail  to  alter  growth 
and  development  by  which  the  founda- 
tion of  constitutional  weaknesses  is  often 
laid.  These  are  in  a  great  measure  pre- 
ventable. The  standard  for  the  paadiat- 
rist  is  the  ideal  child,  a  composite  picture 
of  normal  children,  but  from  this  there 
are  always  many  premissible  variants. 
The  subject  of  peculiar  and  exceptional 
children  is  .reviewed,  in  whom  are  shown 
physical  and  psychical  peculiarities. 
Without  a  fair  knowledge  of  these,  mis- 
takes are  inevitably  made. 

Especial  attention^is  called  to  the 
value  of  palpation,  used  in  a  broader 
sense  than  that  generally  accepted,  and 
a  most  careful  estimation  of  states  of 


CHILDREN,  DIAGNOSIS  OF  DISEASE  IN. 


CONSTIPATION. 


23 


resistance,  the  tone  of  the  tissues,  skin, 
and  other  structures  is  pleaded  for,  the 
fact  being  recalled  that  these  are  often 
of  more  significance  in  the  infant  than 
in  the  adult.  "The  hand  should  be  laid 
flat  down  on  the  part  quietly  and  gently, 
with  a  lingering  touch  permitting  an  ap- 
preciable amount  of  time  to  elapse  for 
sense  impressions  to  grow  and  become 
deliberately  interpreted."  Thus  many 
points  are  revealed  and  organs  can  be 
better  outlined  than  by  percussion. 

Few  children  are  too  young  to  betray, 
at  some  time  or  other,  tension  rigidities, 
transient  or  protracted,  yet  significant  of 
alterations  in  tissue  from  lymph  stasis, 
nerve  irritation,  or  psychical  exaltations 
or  depressions.  The  importance  of  ex- 
amining the  tissues  of  the  back  is  urged, 
because  here  much  is  revealed,  reflected 
through  the  action  of  the  vasomotor 
nerves  through  the  posterior  divisions  of 
the  spinal  cord.  Early  and  pronounced 
disturbances  of  the  viscera  are  thus  ex- 
hibited, reflected  from  the  centers  in  the 
cord  from  whence  the  arteriomotor  in- 
nervation arises,  and  thereby  significant 
changes  takes  place.  There  is  a  compen- 
satory relationship  between  the  circula- 
tion of  the  tissues  of  the  back,  lying  ad- 
jacent to  certain  areas  and  segments  of 
the  spinal  cord,  and  the  viscera.  Thus 
the  phenomena  of  disease  can  be  studied 
from  the  standpoint  of  the  central  nerv- 
ous system  and  also,  as  ordinarily  done, 
along  the  line  of  peripheral  phenomena. 
Thus  one  avenue  of  exploration  is  sup- 
plemented by  the  other. 

The  principle  on  which  this  method  of 
diagnosis  is  founded  is  upon  well-estab- 
lished facts  familiar  to  physiologists,  but 
not  yet  applied  by  clinicians.  Relaxa- 
tion of  the  lateral  and  posterior  spinal 
ligaments,  due  to  nutritive  faults,  pro- 
duces often  the  appearance  of  dislocation, 
curvatures,   etc.,   apparent   rather   than 


real,  and  these  phenomena  disappear  by 
restoration  of  the  tonus  of  the  tempor- 
arily altered  tissues.  Thus  any  agent 
which  causes  vasoconstriction  in  the  tis- 
sues of  the  back  near  the  spinal  column 
will  produce,  conversely,  by  the  law  of 
compensation,  dilatation  of  the  vessels  in 
the  cord,  and  of  the  organs  and  parts 
beyond  the  line  of  innervation.  It  is 
plain  to  the  perceptive  hand  that  these 
muscles  are  affected  and  according  to 
definite  laws  of  innervation,  showing 
conclusively  that  where  certain  organs  or 
parts  are  deranged  the  corresponding 
muscles  will  show  definite  changes. 

The  article  closes  by  a  summary  of  the 
changes  to  be  ascertainable  by  the  x-rays. 
It  is  to  be  continued  at  a  future  time. 
J.  Madison  Taylor  (Medical  News,  De- 
cember 17,  1904). 

CONSTIPATION,  DIETETICS  IN  THE 
TREATMENT   OF. 

The  treatment  of  habitual  constipation 
has  to  begin  with  :  1.  The  correction  of 
bad  habits.  2.  Regulation  of  the  diet. 
The  object  of  the  diet  is  to  avoid  con- 
centrated animal  food  and  to  favor  the 
vegetables  rich  enough  in  coarse  fiber  to 
make  sufficient  bulk  for  the  physical 
stimulation  of  the  intestines,  and  rich  in 
elements  for  the  formation  of  organic 
acids  for  the  chemical  stimulation  of  the 
intestines.  3.  The  liberal  use  of  water, 
at  least  six  to  eight  glasses  in  twenty- 
four  hours,  should  not  be  forgotten. 

If  these  principles  are  followed,  it  is 
not  difficult  at  all  to  make  up  a  diet  for 
the  patient.  In  very  pronounced  cases 
of  faulty  habit  and  diet  their  correction 
may  be  sufficient.  But  in  most  cases 
food  stuff  especially  rich  in  bulk  and  or- 
ganic acids  will  have  to  be  selected. 

As  an  example  of  such  a  diet,  a  break- 
fast may  consist  of  fruit,  some  cereal 
with  cream  and  sugar,  but  no  commercial 


24 


CORNEAL  THERAPEUTICS. 


DIAPHORESIS. 


DIPHTHERIA. 


predigested  foods,  as  "Grape  Nuts"  or 
"Force."  Eye  bread,  with  much  butter ; 
besides  this,  some  meat  or  eggs.  For 
dinner,  besides  soup,  and  meat  or  fish, 
plenty  of  green  vegetables,  as  spinach  or 
cabbage,  beets,  turnips,  potatoes,  beans, 
peas,  and  again  rye  bread  and  butter; 
as  dessert,  a  saucer  of  prunes,  but  it  may 
change  off  with  some  pudding.  Supper 
should  be  rather  light,  and  may  consist 
of  cold  meat,  rye  bread  and  butter,  and 
some  stewed  fruit;  again  prunes  and 
plums  preferred. 

The  success  of  such  a  treatment  is  very 
remarkable,  and  results  are  seen  in  a  few 
days  even  in  cases  of  long  standing.  Of 
course,  in  such  cases,  the  writer  prefers 
a  combination  of  dietetic  and  physical 
therapeutics,  especially  electricity.  This 
combination  will  give  most  brilliant  re- 
sults, but  the  dietetical  treatment  will 
have  to  remain  the  fundamental  one, 
without  which  success  will  hardly  be  ob- 
tained. Sigismund  Cohn  (Journal  of 
Advanced  Therapeutics,  December,  1 9 04 ) . 

CORNEAL  THERAPEUTICS. 

The  low  temperature  of  the  normal 
cornea  (about  18°  F.  below  body  tem- 
perature) inhibits  the  growth  of  pyo- 
genic micro-organisms,  and  the  continu- 
ous closure  of  the  lids  from  photophobia 
or  the  use  of  bandages  raises  the  tem- 
perature to  a  point  not  conducive  to  re- 
pair, but  conducive  to  bacterial  growth. 
In  the  treatment  of  corneal  abrasions  or 
ulcers,  therefore,  the  photophobia  should 
be  specially  attended  to,  and  the  use  of 
bandages  avoided.  Cocaine  ointment  is 
excellent  to  combat  the  photophobia. 
The  removal  of  photophobia  restores  the 
very  important  function  of  winking,  by 
means  of  which  the  wound  is  cleansed  of 
germs  and  their  poisonous  products.  A. 
McGillivray  (British  Medical  Journal, 
November  12,  1904). 


DIAPHORESIS  IN   OPHTHALMOLOGY. 

The  greatest  utility  of  diaphoretics  is 
in  the  acute  congestive  and  exudative  le- 
sions of  the  uveal  tract.  They  are  useful 
in  retinal  detachment  produced  by  exu- 
date from  choroidal  vessels  during  the 
course  of  acute  choroido-retinitis.  Judg- 
ing from  reported  cases,  they  are  also 
useful  in  the  retinal  detachment  of  high 
myopia.  It  is  doubtful  if  restoration  of 
function  in  the  detached  retina  is  useful 
or  permanent.  Diaphoretics  are  useful 
in  alcohol-tobacco  amblyopia  and  prob- 
ably in  other  forms  of  toxic  blindness. 
They  influence  to  a  slight  extent  only, 
if  at  all,  lesions  of  the  cornea  and  sclera, 
and  are  useless  in  atrophic  and  cicatricial 
lesions.  Hiram  Woods  (Journal  of  the 
American  Medical  Association,  Decem- 
ber 24,  1904). 

DIPHTHERIA,  LESIONS  OF  THE  KIDNEY 
IN. 

The  writer  records  a  large  number  of 
observations  of  the  urine  of  diphtheritic 
children  with  a  smaller  number  of  mi- 
croscopical and  macroscopical  examina- 
tions of  the  kidneys  of  patients  dead 
from  diphtheria.  In  only  22  cases 
was  it  possible  to  measure  accurately 
throughout  the  illness  the  amount  of 
urine  passed.  In  half  these  cases  the 
amount  was  normal,  in  the  other  half 
it  was  diminished.  This  diminution  was 
not  usually  very  great.  In  4  cases  out 
of  more  than  300  there  was  suppression 
of  urine,  and  all  4  proved  fatal.  The 
diminution  in  the  amount  of  urine 
varied  irregularly,  and  sometimes  re- 
turned after  normal  quantities  had  been 
passed  for  several  days.  In  10  of  the 
11  cases  oliguria  was  accompanied  by 
albuminuria,  and  when  the  urine  be- 
came more  plentiful  the  albumin  showed 
a  tendency  to  disappear.  Usually  a 
diminution  in  the  amount  of  urine  was 


DIPHTHERIA,  LESIONS  OF  THE  KIDNEY  IN. 


25 


accompanied  by  a  still  better  marked 
increase  in  the  specific  gravity,  which  in 
3  cases  was  observed  to  be  1.030  or  1.031. 
The  author  attributes  the  increase  of 
specific  gravity  to  an  excess  of  urea, 
partly  from  the  febrile  process,  but 
chiefly  due  to  the  antidiphtherial  serum, 
being  the  result  of  the  serum  itself  and 
not  of  the  antitoxin  contained  in  it.  Ob- 
servers differ  as  to  the  effect  of  the  in- 
jection of  antitoxic  serum  on  the  amount 
of  urine  secreted,  and  the  author  consid- 
ers that  it  produces  no  effect  in  either 
direction.  It  is  noted  that  phosphatu- 
ria  was  very  frequent,  and  often  very 
well  marked,  but  that  subject  is  not 
further  investigated.  Albumin  was 
found  in  32  out  of  70  cases  in  which  a 
systematic  daily  search  was  made  of  it. 
It  often  appeared  on  the  fourth  day, 
but  might  not  be  found  until  as  late  as 
the  seventeenth  day.  When  present  at 
all  it  usually  lasted  several  days.  Out 
of  the  32  cases,  20  were  cases  with  severe 
toxaemia.  Severe  cases  without  albu- 
minuria were  rare,  and  so  were  very 
slight  cases  with  albuminuria,  but  there 
were  examples  of  both  these  kinds.  The 
author's  proportion  of  cases  with  albu- 
minuria is  much  lower  than  that  given 
by  some  other  observers — notably  those 
whose  statistics  deal  with  cases  occurring 
before  the  introduction  of  serum  ther- 
apy. The  author  dwells  on  this  fact  in 
opposition  to  the  prevalent  opinion  that 
either  directly  or  indirectly  serum  ther- 
apy has  caused  an  increase  in  the  num- 
ber of  cases  with  albuminuria.  A  fur- 
ther fact  bearing  on  the  question  is  that 
the  author  has  frequently  noted  the  dis- 
appearance of  albumin  from  the  urine 
on  the  day  following  injection. 

Acetone  was  found  in  20  out  of  HO 
cases  in  which  it  was  looked  for  sys- 
tematically, and  in  many  of  these  cases 
it  was  abundant.    It  may  be  present  only 


once,  or  there  may  be  acetonuria  for  as 
long  as  sixteen  days.  The  author  adopts 
Bottazzi's  theory  that  the  diphtherial 
toxin  circulating  in  the  urine  infiltrates 
the  protoplasm  of  the  cells,  increasing 
the  disintegration  of  their  proteid  con- 
stituents, and  at  the  same  time  hinders 
the  complete  oxidation  of  the  results  of 
this  disintegration,  so  causing  azoturia 
and  acetonuria.  Like  albuminuria,  ace- 
tonuria has  a  tendency  to  diminish  or 
disappear  very  soon  after  the  injection 
of  antidiphtherial  serum. 

The  author  attaches  very  great  impor- 
tance to  the  examination  of  the  urinary 
sediment,  and  states  that  the  presence  of 
morphological  elements  in  it  is  the  dis- 
tinguishing characteristic  of  the  urine  of 
those  suffering  from  diphtheria.  Out  of 
70  cases,  there  were  only  8  in  which  he 
failed  to  find  such  elements.  Thus,  they 
were  present  in  32  out  of  38  cases  in 
which  there  was  no  trace  of  albumin 
from  first  to  last,  as  well  as  in  all  the 
32  cases  in  which  albumin  was  found. 
These  elements  were,  in  the  great  ma- 
jority of  cases,  leucocytes  and  renal  epi- 
thelium cells.  Often  bladder  cells  were 
found,  very  rarely  granular  or  hyaline 
casts.  The  leucocytes  were  granular  and 
refracting,  often  showing  no  nucleus. 
They  may  appear  in  masses  of  varying 
number  and  size.  The  renal  cells  are 
usually  in  good  preservation,  but  may  be 
swollen  and  granular.  These  results  are, 
according  to  the  author,  confined  to 
diphtherial  urines,  and  are  practically 
never  found  in  other  febrile  diseases, 
such  as  bronchitis,  pneumonia,  enteric. 
They  usually  last  for  at  least  a  week,  and 
sometimes  almost  for  a  month.  They 
must  be  taken  as  an  index  of  the  severity 
of  the  renal  lesion. 

From  the  histories  of  11  cases  the  au- 
thor deduces  that  the  kidneys  are  almost 
always  injured  in  an  attack  of  diphthe- 


26 


DUODENAL  ULCER  AND  TREATMENT. 


DYSPEPSIA,  CHRONIC. 


ria,  and  that  the  degree  of  the  renal 
change  depends  on  the  severity  of  the  at- 
tack rather  than  on  the  stage  which  it 
lias  reached.  The  renal  changes  are  very 
strictly  proportional  to  the  severity  of 
the  intoxication.  The  changes  fall 
mainly  on  the  renal  parenchyma,  where 
the  epithelial  cells  are  swollen  and  gran- 
ular, and  the  nuclei  stain  badly.  Some- 
times there  is  a  leucocytic  infiltration  of 
the  parenchyma,  not  usually  of  a  very 
severe  nature. 

Haemorrhages  are  very  rare.  In  very 
mild  cases  (fatal  through  some  accident, 
such  as  laryngo-stenosis)  changes  may  be 
confined  to  the  epithelium  of  the  con- 
voluted tubules.  In  more  severe  cases 
the  change  involves  also,  first,  the  as- 
cending limbs  of  Henle's  loop,  and  in 
the  most  severe  cases  the  glomeruli  also 
may  be  involved.  The  collecting  tubules 
almost  always  remain  unaltered.  The 
diphtheria  toxin  has  a  special  predilec- 
tion for  the  renal  epithelium,  and  leaves 
the  renal  vessels  almost  immune. 

These  microscopical  observations  on 
the  kidney  agree  with  the  results  pre- 
viously described  which  the  author  ar- 
rived at  by  examining  the  urinary  sedi- 
ment. Probably  it  is  mainly  by  the  epi- 
thelium of  the  convoluted  tubules  that 
the  toxin  is  excreted.  The  author  sug- 
gests, since  the  toxin  is  excreted  by  the 
epithelium  of  the  tubules,  probably  the 
glomerular  changes  noted  in  some  severe 
cases  are  not  caused  directly  by  the  diph- 
theria toxin,  but  by  some  nondiphtherial 
micro-organism  circulating  in  the  blond. 
Mario  Flamini  (Tl  Policlin.,  September, 
1904,  from  British  Medical  Journal, 
November  19,  1904). 

DUODENAL  ULCER  AND  ITS  TREATMENT. 

Duodenal  ulcers  are  not,  very  uncom- 
mon. As  far  as  the  writer  has  seen  them, 
they  are  single  and  more  frequent  in  men 


than  in  women.  Perforation  may  take 
place  and  acute  symptoms  appear,  or 
they  may  heal,  and  by  cicatrization  lead 
to  symptoms  of  chronic  duodenal  ob- 
struction. The  sequoias  of  a  healed  ulcer 
may  be  so  remote  that  the  symptoms  are 
mistaken  for  those  due  to  cancer  of  the 
pylorus,  and  the  patient  is  allowed  to 
drift  from  bad  to  worse  under  the  er- 
roneous notion  that  he  is  bound  to  die. 
There  is  no  means  of  recognizing  the 
existence  of  a  duodenal  ulcer,  in  a  great 
many  cases,  until  it  perforates  or  until 
the  results  of  its  cicatrization  become 
manifest. 

The  treatment  of  duodenal  ulceration 
consists  in  the  direct  suture  of  a  perfo- 
rated ulcer,  the  prognosis  being  less  fa- 
vorable than  in  similar  cases  of  perfo- 
ration, and  the  performance  of  gastro- 
jejunostomy in  cases  of  dilated  stomach 
due  to  duodenal  constriction,  the  prog- 
nosis being  the  most  favorable  of  all  the 
conditions  for  which  this  operation  is 
performed  at  the  present  time.  D'Arcy 
Power  (British  Medical  Journal,  De- 
cember 17,  1904). 

DYSPEPSIA,    CHRONIC,    SURGICAL    CURE 
OF    CERTAIN    CASES    OE    SO-CALLED. 

The  majority  of  cases  of  so-called 
"chronic  dyspepsia,"  "gastralgia,"  "nerv- 
ous gastralgia,"  "neuralgia  of  the  stom- 
ach," "cardialgia,"  and  "hyperchlorhy- 
dria"  are,  in  fact,  cases  of  ulcer  or  the 
organic  consequences  of  ulcer  of  the 
stomach  or  duodenum,  or  of  both. 

Cases  presumably  amenable  to  medical 
treatment  should  be  cured  in  from  five 
to  six  weeks,  after  which  time,  if  not 
cured,  they  should  be  placed  in  the  sur- 
gical category,  while  haemorrhagic  cases 
should  be  operated  upon  without  the 
delay  prescribed  by  medical  writers. 

Surgical  ulcer  of  the  stomach,  if  neg- 
lected, may  develop  adhesions,  perfora- 


EMBOLISM  FOLLOWING  OPERATION.        ENDOCARDITIS.        ENTERITIS. 


27 


tions,  haemorrhages,  or  cancer,  or,  in  the 
absence  of  these,  may  provoke  sepsis  and 
anosmia,  which,  if  uncorrected  by  opera- 
tion, may  prove  fatal. 

It  is  important,  therefore,  that  the 
cases  should  be  promptly  brought  to  op- 
eration, which,  without  reference  to  de- 
tails, should  establish  rest  and  maintain 
drainage  for  the  diseased  organ.  The 
comfortable  after-course  of  these  cases, 
the  low  primary  mortality,  and  the  per- 
manent curative  results  following:  the 
operation  comprise  its  complete  justifica- 
tion. C.  A.  L.  Eeed  (Cincinnati  Lancet- 
Clinic,  November  26,  1904). 

EMBOLISM  FOLLOWING  OPERATION. 

Thrombosis  and  embolism  are  more 
common  after  operations  in  the  pelvis 
than  after  operations  in  any  other  part 
of  the  body.  It  is  possible  that  many 
cases  of  pleurisy,  pneumonia,  and  pul- 
monary abscess  following  operation  are 
due  to  emboli.  Large  emboli  almost  al- 
ways cause  speedy  death  by  syncope  or 
asphyxia ;  very  small  emboli  usually  run 
a  favorable  course.  Any  sudden  increase 
in  pulse  rate  during  convalescence,  tem- 
perature remaining  about  normal,  should 
remind  us  of  the  possibility  of  thrombo- 
sis. If  there  are  evidences  of  phlebitis 
or  thrombosis,  rest  must  be  absolute. 
S.  S.  Dearborn  (Annals  of  Gynaecology 
and  Paediatry,  Xovember,  1904). 

ENDOCARDITIS,  INFECTIVE,   COURSE   OF. 

In  addition  to  the  pyaemic  and  the 
typhoid  types  of  infective  endocarditis, 
there  is  a  third  and  important  one,  the 
cardiac  type.  In  this  type  the  duration 
may  be  comparatively  long — months 
rather  than  weeks.  It  is  often  difficult 
to  decide  whether  the  cardiac  symptoms 
are  entirely  due  to  old  fibrosis  of  the 


valves,  or  whether  there  are  fungating 
masses  on  the  valves  as  well.  Probably 
the  additional  symptoms  most  suggestive 
of  the  latter  are  some  pyrexia,  multiple 
emboli,  splenic  enlargement,  and  pro- 
gressive anaemia. 

There  is  no  sharp  line  of  demarcation 
between  simple  and  infective  endocar- 
ditis; so  that  whereas  some  cases  of  en- 
docarditis are  slight,  and  recover  soon, 
and  others  are  very  severe,  and  die  soon, 
a  third  group  are  on  the  border-line  be- 
tween the  two,  and  may  continue  doubt- 
ful as  to  their  prognosis  for  weeks  and 
months;  and  may  even  recover  when 
they  seemed  certainly  to  have  fungating 
endocarditis. 

Pyrexia  in  the  ordinary  sense  is  not 
necessarily  present,  although  the  patient 
is  suffering  from  fungating  endocarditis, 
in  which  connection  it  is  most  important 
to  remember  that  the  natural  body  tem- 
perature in  cases  of  old  valvular  heart 
disease  may  be  as  low  as  96.6°  F. ;  so 
that  what  may  be  normal  temperature  in 
normal  subjects  may  be  actual  pyrexia  in 
them.  Herbert  French  (Practitioner, 
December,  1901). 

ENTERITIS,   TRAUMATIC. 

Mucous  enteritis  is  a  syndrome,  acute 
or  chronic,  characterized  by  constipation, 
the  passage  of  glairy  mucus,  and  by 
paroxysmal  crises.  It  is  commonest  in 
women,  and  is  doubtless  greatly  influ- 
enced by  heredity.  The  writer  reports 
three  cases,  in  two  of  which  recovery  was 
only  partial  and  not  permanent.  The 
third  case  terminated  favorably.  All 
were  marked  by  constitutional  depres- 
sion, nervous  symptoms,  and  hysteria. 
The  first  two  cases  were  caused  by  strong 
lifting  movements,  the  third  by  a  fall, 
the  traumatism  affecting  the  region  of 
the  caecum  or  colon.    The  author's  treat- 


28 


EPILEPSY,  DENTITION  IN.  TREATMENT  OF. 


ment  is  tonic  by  iron,  strychnine,  and 
arsenic,  the  last  under  the  form  of  so- 
dium cacodylate;  gently  laxative  by  lic- 
orice powder,  sulphur,  castor  oil;  anti- 
spasmodic, by  cannabis  Indica.  An  old 
remedy,  buckthorn,  has  proved  valuable. 
Intestinal  lavements  may  be  required  in 
fcetid  diarrhoea  or  putrid  fermentation. 
In  pain  the  opiates  should  never  be  used, 
but  mustard  plasters,  hot  compresses,  etc. 
The  diet  should  be  that  usually  pre- 
scribed in  hyperchlorhydria.  Gentle 
massage  of  the  abdomen,  warm  baths, 
rest  in  the  open  air,  and  suggestive  ther- 
apy are  all  valuable.  Vinay  (Lyon  Me- 
dical, October  30,  1904). 

EPILEPSY,   DENTITION  IN. 

Difficult  dentition — i.e.,  the  piercing 
of  the  gums  by  the  tooth — may,  in  suit- 
able subjects,  constitute  a  sufficient  irri- 
tant to  cause  convulsions.  In  suitable 
subjects  these  convulsions  may  ultimately 
lead,  to  epilepsy.  By  "suitable  subjects" 
the  writer  means  infants  who  inherited 
a  neuropathic  tendency  to  disease ;  whose 
parents  had  epilepsy  or  insanity,  or  who 
were  alcoholic,  or  suffered  from  some 
other  general  vice  that  could  be  trans- 
mitted to  the  offspring  in  some  form 
capable  of  vitiating  its  powers  of  resist- 
ance to  disease.  The  writer  does  not  be- 
lieve that  difficult  dentition  alone  in  a 
child  who  inherited  no  ancestral  taints, 
and  who  at  its  birth  is  free  from  a  tend- 
ency to  nervous  disease,  can  cause  epi- 
lepsy. Great  caution  must  always  be 
exercised  to  lay  the  true  cause  in  cases 
of  this  kind  where  it  belongs;  for  the 
reason  that  gastro-intestinal  disorders, 
the  sequela?  of  the  eruptive  fevers  and 
other  factors  common  at  this  age,  may 
produce  similar  results.  W.  P.  Sprat!  ing 
(Medical  News,  December  10,  1904). 


EPILEPSY,  TREATMENT  OF,  IN  CONNEC- 
TION WITH  AUTO-  AND  HETERO- 
TOXIS. 

Besides  every  measure  that  will  favor 
elimination,  the  dietary  should  be  regu- 
lated so  that  the  idiosyncrasies  of  the  in- 
dividual should  be  taken  into  account, 
but  nitrogenous  food  should  be  inter- 
dicted as  far  as  possible.  No  large  quan- 
tity of  food  shall  be  taken  at  any  one 
time.  If  intestinal  autotoxis  exists, 
cholagogues  and  appropriate  ferments, 
as  well  as  antiseptics,  shall  be  prescribed. 
Everything  should  be  done  to  prevent 
the  lighting  up  of  gross  intracerebral 
pathological  processes,  and  the  resulting 
formation  of  cholin.  The  equilibrium  of 
the  arterial  pressure  should  be  every- 
where maintained.  The  bromide  should 
be  given  only  in  doses  sufficient  to  di- 
minish the  activity  of  the  cortical  motor 
cells.  A.  McL.  Hamilton  (Medical  Kec- 
ord,  December  3,  1904). 

EPILEPSY,  TREATMENT  OF,  WITHOUT 
DRUGS. 

The  writer's  experience  in  investigat- 
ing the  causes  of  epilepsy  for  nearly 
twenty  years  lead  to  the  conclusion  that 
epilepsy  is  not  necessarily  an  organic  dis- 
ease; hence  there  is  always  hope  of  a 
radical  cure.  A  very  large  proportion  of 
epileptics  suffer  from  some  type  of  reflex, 
viz. :  ocular,  abdominal,  genital,  or  other 
local  sources  of  nervous  irritation.  Of 
these  reflexes,  the  eyes  are  unquestionably 
the  most  frequent  seat  of  trouble. 

No  medication  should  ever  be  em- 
ployed to  control  epileptic  convulsions 
until  every  possible  exciting  cause  has 
been  intelligently  sought  for  and  scien- 
tifically combated.  The  refraction  of  all 
epileptic  patients  should  first  be  care- 
fully determined  under  the  influence  of 
a  mydriatic.  The  author  usually  em- 
ploys homatrophine  to  dilate  the  pupils 


EPILEPSY,  TREATMENT  OF,  WITHOUT  DRUGS. 


29 


and  to  relax  the  accommodation.  If  in 
doubt  after  this  step,  he  invariably  uses 
atropine.  Such  tests  are  positive.  Many 
instances  have  been  seen  where  a  total 
cessation  of  fits  for  weeks  has  been  caused 
by  the  use  of  atropine  in  the  eyes.  Fur- 
thermore, the  effect  of  paralyzing  the 
accommodation  is  often  of  great  aid  in 
getting  a  patient  to  accept  a  strong  hy- 
permetropic glass  for  constant  use. 

It  is  usually  advisable  first  to  correct 
fully  the  refraction  of  epileptic  patients 
by  properly  prescribed  glasses,  and  to 
have  the  patient  wear  them  for  a  time, 
before  positive  conclusions  are  arrived 
at  regarding  any  maladjustments  of  the 
eye  muscles  (heterophoria.)  A  large 
proportion  of  epileptics  unquestionably 
suffer  from  heterophoria.  After  the 
correction  of  errors  of  refraction  by 
glasses  for  a  time,  the  tests  for  malad- 
justments of  the  eye  muscles  should 
again  be  made.  Such  tests  will  then  be 
far  more  reliable  and  trustworthy  than 
if  made  before  the  refractive  errors  have 
been  intelligently  corrected. 

The  author  considers  that  the  prescrib- 
ing of  glasses  to  correct  errors  of  refrac- 
tion is  vitally  important  in  the  treatment 
of  eyestrain.  It  should,  always  be  done 
most  accurately  and  scientifically.  It  ia 
imperative  to  do  this  first;  and  to  have 
patients  wear  glasses  for  refractive  errors 
constantly  for  some  time  (whenever 
marked  muscular  errors  exist)  in  order 
to  determine  if  they  are  modified  by  the 
refractive  correction.  Refractive  errors 
may  cause  apparent  heterophoria  in  a 
certain  proportion  of  cases;  and  proper 
glasses  may  sometimes  modify  genuine 
heterophoria.  There  is  indisputable 
proof  that  genuine  heterophoria  may  co- 
exist with  refractive  errors  (as  an  inde- 
pendent source  of  eyestrain),  and  it  may 
also  be  found  in  cases  where  absolutely 
perfect  refraction  exists. 


One  radical  and  permanent  cure  of 
genuine  epilepsy  without  drugs  offsets  a 
thousand  failures  as  proof  of  a  scien- 
tific discovery.  Modern  instruments  and 
modern  methods  of  eye  testing  are  in- 
dispensable to  the  eye  treatment  of  epi- 
lepsy. The  most  serious  refractive  errors 
and  muscular  defects  in  the  orbits  do  not 
necessarily  create  eye  symptoms;  even 
when  reflex  symptoms  produced  by  ex- 
isting eye  defects  are  extremely  severe. 

The  percentage  of  cure  of  chronic  epi- 
lepsy under  skilled  eye  treatment  will 
naturally  be  modified  greatly  by  the  ab- 
normal eye  conditions  found,  the  phys- 
ical condition  of  the  patient,  the  amount 
of  drugs  that  have  been  given  to  the  pa- 
tient, and  the  complications  that  may 
coexist  with  eyestrain.  No  one  is  ever 
justified  in  promising  to  an  epileptic  a 
complete  cure  of  epilepsy  by  any  method 
of  treatment.  Such  promises  are  only 
made  by  quacks,  or  by  irresponsible  and 
uneducated  persons.  The  general  con- 
currence of  medical  opinion  is  against 
the  curability  of  epilepsy  by  drugs.  Fits 
may  be  thus  held  in  check  for  long  or 
short  periods;  but  permanent  cures  of 
epilepsy  after  a  complete  cessation  of 
drugs  are  practically  unknown. 

To  colonize  epileptics  or  to  place  suf- 
ferers of  that  type  in  private  sanitariums 
without  any  investigation  of  their  eyes 
and  eye  muscles  cannot  be  too  strongly 
condemned,  in  the  author's  opinion. 

The  total  percentage  of  epileptics  who 
suffer  from  eyestrain  as  an  important 
factor  is  very  large,  after  first  deducting 
from  the  total  number  the  comparatively 
small  number  of  cases  that  owe  their 
epileptic  seizures  directly  to  some  or- 
ganic lesion  of  the  brain  or  to  a  depres- 
sion of  the  skull.  Almost  all  chronic 
epileptics  give  a  history  of  falls  that 
have  at  some  time  injured  the  head  in 
some  way.    Few  of  them,  however,  have 


30 


GASTROENTERITIS. 


GOUT. 


IMMUNITY. 


enough  depression  of  the  skull  to  make 
trephining  imperative,  and  in  every  such 
case  the  injury  must  have  preceded  any 
epileptic  seizures  to  make  it  probable 
that  the  fits  were  the  direct  result  of  the 
injury. 

The  duration  of  eye  treatment  in  epi- 
lepsy varies  from  three  months  to  three 
years.  Most  of  the  work  is  done  during 
the  first  six  weeks ;  but  long  intervals  of 
rest,  between  the  sucessive  operative 
steps  that  are  commonly  demanded,  often 
extend  the  period  of  treatment  over 
quite  a  long  period  whenever  the  con- 
vulsive seizures  are  not  totally  arrested. 
A.  L.  Eanney  (New  York  Medical  Jour- 
nal and  Philadelphia  Medical  Journal, 
December  3,  1904). 

GASTRO-ENTERITIS,   BUTTERMILK   IN. 

Infants  with  severe  gastro-intestinal 
troubles  improve  to  a  remarkable  extent 
when  put  on  buttermilk.  In  22  cases  of 
acute  gastro-enteritis,  including  8  very 
severe  ones,  all  the  children  recovered 
rapidly,  as  also  3  adults  with  muco-mem- 
branous  enterocolitis  and  a  large  number 
of  children  with  chronic  gastro-intestinal 
troubles.  The  toxi-infectious  symptoms 
vanished  in  the  acute  cases  in  less  than 
twenty-four  hours.  Dccherf  (Semaine 
Medicale,  vol.  xxiv,  No.  44,  1904). 

GOUT,  ETIOLOGY  AND  PATHOLOGY  OP. 

Heredity,  overindulgence  in  malt  liq- 
uors, poor  food  with  bad  hygienic  sur- 
roundings or  overeating  with  insufficient 
exercise,  and  lead  intoxication  are  un- 
doubtedly important  predisposing  etio- 
logic  factors  in  the  production  of  gout. 
An  anatysis  of  54  cases  treated  in  the 
medical  wards  of  the  Johns  Hopkins 
Hospital  shows  that  the  overuse  of  fer- 
mented beverages  seems  to  be  the  most 
potenl   factor  in  this  country.     Gout  in 


the  United  States  appears,  therefore,  in 
the  majority  of  cases  to  be  acquired,  or 
"freehold,"  rather  than  "copyhold,"  or 
inherited. 

Studies  of  the  metabolism  in  gout 
have  as  yet  afforded  no  satisfactory  ex- 
planation for  the  causation  of  the  dis- 
ease. There  seems  very  little  doubt  but 
that  it  is  due  to  disturbance  in  the 
metabolism  of  the  "endogenous"  and 
"exogenous"  purins.  As  yet  there  is  not 
sufficient  experimental  evidence  to  war- 
rant the  abandoning  of  the  theory  that 
the  manifestations  are  in  large  part  due 
to  disturbances  in  uric  acid  metabolism. 
Practically  all  researches  agree  in  show- 
ing that  the  blood  in  gout  contains  a 
marked  excess  of  uric  acid,  and  the  bal- 
ance of  opinion  is  in  favor  of  the  view 
that  this  excess  is  due  to  deficient  ex- 
cretion on  the  part  of  the  kidneys.  The 
alkalinity  of  the  blood  apparently  is  not 
diminished,  as  Garrod  supposed. 

The  joint  manifestations  are  essen- 
tially clue  to  the  deposition  of  the  uric 
acid  combinations  of  the  blood  in  the 
form  of  the  c^stalline  sodium  biurate. 
Whether  a  local  tissue  necrosis  is  pri- 
mary or  secondary  to  this  deposition  is  a 
question  still  in  dispute.  Nephritis,. usu- 
ally of  a  chronic  interstitial  type,  arterio- 
sclerosis, myocarditis,  pericarditis,  and 
emphysema  are  the  other  most  frequent 
pathological  findings.  T.  B.  Futcher 
(Journal  of  the  American  Medical  Asso- 
ciation, December  3,  1904). 


IMMUNITY,     INHERITED,     INSTEAD     OF 
INHERITED  PREDISPOSITION. 

The  writer  has  been  much  impressed 
with  the  variations  in  the  frequency  and 
virulence  of  the  affections  noted  among 
various  races.  Others  -have  explained 
ibis  by  "inherited  predisposition,"  but 
he  thinks  that  a  much  better  explanation 


INTERMITTENT  CLAUDICATION. 


INTERNAL   HEMORRHAGE. 


31 


is  an  "inherited  immunization."  His 
idea  is  that  all  infectious  diseases  have 
a  tendency  to  diminish  in  virulence. 
Diseases  pass  through  three  phases :  The 
miasmatic  phase, — that  is,  when  they  are 
transmitted  by  insects  able  to  travel  over 
considerable  territory.  Then,  as  they 
become  less  malignant,  they  can  be  trans- 
mitted only  by  direct  contact,  and  they 
are  called  "contagious."  Then,  as  they 
become  still  less  malignant,  they  require 
still  more  intimate  contact  for  transmis- 
sion, and  are  termed  "venereal."  All  in- 
fectious diseases  are  destined  to  disap- 
pear gradually  from  the  earth,  but  they 
retire  in  good  order,  obedient  to  these 
laws  of  becoming  more  benign,  more  in- 
frequent, and  more  venereal.  The  cradle 
of  a  disease  should  be  sought,  therefore, 
in  races  which  have  passed  through  these 
stages  and  have  acquired  an  inherited 
immunity,  so  that  these  races  are  most 
exempt  from  the  disease.  Immunization 
by  saturation  with  the  virus  does  not 
seem  to  impair  the  general  health. 
"Nature  strikes  with  her  hand,  but  cures 
with  her  feet."  The  author  calls  atten- 
tion to  the  amazing  immunity  of  the 
natives  of  Mexico  to  syphilis  and  to 
wound  infection.  Their  bare  legs  always 
have  some  scratch  or  sore,  and  these 
small  ulcerations  in  time  have  induced 
an  immunity  to  wound  infections.  The 
author  thinks  that  their  immunity  to 
syphilis  is  also  due  to  inherited  immu- 
nization. There  is  an  extremely  mild 
venereal  affection  observed  among  them, 
and  this,  he  thinks,  is  the  relics  of  ma- 
lignant syphilis  in  preceding  centuries. 
It  is  liable  to  transmit  malignant  syph- 
ilis to  foreigners.  Diseases  can  be  ex- 
terminated only  by  inherited  immuniza- 
tion. This  theory  explains  the  successes 
of  serotherapy.  0.  Effertz  (Janus,  vol. 
ix,  No.  9 ;  Journal  of  the  American  Med- 
ical Association,  December  17,  1904). 


INTERMITTENT  CLAUDICATION. 

Intermittent  claudication  is  a  far  more 
frequent  symptom  complex  than  gener- 
ally recognized.  It  is  doubtless  fre- 
quently and  freely  confounded  with 
sciatica,  neuralgia,  and  rheumatism. 
Careful  and  detailed  inquiry  into  the 
symptoms  which  usually  come  on  while 
walking  and  are  absent  when  at  rest, 
together  with  their  intermittency,  should 
lead  to  a  suspicion  of  the  diagnosis ;  this 
will  be  made  absolutely  by  finding  that 
pulsation  is  absent  in  one  or  more  distal 
arteries  (dorsalis  pedis  and  tibialis  pos- 
ticus) of  one  or  both  legs.  The  pain  is 
of  vascular  origin  and  due  to  an  arteritis 
plus — in  many  cases — angiospasm  of  the 
affected  vessel. 

The  various  internal  viscera  may  suf- 
fer from  such  an  angiospasm  when  their 
vessels  are  sclerosed,  the  most  prominent 
prototype  being  the  heart  in  the  common 
condition,  angina  pectoris.  Total  occlu- 
sion of  the  vessels,  as  occasionally  found 
in  intermittent  claudication,  may  lead 
to  gangrene  of  an  extremity.  Early  rec- 
ognition is  essential,  in  order,  by  appro- 
priate treatment,  to  prevent  this  dire 
and  frequent  complication.  A.  J.  Patek 
(Medical  News,  December  3,  190-1). 

INTERNAL  HEMORRHAGE. 

It  is  necessary  to  bear  in  mind  that 
the  direct  indications  for  treatment  vary 
with  the  individual  case.  These  indica- 
tions include  the  source  of  the  hasmor- 
rhage,  the  condition  of  the  circulation, 
and  the  amount  of  blood  lost.  In  cases 
of  total  collapse,  alcohol  and  strychnine 
should  probably  prove  of  value.  Faint- 
ing from  loss  of  blood  may  not  in  itself 
be  an  indication  for  medical  treatment, 
for  the  value  of  this  condition  in  induc- 
ing thrombosis  is  known. 

The  use  of  the  vegetable  and  mineral 
astringents  in  those  cases  in  which  the 


32 


INTERNAL  HEMORRHAGE. 


IRON,  THERAPEUTIC  VIRTUES  OF. 


bleeding  point  can  be  reached  directly  is 
highly  illogical.  The  same  is  true  of  the 
use  of  the  mineral  acids.  Aconite  ap- 
proaches the  action  of  this  group  on  the 
circulation,  without  the  untoward  local 
effects. 

Ergot  seems  distinctively  harmful  in 
pulmonary  haemorrhage,  and  from  its  ac- 
tion can  scarcely  prove  of  any  value  in 
other  than  uterine  bleeding. 

Hydrastis  has  some  value  in  similar 
conditions.  The  susceptibility  of  the 
splanchnic  area  to  vasomotor  influence 
might  be  utilized  by  administering  hy- 
drastis  and  strychnine  in  bleeding  of  this 
region. 

The  author  has  never  seen  noteworthy 
or  conclusive  results  follow  the  employ- 
ment of  gelatin  or  calcium  chloride. 
Normal  salt  solution  is  undoubtedly  a 
valuable  agent,  and  immediate  response 
often  follows  its  use.  Poor  success  has 
attended  the  use  of  suprarenal  extract 
administered  for  its  internal  haemostatic 
effect,  and  the  author  believes  that  the 
indications  for  its  employment  are  dis- 
tinctly local. 

There  is  great  reliance  to  be  placed  on 
rest  and  quiet  for  the  patient  who  is 
bleeding,  and  often  this  will  suffice. 
Collateral  measures,  ligation  of  the 
limbs,  change  of  posture,  etc.,  are  of 
great  service.  Next  in  importance 
should  be  placed  morphine  to  induce 
quiet.  In  those  patients  whose  circula- 
tion is  powerful,  aconite  is  of  unques- 
tioned value.  In  gastric  haemorrhage 
there  is  a  great  tendency  to  employ  the 
astringents.  It  is  well  to  mention  the 
possibility  of  their  reaching  the  bleed- 
ing point,  the  stomach  being  filled  with 
blood  and  often  with  partly  digested 
food.  Suprarenal  extract,  while  at  times 
serviceable  in  such  conditions,  may  fail 
for  the  same  reason.  Many  of  the  drugs 
advised  are  nauseous  and  should  be  espe- 


cially avoided ;  emetics  or  drugs  disturb- 
ing the  stomach  are  only  likely  to  cause 
increased  bleeding,  owing  to  the  physical 
strain  of  the  emesis.  T.  L.  Coley  (Jour- 
nal of  the  American  Medical  Association, 
December  24,  1904). 

IRON,   THERAPEUTIC  VIRTUES  OF. 

In  the  present  state  of  combined  scien- 
tific and  clinical  knowledge  the  general 
results  of  all  collective  research  on  the 
internal  administration  of  iron  go  to 
show  that,  while  the  preparations  of  this 
metal  form  a  practically  specific  means 
of  cure  in  the  anaemia  of  chlorosis,  they 
are  not  so  fully  to  be  relied  on  in  the 
management  of  other  varieties.  Clinical 
evidence  also  goes  to  prove  that,  in  order 
to  obtain  the  full  benefit  of  its  blood- 
making  powers,  free  action  of  the  bowels 
must  be  maintained  throughout;  and 
that  they  are  most  effectively  grasped 
when  the  administration  of  iron  is  com- 
bined with  that  of  arsenic.  The  other 
actions  of  iron  salts  which  have  from 
time  to  time  been  utilized  in  clinical 
medicine  are  well  known  in  a  general 
way  to  all  practitioners,  and  are  not  of 
sufficient  importance  to  the  present  state 
of  our  knowledge  for  any  critical  dis- 
cussion. The  antiseptic  value  of  ferrous 
sulphate  is  still  recognized ;  and  it  was 
probably  some  foreshadowing  of  such 
property  which  brought  Velpeau — long 
before  the  scientific  establishment  of 
antisepsis — to  announce'  its  efficacy  in 
the  treatment  of  erysipelas;  locally  as 
an  ointment  and  a  lotion,  and  internally 
as  a  general  tonic  remedy.  Also  the 
dictum  of  the  famous  syphilographer, 
Eicord,  that  the  "tartrate  ferrico-potas- 
sique"  was  "the  born  enemy  of  phage- 
dena," in  the  treatment  of  which  he  used 
this  salt  both  locally  ancT  generally,  owed 
its  genesis  pretty  surely  to  some  corre- 
sponding revelation  of  the  light  to  come. 


LEUCOCYTES,  DIAGNOSTIC  VALUE  OF. 


LEUKEMIA. 


33 


The  haemostatic  (coagulative)  powers  of 
some  of  the  ferric  salts,  and  the  mildly 
caustic  action  of  a  few  of  them,  are 
familiar  to  all  practitioners.  So  are  the 
application  of  freshly  precipitated  ferric 
oxide  as  an  antidote  to  arsenic,  and  the 
more  or  less  satisfactory  endeavors  which 
have  been  made  from  time  to  time  to 
prepare  iron  compounds  in  such  a  way 
as  to  insure  their  absorption  by  the  gas- 
trointestinal mucous  membrane  with- 
out the  production  of  digestive  disorder 
or  constipation.  John  Knott  (American 
Medicine,  December  17,  1904). 

LEUCOCYTES,    THE    DIAGNOSTIC    VALUE 
OF. 

A  routine  enumeration  of  the  white 
cells  in  the  peripheral  blood  is  of  suffi- 
cient importance  to  be  made  a  regular 
procedure  so  far  as  possible  in  all  cases. 
A  single  leucocyte  count  is  entirely  in- 
sufficient as  a  basis  of  conclusion  in  any 
given  case,  and  should  be  followed  up 
by  several  made  under  different  condi- 
tions. An  increase  beyond  ten  or  twelve 
thousand  leucocytes  in  the  peripheral 
blood  indicates  varying  grades  of  intoxi- 
cation, with  chemotactic  substances  of 
some  sort  or  another.  Whether  it  indi- 
cates suppuration  or  not  is  a  question  to 
be  determined  by  carefully  weighing  all 
the  facts  in  each  case.  The  leucocytes 
indicating  suppurative  and  allied  proc- 
esses are  of  the  neutrophile  type. 

The  eosinophile  form  of  leucocytosis 
indicates  among  other  things,  and  per- 
haps principally,  cutaneous  or  parasitical 
diseases  in  the  intestine  or  elsewhere. 
Lymphocytosis  clinically  signifies  an  irri- 
tative lesion  of  the  lymphatic  apparatus. 
A  differential  count  should  be  made  in 
all  cases  to  determine  the  type  of  cell 
which  has  been  the  subject  of  the  prin- 
cipal increase  where  such  increase  exists, 


and  such  records  carefully  kept  and  col- 
lated as  a  basis  for  the  determination  of 
the  clinical  significance  of  leucocytosis 
in  the  future.  In  the  diagnosis  of  ma- 
lignant disease  a  leucocytosis  is  of  very 
subordinate  value,  and  when  present  is 
probably  not  due  to  the  malignant  dis- 
ease, per  se,  but  to  co-existing  chemotac- 
tic toxins.  G.  W.  McCaskey  (American 
Journal  of  the  Medical  Sciences,  De- 
cember, 1901). 

LEUKEMIA,    ROENTGEN    RAYS    IN    THE 
TREATMENT   OF. 

Under  treatment  with  Roentgen  rays 
some  cases  of  leukaemia  undergo  marked 
change  for  the  better.  The  leucocytes 
fall  to  normal  numbers  and  sometimes 
show  no  more  pathological  cells,  the  red 
blood  corpuscles  improve,  the  enlarged 
spleen  and  lymphatic  glands  resume  nor- 
mal proportions,  and  the  general  health 
seems  restored.  In  some  cases  the  effects 
are  imperfect. 

In  no  case  has  observation  been  carried 
out  long  enough  to  speak  of  cure.  In 
several  cases  death  has  occurred  while 
the  symptoms  seemed  to  indicate  im- 
provement. The  mode  of  action  of  the 
Roentgen  rays  is  not  known.  It  prob- 
ably consists  in  affecting  the  tissues  that 
produce  the  pathological  leucocytes, 
either  directly  or  more  probably  through 
the  production  or  setting  free  of  sub- 
stances that  affect  cell  formation,  or  de- 
generation, or  chemotaxis,  or  all  of  these 
processes;  but  further  investigation  is 
necessary.  At  present  the  improvement 
must  be  considered  functional,  and  not 
affecting  the  original  cause,  nor  in  a  per- 
m.ineni  way  the  morbid  histology  of  the 
disease.  The  improvement  of  the  red 
blood  cells  may  be  due  to  general  stimu- 
lation of  nutrition,  in  which  suggestion 
may  have  a  part,  or  by  diminution  of 


34 


LEUKAEMIA. 


MAMMARY  GLAND,  CARCINOMA  OF. 


lymphoid  or  myeloid  tissue,  and  thus 
permitting  development  of  red  cells,  as 
suggested  by  Ahrens. 

Though  the  change  seems  a  functional 
one,  it  is  possible  that  treatment  in  very 
early  stages  may  be  more  effective  than 
it  has  hitherto  been. 

Eoentgen  ray  treatment  of  leukaemia 
is  dangerous  on  account  of  the  usual  risk 
of  dermatitis  and  burns,  but  probably 
also  on  account  of  toxic  processes  as  yet 
impossible  to  explain.  No  stronger 
claims  can  be  made  for  it  than  can  be 
made  for  arsenic  and  certain  serums  and 
bacterial  toxic  substances,  but  it  may 
prove  more  certain  in  its  action  than 
arsenic  and  can  be  more  readily  applied 
in  practice  than  the  injection  methods. 
Careful  observation  and  recording  of  all 
cases  in  which  the  treatment  was  fol- 
lowed promise  advances  in  our  knowl- 
edge of  leukaemia,  with  the  possibility  of 
gains  in  practical  therapeutics. 

No  special  rules  can  be  laid  down  at 
present  for  treatment  with  Eoentgen 
rays.  Great  cafe  should  be  taken  to 
avoid  burns.  Methods  should  be  as  fully 
described  as  possible  in  each  case;  the 
blood  should  be  carefully  examined  as 
fully  and  as  frequently  as  possible,  and, 
if  possible,  urine  examinations  should  be 
made,  to  throw  additional  light  upon  the 
metabolic  changes.  George  Dock  (Amer- 
ican Medicine,  December  24,  1904). 

MAMMARY  GLAND,  CARCINOMA  OF  THE. 

Cancer  is  not  only  increasing  in  fre- 
quency, but  in  doing  so  is  breaking  down 
barriers  hitherto  recognized.  It  occurs 
more  frequently  than  formerly  in  young 
subjects,  and  has  become  common  in 
races  at  one  time  immune. 

When  affecting  young  subjects  the 
prognosis  is  distinctly  less  favorable,  as 
the  lymphatics  are  both  numerous  and 


patent,  whereas  in  the  aged  many  lymph 
vessels  atrophy. 

An  early  diagnosis  should  be  made, 
and  no  time  lost  in  waiting  for  an  op- 
eration, as  metastases  to  the  axillary 
glands  and  internal  organs  occur  early, 
often  before  they  are  suspected.  In  9 
per  cent,  of  all  cases  it  is  impossible  to 
make  a  clinical  diagnosis. 

When  in  doubt  as  to  malignancy  a 
complete  operation  should  be  arranged 
for;  but  before  removing  the  breast  an 
exploratory  incision  should  be  made  into 
the  growth,  and  a  piece  from  near  its 
center  submitted  to  a  competent  pathol- 
ogist, who,  as  a  rule,  will  give  an  accu- 
rate report  in  ten  minutes.  If  malig- 
nant, a  complete  operation  should  be 
done  immediately.  In  women  past  40 
the  chances  in  favor  of  malignancy  are 
as  13  to  1,  and  should,  therefore,  be 
assumed. 

Carcinomata  of  the  sternal  hemisphere 
are  less  common  than  similar  growths  in 
the  axillary  half  of  the  gland,  but  are 
probably  more  frequent  than  they  are 
thought  to  be.  The  prognosis  is  worse 
in  them  than  in  cancers  of  the  axillary 
hemisphere. 

Eecurrences  being  usually  in  the  skin, 
its  removal  cannot  be  too  free.  Skin 
grafting,  or  closure  of  the  wound  by 
plastic  flaps, — the  preferable  method, — 
will  frequently,  if  not  usually,  be  nec- 
essary. 

The  pectoral  muscles,  major  and 
minor,  should  always  be  removed,  re- 
gardless of  infection,  so  that  all  diseased 
tissues  can  be  removed  in  one  piece,  and 
the  axillary  dissection  both  more  thor- 
oughly and  safely  made.  Their  loss 
neither  increases  the  mortality,  lenghens 
the  convalescence,  nor  seriously  impairs 
the  subsequent  usefulness  of  the  arm. 
The  supraclavicular  glands  should  be  re- 
moved if  palpably  enlarged  or  if  the  top- 


METABOLISM,  DISEASES  OF  THE  SKIN  CONNECTED  WITH  ERRORS  OF.        35 


most  axillary  glands  show  macroscopical 
involvement;  otherwise  their  removal  is 
unnecessary. 

Wounds  of  the  axillary  vessels  have 
been  infrequent  since  the  muscles  have 
been  removed  as  a  routine  practice. 
When  occurring  in  an  aseptic  operation 
they  have  always  been  recovered  from. 
Of  24  deliberate  resections  of  the  axil- 
lary vein  none  were  fatal.  Moreover,  the 
oedema  following  was  inconstant  and 
transitory,  and  never  a  troublesome 
symptom.  Drainage  should  always  be 
made. 

The  three-year  limit  of  Volkmann  is 
insufficient,  and  should  be  extended  to  at 
least  five  years.  Recurrences  may  occur 
after  ten  or  more  years. 

The  operative  mortality  in  2133  op- 
erations performed  since  1893  by  twenty- 
one  American  surgeons  reporting  to  the 
writer  was  less  than  1  per  cent.  This 
seems  almost  incredible  when  contrasted 
with  the  15  to  25  per  cent,  mortality  for 
incomplete  operations  on  the  breast  in 
pre-antiseptic  days.  Kadical  operations, 
if  early,  should  give  more  than  50  per 
cent,  of  cures.  W.  L.  Rodman  (Medical 
Bulletin,  December,  1904). 

METABOLISM,    DISEASES    OF    THE    SKIN 
CONNECTED    WITH    ERRORS    OF. 

Metabolism  represents  the  changes  oc- 
curring in  the  system  whereby  nutritive 
materials  and  oxygen  arc  transformed 
into  living  tissue,  and  retransformed  into 
waste  products,  while,  during  these  proc- 
esses, their  potential  energy  is  being  given 
off  in  living  force  and  heat.  As  healthy 
cell  action  and  transformation  is  pro- 
duced and  maintained  by  perfect  metabo- 
lism, so  when  there  is  perverted  metabo- 
lism the  structures  in  various  parts  of 
the  body  must  suffer,  and  this  is  called 
disease.     As  every  cell  in  the  body  con- 


stantly takes  up  and  gives  off  material, 
so  the  results  of  metabolism  can  be  af- 
fected by  the  normal  or  abnormal  action 
of  every  living  cell  in  the  organism. 

Metabolism  is,  however,  principally 
affected  by  (1)  the  kind  of  nutriment 
taken;  (2)  the  action  of  the  digestive 
organs  and  ductless  glands,  and  (3)  the 
action  of  the  nervous  system.  Certain 
skin  lesions,  or  eruptions,  have  been 
credibly  reported  as  connected  with  or 
dependent  upon  the  generally  recognized 
metabolic  conditions  of  (1)  gout;  (2) 
rheumatoid  arthritis;  (3)  diabetes;  (4) 
obesity;  (5)  scrofulosis.  As  yet  no  ab- 
solute statements  can  be  made  as  to  the 
necessary  connection  of  the  two,  for  the 
same  eruptions  occur  in  several  of  the 
metabolic  affections. 

The  idiosyncrasy  of  the  patient,  and 
many  causative  elements,  external  or  in- 
ternal, nervous,  etc.,  often  determine 
which  form  of  skin  disturbance  or  altera- 
tion shall  take  place.  Errors  of  diet,  dis- 
orders of  digestion,  faulty  excretion,  and 
nervous  derangement,  which  have  all 
along  been  recognized  as  causative  ele- 
ments in  many  diseases  of  the  skin,  often 
find  their  ultimate  expression  or  mode 
of  action  through  the  faulty  metabolism 
induced  thereby. 

Metabolic  errors  are  exhibited  in  the 
excreta  from  the  lungs,  skin,  intestines, 
and  kidneys;  and,  of  these,  the  urine 
best  affords  a  satisfactory  indication,  as 
it  represents  nearly  one-half  of  the  total 
excreta,  and  practically  all  of  the  nitro- 
genous and  soluble  mineral  substances, 
together  with  about  one-half  of  the  water 
expelled  from  the  system.  Complete  and 
minute  urinary  analysis  is  a  very  great 
aid  in  discovering  metabolic  errors,  ami 
in  establishing  proper  therapeutic  meas- 
ures for  the  cure  of  many  diseases  of  the 
skin.  L.  D.  Bulkley  (Medical  Record, 
November  20,  1904). 


36 


MILK  DIET. 


MYOCARDIUM. 


NERVOUS  THROAT  PAIN. 


MILK  DIET,  INFLUENCE  OF,  ON  THE  CIR- 
CULATION. 

The  effect  of  an  exclusive  milk  diet 
on  the  circulation  of  a  healthy  person  in- 
vestigated, and  some  interesting  conclu- 
sions drawn  as  to  the  effect  of  this  diet 
on  the  blood  pressure.  The  only  work 
thus  far  published  on  this  question  is 
that  of  Maximovitsch  and  Kieder,  who 
found  that  the  ingestion  of  large  amounts 
of  certain  fluids  raises  the  blood  pressure. 
This  they  found  especially  to  be  true  of 
beer,  and  next  to  this  of  wine,  coffee, 
tea,  milk,  cocoa,  and  water.  The  writer, 
however,  does  not  concede  the  correctness 
of  their  conclusions  and  believes  that 
the  instruments  which  they  used  were  in- 
accurate. He  used  Mosso's  accurate 
sphygmomanometer,  which  graphically 
records  the  blood  pressure.  In  a  former 
paper  (1899)  he  showed  that  the  fre- 
quency of  the  pulse  and  the  height  of  the 
blood  pressure  are  inversely  proportion- 
ate to  each  other.  During  digestion  after 
meals,  the  blood  pressure  is  lowered, 
owing  to  the  dilatation  of  the  abdominal 
vessels,  and  at  the  same  time  the  pulse 
rate  increases,  the  respiration  becomes 
more  frequent,  and  the  temperature  rises 
slightly.  The  ingestion  of  large  amounts 
of  milk  elevates  the  blood  pressure  at 
first,  owing  to  the  mechanical  presence 
of  increased  fluid,  and  not  owing  to  the 
simple  vasomotor  effect  of  digestion.  At 
the  same  time  the  pulse  rate  is  increased, 
owing  to  the  necessity  of  the  heart  to 
drive  more  fluid  through  the  arteries,  but 
the  temperature  is  not  elevated  percep- 
tibly, owing  to  the  lessened  heat  produc- 
tion in  the  blood  as  the  result  of  in- 
creased fluid.  After  the  milk  has  been 
absorbed,  however,  there  is  a  slight  rise 
of  temperature  and  a  fall  of  blood  pres- 
sure. This  depression  of  the  blood  ten- 
sion is  due  to  the  fact  that  milk  induces 
diuresis,  and  is  eliminated  more  rapidly 


than  is  necessary  to  maintain  the  bal- 
ance of  the  organism.  Carlo  Colombo 
(Biforma  Medica,  November  2,  1904, 
from  New  York  Medical  Journal  and 
Philadelphia  Medical  Journal,  December 
10,  1904). 

MYOCARDIUM,  DEGENERATIVE  CHANGES 
IN  THE. 

In  the  early  course  of  toxic  diseases, 
sepsis,  and  cachectic  conditions,  acute 
parenchymatous  myocarditis  is  more 
than  apt  to  develop ;  should  the  toxaemia 
continue  the  cloudy  swelling  usually  de- 
velops into  a  fatty  degeneration.  Per- 
sons suffering  from  fatty  or  parenchy- 
matous degeneration  of  the  myocardium 
should  have  their  blood  pressure  watched 
very  carefully  so  that  it  may  be  kept 
low.  Sudden  cardiac  exertion  or  sudden 
rise  of  blood  pressure  is  prone  in  espe- 
cially fatty  degeneration  to  cause  acute 
dilatation  of  the  heart,  resulting  either 
in  death  or  serious  cardiac  disease. 

In  all  the  autopsies  of  fatty  degenera- 
tion and  infiltration  the  valves  were  in  a 
normal  state ;  this  is  an  important  factor 
to  be  remembered  in  making  diagnosis  of 
cardiac  lesions.  Fatty  hearts  are  nor- 
mal or  under  size  generally,  and  often 
are  associated  with  atheromatous  changes 
and  cerebral  apoplexy. 

Nephritis  or  poor  renal  elimination  is 
prone  to  produce  fatty  degenerative 
changes.  Chronic  diseases  which  cause 
an  interference  with  the  proper  oxida- 
tion of  the  blood  cause  fatty  degeneration 
of  the  myocardium.  Eaymond  Clark 
(Brooklyn  Medical  Journal,  December, 
1904). 

NERVOUS  THROAT  PAIN. 

A  not  unusual  class_  of  patients  com- 
prises otherwise  healthy  and  not  neurotic 
individuals  who  complain  of  more  or  less 
constant  pain  in  the  throat,  which  is  in- 


OBESITY. 


OVARIES,   OPERATIONS   ON. 


PAROTITIS. 


37 


creased  on  swallowing-.  Examination  of 
the  throat  reveals  no  satisfactory  ex- 
planation, for  the  slight  chronic  catar- 
rhal condition  usually  present  is  not 
sufficient  to  account  for  the  symptoms. 
By  palpating  the  neck,  however,  two  lo- 
calized painful  spots  will  commonly  be 
found,  one  over  the  point  of  emergence 
of  the  superior  laryngeal  nerve  through 
the  thyroid  membrane,  and  the  other 
above  the  clavicle  over  the  recurrent 
laryngeal  nerve.  Pressure  on  these  spots 
causes  the  throat  pain  to  be  felt,  and  the 
author  considers  that  the  condition  is 
due  to  neuritis  of  one  or  both  of  these 
nerves.  Treatment  consists  in  massage  of 
the  painful  regions  in  the  neck,  and  is 
usually  effectual.  In  the  few  cases  in 
which  it  fails,  other  plans  of  treatment 
usually  are  also  without  result.  The  ca- 
tarrhal condition  which  probably  forms 
the  starting  point  of  the  neuritis  should, 
of  course,  receive  the  usual  treatment. 
Boenninghaus  (Deutsche  medicinische 
Wochenschrift.  November  10,  1904). 

OBESITY. 

The  writer  insists  on  the  constancy  of 
dyspeptic  troubles  in  the  obese.  A  num- 
ber of  cases  have  been  observed  in  which 
the  patients  suffered  with  diarrhoea,  and 
whose  weight  increased  in  spite  of  the 
chronic  diarrhoea.  The  cessation  of  the 
bowel  disturbance  after  appropriate 
treatment  was  accompanied  by  loss  in 
weight.  These  apparently  paradoxical 
facts  are  explained  on  the  ground  that 
the  weight  is  regulated  by  the  nervous 
system  whose  mechanism  may  be  dis- 
turbed by  any  diseased  condition  what- 
ever. The  necessity  of  decreasing  the 
weight  slowly  is  insisted  upon,  since  a 
rapid  loss  in  weight  depends  more  on 
dangerous  dehydration  of  the  tissues 
than  on  the  loss  of  fat.  Lorand  thinks 
that  there  exists  an  obesity  due  \o  rich 
5 


food  and  a  sedentary  life;  and  also  an 
obesity  due  to  morbid  processes  of  cer- 
tain glands  whose  internal  secretions 
powerfully  influence  all  of  the  processes 
of  nutrition.  The  removal  of  the  ovaries 
or  of  the  thyroid  is  followed  by  a  diminu- 
tion of  oxidation,  while  the  products  of 
these  glands  increase  it.  The  line  be- 
tween these  cases  of  obesity  and  complete 
myxcedema  is  very  narrow.  Leven  (La 
Tribune  Medicale,  November  5,  1904). 

OVARIES,  CONSERVATIVE  OPERATIONS 
ON   THE. 

Operations  on  the  ovaries  that  pre- 
serve the  menstrual  and  reproductive 
functions  should  be  employed,  when  pos- 
sible, in  lieu  of  complete  extirpation. 
Healthy  displaced  ovaries  may  be  anch- 
ored to  posterior  surface  of  the  broad 
ligament  or  by  shortening  the  infundi- 
bulo-pelvic  ligament.  Sterile  women 
and  married  women  who  are  using  means 
to  avoid  pregnancy  are  unfavorable  sub- 
jects on  which  to  do  conservative  opera- 
tions on  the  ovaries.  Conservative  op- 
erations should  be  avoided  on  all  pus 
cases,  as  a  general  rule.  J.  W.  Coke- 
no  wer  (Journal  of  the  American  Med- 
ical Association,  December  17,  1904). 

PAROTITIS  FOLLOWING  INJURY  OR  DIS- 
EASE OF  THE  ABDOMINAL  AND  PEL- 
VIC  VISCERA. 

It  appears  most  probable  that  cceliac 
parotitis  is  due  to  the  action  on  the  paro- 
tid glands  of  toxic  substances  absorbed 
into  the  blood  and  derived  from  (a)  the 
secretions  of  certain  organs  modified  by 
injury  or  disease  ;  (b)  toxins  of  microbic 
origin  {e.g.,  bacillus  coli)  absorbed  either 
from  the  alimentary  canal,  peritoneal 
cavity,  or  bladder;  (c)  products  of  de- 
ranged digestion. 

Tn  any  given  case  of  injury  or  disease 
of  the  abdominal   or  pelvic  viscera  the 


38 


PNEUMONIA,  ACUTE  LOBAR. 


PNEUMONIA  OF  ADULTS. 


occurrence  or  not  of  parotitis  will  there- 
fore depend  on  the  presence  and  the  ab- 
sorption in  sufficient  quantity  of  some  of 
these  various  toxic  agents.  Suppuration 
is  not  an  essential  feature  of  the  condi- 
tion, but  is  due  to  the  fact  that  the  par- 
otid gland,  when  inflamed  by  the  action 
of  these  toxic  agents,  forms  a  locus 
minoris  resist  entice,  and  becomes  second- 
arily infested  by  pyogenic  organisms 
reaching  it  (a)  by  the  blood-stream; 
(b)  by  Stenson's  duct.  Brennan  Dyball 
(Annals  of  Surgery,  December,  1904). 

PNEUMONIA,  ACUTE  LOBAR.  TREATMENT 
OF. 

The  writer  advises  that  judicious,  ra- 
tional treatment  should  be  begun  imme- 
diately and  continued  during  the  attack. 
The  most  useful  single  agent  in  treat- 
ment, as  preventive  and  curative,  is  creo- 
sote, used  preferably  as  inhalations,  prop- 
erly given  and  continued  for  a  sufficient 
length  of  time.  Strict  avoidance  of  ex- 
tremes of  treatment  in  any  direction 
should  be  observed,  whether  it  be  toward 
the  use  of  so-called  specifics  or  the  em- 
ployment of  certain  drugs,  notably  digi- 
talis and  strychnine.  It  should  be  graven 
on  the  mind  that  pneumonia  may  be 
throttled  or  minimized  most  surely  in 
the  beginning.  Later,  when  the  disease 
is  fully  developed  our  role  is  inferior, 
but  should  consist  mainly  in  doing  least 
harm.  Harm  proceeds  almost  invariably 
from  ignorance  or  undue  enthusiasm. 
Beverley  Eobinson  (American  Journal 
of  the  Medical  Sciences,  December, 
1904). 

PNEUMONIA  OF  ADULTS,  TREATMENT  OF. 

The  tendency  is  to  forget  that  this  is 
a  general  disease  in  which  there  may  be 
great  disparity  between  the  local  signs 


and  the  patient's  general  condition,  se- 
vere cases  sometimes  giving  evidence  of 
but  slight  lung  involvement,  and  vice 
versa.  So  far,  the  attempts  to  devise  a 
specific  treatment  have  not  been  success- 
ful, and  but  little  is  to  be  expected  in  this 
direction,  for  the  pneumococcus  is  not 
always  a  constant  quantity,  and  various 
other  organisms,  including  the  influenza 
bacillus,  which,  of  late,  has  markedly  in- 
fluenced the  disease,  may  be  present  in 
mixed  infections.  The  author's  detailed 
discussion  of  the  treatment  is  subdivided 
under  the  following  heads :  1.  To  main- 
tain life.  The  careful  management  of 
the  stomach  by  a  suitable  diet  to  pre- 
vent distension  and  the  consequent  car- 
diac embarrassment  is  of  the  highest  im- 
portance. It  is  wiser  to  give  too  little 
food  than  too  much  and  to  avoid  all  car- 
bonated beverages.  2.  To  support  the 
heart.  The  best  drugs  for  this  purpose 
are  strychnine,  caffeine,  alcohol,  cam- 
phor, and  ergot.  If  prompt  results  are 
not  obtained  all  the  drugs  should  be 
given  hypodermically  and  in  sufficient 
amount  to  exert  their  physiological  ac- 
tion. Views  as  to  the  value  of  large 
doses  of  digitalis  are  still  divided.  Ad- 
renalin, the  precordial  icebag,  cupping, 
and  venesection  are  also  useful  measures. 
3.  To  control  hyperpyrexia.  Large,  flat 
icebags  on  the  chest  will  be  found  useful, 
but  care  is  necessary  to  avoid  producing 
intercostal  neuritis.  Cold  sponging  and 
packs  are  of  value,  but  must  be  used 
with  caution,  and  cold  baths  are  contra- 
indicated.  The  rational  use  of  coal  tar 
antipyretics  in  small  doses  may  contrib- 
ute much  to  the  patient's  comfort.  4. 
To  relieve  suffering.  The  cough  and 
pain  are  combated  by  the  use  of  small 
doses  of  morphine  hypodermically,  or  of 
heroin  hydrochlorate.  The  Paquelin 
cautery  is  of  great  value  for  the  pleuritic 
stitches.      Oxygen    is    probably    of    less 


PNEUMONIA,  SERUM  TREATMENT  OF.     RABIES,  NEGRI'S  BODIES. 


39 


value  than  is  generally  supposed.  Every 
effort  should  be  made  to  secure  as  much 
sleep  for  the  patient  as  possible.  5.  To 
control  complications.  Pleurisy  with 
effusion,  empyema,  pericarditis,  endocar- 
ditis, etc.,  require  the  treatment  ordi- 
narily pursued.  M.  Manges  (Medical 
Record,  December  10,  1904). 

PNEUMONIA.  SERUM  TREATMENT  OF. 

A  sufficiently  extensive  trial  of  the 
antipneumococcal  sera  has  been  made  to 
determine  with  a  reasonable  degree  of  ac- 
curacy their  efficency,  and  the  results,  as 
a  whole,  fail  to  carry  conviction.  An 
efficient  serum,  or  one  that  will  cut  short 
the  pneumonic  process,  is  yet  to  be  pro- 
duced, although,  according  to  some  clin- 
icians, the  sera  available  at  present  have 
a  restricted  field  of  usefulness.  Recent 
observers  have  employed  the  serum  in 
massive  doses  from  the  commencement 
of  the  disease  without  gratifying  results. 
The  practical  results  of  the  use  of  the 
antipneumococcus  serum,  as  shown  by 
the  very  slight  reduction  in  the  mortality 
percentage,  does  not  warrant  its  general 
introduction.  The  sera  thus  far  found 
possess  no  antitoxic  qualities,  and  their 
supposed  anti-infectious  properties  have 
not  been  proven.  Further  investigations 
into  the  subject  with  a  view  to  discover- 
ing an  efficacious  serum  are  to  be  strongly 
advised  and  encouraged.  J.  M.  Anders 
(Journal  of  the  American  Medical  Asso- 
ciation, December  10,  1904). 

RABIES.     NEGRIS     BODIES    AND     THEIR 
SIGNIFICANCE   IN. 

The  writer  concludes  as  follows  from 
a  detailed  study  of  the  question  as  to  the 
meaning  of  Negri's  bodies  in  the  causa- 
tion of  hydrophobia.  (These  bodies  are 
special  structures  found  by  Negri  in  the 


cells  of  the  central  nervous  system  of 
animals  affected  with  rabies)  :  If  some 
nervous  tissue  of  a  rabid  animal  be  de- 
posited upon  the  cerebral  cortex  of  a 
rabbit,  the  virus  will  be  found  localized 
at  this  site  during  the  entire  period  of 
incubation,  and  will  be  still  found  there 
when  the  more  distant  portions  of  the 
nervous  system  have  already  become  af- 
fected. If  a  cornu  ammonis  rich  in 
Negri's  bodies  be  deposited  upon  the 
cerebral  cortex  of  a  rabbit,  these  bodies 
do  not  disappear  until  the  fourth  or  fifth 
da}'  after  the  inoculation,  and  do  not 
present  any  modifications  which  would 
point  to  any  biological  activity.  They 
simply  take  part  in  the  general  necrosis 
which  takes  place  in  the  inoculated  tis- 
sue. During  the  following  days,  when 
the  cornu  ammonis  is  gradually  disap- 
pearing, it  is  no  longer  possible  to  recog- 
nize the  Negri's  bodies.  Neither  are 
these  bodies  to  be  found  in  the  lepto- 
meninges  which  cover  the  inoculated 
spot,  nor  in  the  cortex  which  underlies 
it.  The  eosinophile  granules  which  are 
observed  in  these  cases  are  not  derivatives 
of  Negri's  bodies,  as  they  occur  also 
when  a  non-hydrophobic  nervous  tissue 
is  inoculated.  Negri's  bodies,  when  ob- 
served in  hanging  drop  preparations  on 
warmed  slides,  do  not  exhibit  any  spon- 
taneous movements.  Neither  do  they  ex- 
hibit such  movements  when  they  are  al- 
lowed to  remain  for  some  days  within 
the  peritoneum  of  an  animal,  enclosed 
in  saes  of  celloidm.  Tf  pieces  of  a  cornu 
ammonis  rich  in  Negri's  bodies  are 
placed  in  ;;  celloidin  sac  and  kept  in  a 
peritoneal  cavity  for  some  time,  the 
Negri's  bodies  do  not  show  any  biological 
changes,  but  undergo  necrosis.  There- 
fore, we  have  no  reasons,  as  yet,  to  think 
of  the  Negri's  corpuscles  as  being  etio- 
logical factors  in  rabies.  Luigi  D'Amato 
(Riforma    Medica,    November   9,    1904, 


40    RADIOTHERAPEUTIC  TECHNIQUE.      REFRACTION.     RHEUMATIC  AFFECTIONS. 


from  New  York  Medical  Journal  and 
Philadelphia  Medical  Journal,  Decem- 
ber 24,  1904). 

RADIOTHERAPEUTIC   TECHNIQUE,   VARI- 
ATIONS  OF. 

The  writer  believes  that  technique  is 
the  key  to  success  in  Koentgen  ray  work. 
The  application  of  this  treatment  either 
in  diagnosis  or  treatment,  should  be  done 
by  mathematical  calculations  to  do  the 
most  successful  work.  Usually  the  com- 
bination of  surgery  and  the  Roentgen 
ray  will  produce  the  best  results.  Tubal 
distance  is  very  important  in  treating 
deep-seated  glands.  The  Roentgen  ray 
should  be  of  large  volume  when  deep  le- 
sions are  to  be  treated.  The  Roentgen 
ray,  like  the  intensity  of  light,  varies 
inversely  as  the  square  of  the  distance. 
In  treating  deeper  lesions,  the  best  re- 
sults will  be  produced  by  using  a  light 
which  affects  the  different  layers  of  tis- 
sue the  most  uniformly.  The  intensity 
of  the  rays,  for  example,  is  more  uniform 
in  the  different  layers  of  tissue  with  the 
tube  placed  at  16  inches  than  at  8  inches. 
In  the  treatment  of  superficial  lesions  a 
low  tube  placed  near  to  the  surface  of 
the  skin  eliminates  the  danger  of  injur- 
ing the  deeper  tissues.  Periostitis  has 
been  caused  by  a  high  tube  placed  at  a 
distance.  Each  case  is  an  individual  one 
and  should  be  treated  as  such.  Adjunct 
treatment  in  these  cases  should  not  be 
overlooked.  Every  help  possible#  should 
be  taken  advantage  of  to  keep  the  system 
in  perfect  condition.  In  cases  of  car- 
cinoma, when  toxasmia  is  present,  electric 
light  baths  are  very  valuable.  Diet  is 
important.  Much  liquid  should  be  taken. 
Alcoholic,  syphilitic,  or  very  anamiic  pa- 
tients as  a  rule  do  not  improve  rapidly. 
and  such  patients  often  burn  easily.  R. 
H.  Boggs  (American  Medicine,  Novem- 
ber 26,  1904). 


REFRACTION     IN     CHILDREN,     NERVOUS 
SYMPTOMS   PRODUCED  BY. 

Nervous  symptoms  of  a  variety  of 
kinds  occur  as  the  result  of  eye-strain. 
Eye-strain  is  due  to  refractive  error*,  to 
imbalance  of  the  external  ocular  mus- 
cular system,  or,  more  frequently,  to  a 
combination  of  the  two.  Of  these  two. 
the  refractive  errors  are  by  far  the  more 
frequent  cause.  Muscular  imbalance 
alone  may  cause  it.  Headache  is  by  far 
the  most  common  nervous  symptom  in 
children,  caused  by  eye-strain.  Headache 
is  chronic  or  induced  directly  by  near 
work  and  is  generally  in  the  forehead  or 
temples.  Migraine  or  hemicrania,  due 
to  eye-strain,  is  comparatively  rare  in 
children.  Any  nervous  symptom  in  chil- 
dren should  arouse  the  suspicion  of  ocu- 
lar defects,  either  as  the  direct  or  a  con- 
tributory cause.  The  refractive  correc- 
tion should  be  made  under  atropine. 
Muscular  defects  are  secondary  to  the 
refractive,  and  should  be  corrected  only 
in  certain  cases.  J.  H.  Claiborne  (Jour- 
nal of  the  American  Medical  Association, 
December  10,  1904). 

RHEUMATIC  AFFECTIONS,  INTRAVENOUS 
INJECTIONS    OF    SALICYLATES    FOR. 

The  writer  lauds  the  method  advocated 
by  Mendel  for  the  treatment  of  rheu- 
matic conditions  by  means  of  the  injec- 
tion of  a  salicylate  solution  consisting  of 
sodium  salicylate  8.0.  caffeine  sodio- 
salicylate  2.0,  distilled  water  ad  50.0. 
The  therapeutic  results  of  this  method 
are  excellent,  and  prompt  relief  is  af- 
forded in  nearly  all  forms  of  rheumatic 
affections'.  A  careful  diagnosis  is  neces- 
sary, however,  for  non-rheumatic  disor- 
ders are  not  amenable  to  this  plan  of 
treatment,  and  the  effect  in  rheumatic 
cases  is  less  pronounced  the  longer  the 
duration  of  the  trouble  lias  been.  The 
injection  should   be  marie  with  all  due 


SIGMOID,  SURGICAL  DISEASES  OF  THE.  SKULL  AND  BRAIN. 


41 


aseptic  precautions,  and  care  should  be 
taken  to  see  that  the  presence  of  the 
point  of  the  needle  within  the  lumen  of 
the  vein  is  demonstrated  by  the  appear- 
ance of  a  column  of  blood  within  the 
syringe  before  the  fluid  is  expelled,  as 
the  solution  gives  rise  to  severe  pain  if 
thrown  into  the  tissues  instead  of  di- 
rectly into  the  vein.  The  author  has 
seen  no  disagreeable  complications  at- 
tend the  method  when  carefully  em- 
ployed, and  recommends  it  especially  for 
cases  where  it  is  of  great  importance  not 
to  upset  the  stomach,  as  in  treating 
tubercular  patients,  for  example.  Behr 
(Miinchener  medicinische  Wochen- 
sehrift,    Xovember    3.    1904). 

SIGMOID,    SURGICAL    DISEASES    OF    THE. 

The  various  pathologic  changes  to 
which  the  physiologic  functions  and 
anatomic  structure  and  relations  of  the 
sigmoid  render  it  especially  susceptible, 
may  be  regarded  as  successive  stages  or 
steps  of  one  morbid  process,  rather  than 
as  so  many  different  diseases. 

An  impartial  study  of  the  various  suc- 
cessive pathologic  changes  that  precede, 
accompany,  and  follow  inflammatory  ob- 
structions and  malignant  diseases  of  the 
sigmoid,  furnishes  convincing  evidence 
of  how  little  can  reasonably  be  expected 
of  medical  treatment,  and  how  much 
timely  operative  interference  must  be  re- 
lied upon  to  correct  disease  in  this  re- 
gion. 

Advanced  malignant  disease  of  the 
sigmoid  is  always  preceded  by  pathologic 
processes  which  it  should  be  striven  to 
recognize  early  and  correct  by  timely 
operative  procedure. 

Acute  obstruction  due  to  volvulus,  un- 
less relieved  promptly  by  inflation  of  the 
rectum  with  water  or  gas,  is  always  an 
indication  for  operative  interference. 
All  torsions  of  the  bowel  with  partial  or 


complete  stricture  usually  demand  opera- 
tive interference.  All  inflammatory  or 
necrotic  processes  that  include  the  peri- 
toneal coat  of  the  gut,  with  or  without 
angulation  or  stricture  of  the  bowel, 
should  be  regarded  as  surgical  conditions. 
The  known  frequency  of  cancer  and 
all  forms  of  intestinal  ulcerations  in  this 
region,  the  occasional  occurrence  of  vol- 
vulus, a  practical  consideration  of  the 
anatomic  structure  and  relations  of  the 
sigmoid,  combined  with  the  lessons 
gleaned  from  a  limited  number  of  clin- 
ical experiences  and  postmortem  exami- 
nations,— all  tend  to  confirm  the  belief 
that  inflammatory  lesions  and  obstruc- 
tive distortions  of  the  sigmoid  are  by  no 
means  rare;  and  that  their  rational 
treatment  should  be  based  upon  the  sur- 
gical conception  of  the  conditions.  H. 
D.  Xiles  ( Xorthwestern  Lancet,  Decem- 
ber 1,  1904). 

SKULL  AND  BRAIN,  EFFECT  OF  DIRECT 
AND  INDIRECT  VIOLENCE  UPON 
THE. 

Injuries  of  the  skull  and  brain  may 
be  classed  under  two  heads,  those  of  im- 
pact and  those  of  momentum,  either  of 
which  may  be  occasioned  either  directly 
or  indirectly.  Injuries  of  impact,  how- 
ever extensive,  offer  a  better  immediate 
and  remote  prognosis,  but  must  be 
treated  with  as  little  delay  as  possible, 
and  almost  always  surgically. 

Injuries  of  momentum  show  graver 
probabilities  both  in  the  immediate  and 
remote  effects.  In  injuries  of  momen- 
tum, lesions  through  contrecoup  are 
more  apt  to  occur,  with  extensive  damage 
to  the  brain  structures  and  often  wifh- 
"ii i  fracture  of  the  skull,  or  external 
wound. 

After  trauma  to  the  skull  ami  bruin 
I  lie  immediate  necessity  is  free  drainage 
and   avoidance  of  intracranial  pressure. 


42        SKULL,  BIRTH  FRACTURE  OF  THE. 


SPINA  BIFIDA,  TREATMENT  OF. 


The  possibility  of  fracture  should  ever 
be  kept  in  view  after  injuries  to  the 
head,  and  scalp  wounds  should,  if  neces- 
sary, be  freely  enlarged  to  determine  the 
wisdom  of  further  operative  interference. 
Progressive  coma,  after  momentum  in- 
juries, is  a  strict  indication  for  opera- 
tion. A.  E.  Sterne  (Cincinnati  Lancet- 
Clinic,  November  26,  1904). 

SKULL,  BIRTH-FRACTURE  OF  THE. 

A  survey  of  the  literature  available, 
and  the  experience  of  a  number  of  cases 
seen,  and  particularly  of  the  twenty- 
three  cases  operated  on,  appear  to  the 
author  to  warrant  the  following  conclu- 
sions :  The  statement  made  by  a  number 
of  authors  to  the  effect  that,  in  the  ma- 
jority of  cases,  depressed  greenstick  frac- 
ture of  the  skull  in  infants  rectifies  it- 
self if  left  alone,  lacks  substantiation. 
It  is  certainly  no  more  true  of  the  trau- 
matic (as  opposed  to  the  parturition) 
greenstick  fracture  of  the  skull  than  it 
would  be  if  made  of  any  other  green- 
stick fracture  in  the  body.  In  regard  to 
the  parturition  cases  it  may  be  true  of 
some,  viz. :  the  slighter  cases  of  indenta- 
tion, which  may  spontaneously  disappear 
within  a  day  or  two  of  birth.  In  the 
more  marked  cases  the  writer  regards 
such  a  statement  as  misleading.  In 
cases  over  one  month  old,  after  the  de- 
formity has  become  "set,"  its  spontane- 
ous obliteration  must  be  regarded  as 
problematical,  and  as  being,  at  best,  both 
slow  and  partial. 

In  cases  of  greenstick  depressed  frac- 
ture of  the  skull  in  infants  and  children 
which  have  not,  when  recent  and  soft, 
been  remedies  by  Munro  Kerr's  method, 
operation  is  justifiable  even  if  only  for 
the  correction  of  deformity.  The  ex- 
cision of  a  nsevus  of  the  face  or  a  small 
keloid  scar  from  the  neck  is  an  everyday 
surgical   procedure.      The   deformity   of 


a  cranial  depression  is  quite  as  unsightly 
as  either,  and  is  the  cause  of  much  more 
anxiety  to  the  parents,  who  attribute  any 
little  real  or  imaginary  eccentricity  of 
the  child  to  his  "queer  head,"  while  the 
operation  for  its  correction  is  no  more 
serious  than  is  the  removal  of  the  nsevus 
or  the  keloid.  The  twenty-three  cases 
on  which  the  author  operated  recovered 
without  a  death,  many  of  them  as  hos- 
pital out-patients. 

Of  the  two  methods  available,  eleva- 
tion and  inversion,  the  latter  is  decidedly 
the  better,  alike  in  the  freedom  from  risk 
and  the  perfection  of  the  result  ob- 
tained. James  H.  Nicoll  (Annals  of 
Surgery,  December,  1904). 

SPINA  BIFIDA,   OPERATIVE   TREATMENT 
OF. 

There  are  no  absolute  contra-indica- 
tions  to  the  operative  treatment  of  spina 
bifida.  The  worse  the  ease  the  more 
marked  becomes  the  futility  of  other 
than  operative  measures,  and  the  greater 
the  probability  that  the  child  will  die  if 
let  alone.  Paralysis,  hydrocephalus,  and 
marasmus,  often  spoken  of  as  contra- 
indications, should  not  be  so  considered. 
Each  has  been,  and  may  be  improved. 

As  to  method,  in  meningocele,  opening 
of  the  sac,  after  dissecting  up  the  skin 
by  a  pair  of  lateral  incisions,  suture  of 
the  neck,  and  removal  of  redundant  tis- 
sue. In  myelomeningocele  and  syringo- 
myelocele, the  same  method  combined 
with  loosening  of  the  nerve  cords,  and 
return  of  the  same  to  the  canal. 

As  to  prognosis,  meningoceles,  with 
more  extended  experience,  should  yield 
practically  uniformly  favorable  results. 
In  cases  of  syringomyelocele  and  mye- 
lomeningocele, owing  to  oft-present 
nerve  involvement,  the  results  will  not 
be  so  encouraging.  Paralysis-  may  be 
relieved. 


STOMACH. 


SYPHILIS,  PROGNOSIS   OF. 


TUBERCULIN   TEST. 


43 


As  to  technique,  absolute  asepsis,  com- 
bined with  as  little  handling  of  nerve 
tissue  as  is  essential,  will  give  the  best 
results.  Loss  of  cerebro-spinal  fluid  in 
moderate  amounts  is  not  of  importance. 
Operating  on  an  inclined  plane  is  not 
necessary,  and  the  use  of  bony  flaps  is 
rarely,  if  ever,  essential.  E.  K.  Secord 
(Canadian  Practitioner  and  Eeview, 
December,  1904). 

STOMACH,  MOTOR  INSUFFICIENCY  OF 
THE. 

Many  cases  of  long  standing  digestive 
diseases  are  due  to  motor  insufficiency 
to  overcome  a  partial  obstruction,  benign 
in  nature,  at  the  pylorus.  And  any  treat- 
ment is  but  palliative,  even  if  as  much 
as  that,  except  a  treatment  that  will 
either  enlarge  the  pyloric  opening,  or, 
as  has  been  found  better  in  most  cases, 
making  a  new  opening  by  gastroenter- 
ostomy. 

In  the  atonic  form  of  motor  insuffi- 
ciency, operation  is  not  indicated.  In 
selecting  a  remedy,  chief  attention  should 
be  given  to  constitutional  or  general 
symptoms  rather  than  to  those  especially 
pertaining  to  the  stomach.  In  the  atonic 
form,  in  addition  to  remedies  and  other 
means  of  a  general  nature,  pneumatic, 
intra-gastric  massage,  is  an  adjuvant  of 
much  value  in  helping  to  develop  the 
muscular  walls  of  the  stomach.  E.  0. 
Adams  (Cleveland  Medical  and  Surgical 
Reporter,  November,  1904). 

SYPHILIS,  PROGNOSIS  OF. 

Syphilis  is  a  curable  affection,  pro- 
vided treatment  is  begun  early  and  faith- 
fully and  persistently  carried  out.  At 
least  three,  if  not  four  years  of  continu- 
ous treatment  is  required  to  bring  the 
morbid  process  under  control,  with  all 
dangers  of  recrudescence  eliminated. 

The  indications  of  the  total  cessation 


of  the  destructive  condition  consist  of 
the  absence  of  all  manifestations  and  le- 
sions for  a  period  of  not  less  than  two 
years,  a  steady  gain  of  bodily  weight,  or 
at  least  no  loss  of  same,  and  the  prop- 
agation of  healthy  children.  These  in- 
dications are,  at  the  present  juncture  of 
our  knowledge  of  the  prognosis  of  syph- 
ilis, unfortunately,  far  from  positive  and 
reliable.  N.  E.  Aronstam  (Medical  Age, 
November  25,  1904). 

TUBERCULIN  TEST,  THE  VALUE  OF  THE. 

A  reaction  to  tuberculin  is  positive 
proof  of  tuberculosis.  The  failure  to 
react  may  be  of  negative  value  if  the 
tuberculin  test  is  used  when  the  disease 
is  far  advanced.  When  the  errors  of  the 
diagnosticians  using  the  tuberculin  are 
eliminated,  the  percentage  of  failures 
must  be  exceedingly  small.  Owing  to 
the  variability  of  all  the  general  and 
local  symptoms  of  a  "reaction,"  reliance 
must  be  placed  entirely  on  the  induced 
fever.  Cases  apparently  "recovered" 
often  react  to  tuberculin,  thus  proving 
that  there  is  tuberculosis,  and  that  the 
disease  is  present  in  a  latent  form. 

The  average  time  for  the  reaction  is 
12  hours.  The  reaction,  however,  may 
be  delayed,  some  cases  showing  the  char- 
acteristic rise  after  20  hours.  Large 
initial  doses  for  injection  should  be  used, 
as  small  doses  tend  to  establish  a  toler- 
ance, thus  preventing  a  reaction.  Ex- 
treme care  is  essential  when  reaction  to 
tuberculin  is  suspected.  The  prelimi- 
nary temperature  should  be  carefully 
considered,  and  all  errors  eliminated. 

Advanced  cases  of  tuberculosis  do  not, 
as  a  rule,  react.  If  a  reaction  is  secured, 
it  is  generally  obscured  by  preliminary 
temperature  oscillations.  The  use  of  the 
tuberculin  test  in  general  practice  is  to 
be  commended,  if  the  physicians  remem- 
ber the  extreme  delicacy  of  the  test,  its 


44        TUBERCULOSIS  OF  THE  MIDDLE  EAR. 


TUBERCULOSIS,  PULMONARY. 


limitations,  and  the  necessity  of  the  em- 
ployment of  a  thorough  and  unvarying 
technique.  I.  H.  Neff  (Journal  of  the 
Michigan  State  Medical  Society,  De- 
cember, 1904). 

TUBERCULOSIS     OF     THE     MIDDLE     EAR, 
BILATERAL. 

If  there  is  free  drainage  of  the  tym- 
panic cavity  through  the  auditory  canal ; 
if  there  are  no  granulations  present  and 
no  symptoms  of  facial  nerve  paralysis; 
if  the  mastoid  does  not  show  and  has 
never  shown  any  signs  of  involvement; 
and  if  there  are  no  extensive  areas  of 
necrosis,  the  author  would  treat  the  con- 
dition expectantly  through  the  auditory 
canal.  If  there  is  facial  paralysis  and 
extensive  granulations  extending  out 
into  the  canal;  if  the  mastoid  shows  or 
has  shown  involvement,  whether  tuber- 
cular or  not;  and  the  patient  shows 
vitality  enough  to  stand  the  anaesthetic, 
the  radical  operation  should  be  proposed 
immediately.  Dunbar  Eoy  (Journal  of 
the  American  Medical  Association,  No- 
vember 26,  1904). 

TUBERCULOSIS,    PULMONARY.    METHODS 
OF  INFECTION  IN. 

The  author  assumes  that  the  bacillus 
probably  does  not  grow  on  a  mucous 
membrane  with  mucus  as  a  medium,  and 
that  it  can  and  does  penetrate  mucous 
membranes,  alimentary  or  respiratory, 
without  leaving  the  slightest  sign  of  its 
passage.  The  first  disputable  point  is 
whether  foreign  matter  can  be  inhaled 
directly  into  the  lungs,  and  the  author 
bases  his  affirmative  answer  largely  upon 
the  study  of  anthracosis  and  the  allied 
conditions.  The  basement  membrane  of 
the  bronchi  is  not  perforated  by  the 
lymph  radicles,  and  foreign  matter  can 
therefore  only  reach  the  bronchial  glands 
by  penetrating  the  air  sac  to  the  lymph 


radicles  below  or  as  by  being  "screened 
out"  of  the  pulmonary  circulation  into 
the  interalveolar  lymph  radicles.  In 
favor  of  the  former  as  a  possible  method 
is  the  fact  that  in  rabbits  which  have 
been  confined  in  a  heavy  atmosphere  of 
lamp  black  the  pigment  is  found  both  in 
the  air  sac  itself  and  sticking  through 
the  walls  of  the  sac.  Another  observa- 
tion pointing  in  the  same  direction  is 
that  the  pneumococcus  when  introduced 
experimentally  into  the  circulation  of 
animals  seeks  a  serous  membrane  and 
does  not  cause  pneumonia.  By  analogy 
it  would  appear  probable  that  in  pneu- 
monia, as  met  with  clinically,  infected 
dust  has  been  able  to  reach  the  air  sacs 
of  the  lung  directly.  The  question 
whether  foreign  matter  can  reach  the 
lungs  by  way  of  the  intestinal  tract  is 
also  answered  in  the  affirmative. 

The  method  by  which  the  cow  con- 
tracts the  disease  is  important.  The  au- 
thor believes  it  to  be  by  ingestion  of 
food  infected  by  tuberculous  sputum, 
and  probably  never  by  inhalation. 
Against  the  view  that  in  man  the  infec- 
tion is  due  in  many  cases  to  food  infec- 
tion is  the  rarity  of  abdominal  tubercu- 
lous lesions,  but  little  weight  attaches  to 
this  argument  when  it  is  remembered 
that  the  site  of  the  lesion  does  not  indi- 
cate the  point  of  entrance  of  the  bacillus. 
A  useful  formula  in  this  connection  is 
that  "a  specific  organism  seeks  an  organ, 
serous  or  mucous  membrane,  for  the 
reason  that  the  particular  animal  tissue 
furnishes  the  exact  kind  and  exact 
amount  of  nutritive  medium  under  exact 
biothermal  conditions  which  make  it  pos- 
sible for  it  to  multiply,  colonize,  and  sur- 
vive its  incubative  period  in  the  animal 
organism."  In  adults  such  tissue  is 
found  in  the  lung,  while  in  children  in- 
testinal affection  is  more  common.  That 
tuberculous  milk  is  only  a  minor  link  in 


TYPHOID  FEVER.  TREATMENT  OF. 


45 


the  chain  of  infection  to  man  is  indi- 
cated by  the  prevalence  of  tuberculosis 
among  oriental  nations,  to  whom  milk 
as  an  article  of  diet  is  almost  unknown. 
The  author  believes  that  infection  by 
either  the  alimentary  or  respiratory 
tract  is  possible,  but  that  the  former  is 
a  frequent  and  possibly  the  most  fre- 
quent method,  and  that  the  common 
house  fly  forms  a  medium  for  the  con- 
veyance of  the  bacilli  from  the  ejected 
sputum  to  the  food.  J.  0.  Cobb  (Zeits. 
fur  Tub.  u.  Heilstatt.,  bd.  vi,  lit.  i; 
British  Medical  Journal,  December  10, 
1904). 

TYPHOID  FEVER,  TREATMENT  OF. 

The  writer  divides  the  methods  of 
treatment  of  typhoid  fever  into  four 
classes,  as  follows:  1.  Specific.  So  far 
no  antitoxic  serum  has  been  produced, 
although  Chantemesse  claims  to  have 
done  so.  On  the  other  hand,  Wright's 
method  of  antityphoid  inoculation  with 
attenuated  typhoid  cultures,  not  only 
confers  a  considerable  degree  of  protec- 
tion, but  it  also  exercises  a  mitigating 
influence  on  the  severity  of  the  attack. 
2.  Antipyretic,  (a)  Drugs.  Of  all  the 
drugs  used  to  reduce  the  temperature  in 
typhoid  fever,  quinine  is  undoubtedly 
the  best.  It  is  markedly  inhibitory  to 
the  growth  of  the  typhoid  bacillus  in 
cultures,  has  no  depressant  influence 
upon  the  heart,  and  does  not  inhibit  the 
elimination  of  toxins  from  the  system. 
Its  full  effect  is  not  reached  until  after 
four  or  five  hours,  (b)  Cold.  The  best 
method  of  treatment  by  means  of  the 
abstraction  of  heat  is  the  cold  bath,  as 
advocated  by  Brand.  But  in  England 
its  use  has  been  mainly  restricted  to  the 
combating  of  hyperpyrexia  in  special 
classes.  It  owes  its  superiority  to  its 
influence  on  the  nutrition  of  the  skin 
and  the  maintaining  of  the  excretory  ac- 


tivity of  the  skin  and  kidneys.  Barr's 
method  of  treatment  by  means  of  the 
continuous  tepid  bath  gives  excellent  re- 
sults, but  relapses  are  unduly  frequent. 
Ice  cradles,  cold  and  wet  packs,  and  cold 
sponging  all  have  their  advantages  in 
special  cases.  3.  Antiseptic.  It  is  now 
recognized  that  any  attempt  to  achieve 
the  destruction  of  typhoid  bacilli  in  the 
lower  region  of  the  intestinal  canal  by 
the  administration  of  antiseptic  drugs 
by  the  mouth  is  nothing  short  of  futile 
unless  given  in  such  quantity  as  to  harm 
the  patient.  But  antiseptics  are  rightly 
given  in  the  confident  hope  that  they 
will  inhibit  the  growth  of  the  typhoid 
bacillus  and  of  the  various  putrefactive 
organisms  associated  with  it  in  the  ali- 
mentary canal.  In  suitable  cases  calomel 
is  an  excellent  antiseptic;  in  others  it 
produces  harmful  intestinal  irritation. 
Sulphurous  acid  in  20  minim  doses  is 
capable  of  checking  fermentative  changes 
in  the  bowel;  the  oil  of  turpentine  is 
also  valuable  in  the  same  way. 

The  author  has  used  the  essential  oil 
of  cinnamon  in  a  series  of  147  cases.  Of 
these  14  died,  a  mortality  of  9.5  per  cent. 
The  favorable  effects  noted  were  as  fol- 
lows: The  temperature  ran  at  a  lower 
level  than  is  customary  in  typhoid,  the 
daily  mean  approximating  101°  F.  The 
patients  remained  for  the  most  part 
drowsy  throughout  their  illness,  many  of 
them  evincing  a  constant  desire  to  sleep, 
as  a  result  of  which  mental  rest  was  se- 
cured and  delirium  was  less  frequent. 
Intraintestinal  fermentation,  as  evinced 
by  abdominal  pain,  distention,  and  fcetor, 
was  controlled  to  a  striking  extent.  To 
obtain  the  full  effect,  2  1/2  to  5  minims 
of  the  essential  oil  must  be  given  every 
2  hours,  but  it  must  be  begun  in  much 
smaller  doses.  Cam  should  be  taken  that 
the  best  quality  of  the  oil  be  used;  the 
earlier  in  the  disease  it  is  begun  the  bet- 


46 


ULCER  OF  THE  STOMACH. 


VOMITING  OF  PREGNANCY. 


ter  the  result.  Experiments  show  that 
the  oil  of  cinnamon  has  an  appreciable, 
though  slight,  inhibitory  influence  on  the 
growth  of  the  typhoid  bacillus  in  a  dilu- 
tion of  1  in  2600:  at  1  in  1000  its 
strength  is  complete.  The  pulse  fur- 
nishes an  indication  of  the  highest  value : 
in  at  least  half  the  cases  death  is  due  to 
circulatory  failure.  In  most  cases  alco- 
hol is  not  only  not  required,  but  it  is 
occasionally  harmful.  The  special  indi- 
cations demanding  its  use  are :  Constant 
delirium  and  sleeplessness,  with  tremor, 
weak  circulation,  and  a  dry  tongue ;  un- 
due weakness  of  the  pulse;  cardiac  dila- 
tation, cyanosis,  and  pneumonia ;  hyper- 
pyrexia, excessive  diarrhoea,  and  intes- 
tinal perforation. 

The  treatment  of  intestinal  haemor- 
rhage consists  in  the  giving  of  a  full 
dose  of  opium,  the  use  of  the  icebag,  and 
the  complete  deprivation  of  fluids.  As 
regards  perforation,  a  moribund  condi- 
tion of  the  patient  is  the  only  contra- 
indication to  operation.  F.  F.  Caiger 
(Lancet,  November  26,  1904). 

ULCER  OF  THE  STOMACH  AND  DUO- 
DENUM. 
Gastric  ulcer  is  rare  in  the  Johns  Hop- 
kins Hospital  as  compared  with  cancer, 
the  respective  incidence  being  1  to  225 
and  1  to  56  general  admissions.  In  the 
writer's  series,  gastric  ulcer  was  as  com- 
mon in  the  male  as  in  the  female.  In 
the  male  the  percentage  of  greatest  fre- 
quency was  between  the  ages  of  forty 
and  fifty — a  decade  later  than  usual.  It 
was  relatively  more  frequent  in  the  col- 
ored race  and  among  Germans.  Vomit- 
ing occurred  in  85.3  per  cent. ;  pain  in 
82.9  per  cent,,  and  haematemesis  in  75.6 
per  cent.  Great  loss  of  weight  may  be 
present;  thus,  in  36  cases  there  was  a 
loss  of  more  than  10  pounds,  and  in  9 
of  40  pounds  or  more. 


The  writer's  statistics  would  indicate 
that  hyperchlorhydria  is  not  so  constant 
as  usually  maintained ;  it  was  present  in 
only  17.6  per  cent,  of  the  cases.  The 
blood  picture  is  one  of  chloranaernia  as 
seen  from  the  average  count  (haemo- 
globin, 58  per  cent. ;  red  blood  corpus- 
cles, 4,071,000;  white  blood  corpuscles, 
7500  per  cubic  millimeter).  Haemor- 
rhage was  the  cause  of  death  in  8.5  per 
cent,  of  the  total  number  of  cases,  and 
in  29.5  per  cent,  of  the  fatal  cases. 
Perforation  is  rare  (3  cases,  3.6  per  cent, 
of  present  series).  General  peritonitis 
occurred  in  but  one  instance  (1.2  per 
cent,).  Ulcus  carcinomatosum  is  rare — 
at  least  4.8  per  cent,  of  present  series. 

Operation  is  indicated  in  all  cases 
with  perforation  or  perigastric  adhesions, 
and  in  cases  of  copious  or  recurring 
haemorrhage  when  medical  means  have 
failed  after  a  fair  trial. 

The  mortality  of  the  series  was  29.3 
per  cent. ;  in  the  cases,  however,  who 
received  treatment  there  was  a  mortality 
of  only  18.8  per  cent. ;  in  those  receiving 
medical  treatment  alone,  8.6  per  cent, 
C.  P.  Howard  (American  Journal  of  the 
Medical  Sciences.  December,  1904). 

VOMITING  OF  PREGNANCY. 

There  is  simple  nausea  with  or  with- 
out actual  emesis  of  physiological  and 
reflex  origin,  a  symptom  only  due  to 
hyperaemia,  the  developing  uterus,  ves- 
sels, and  nerves  in  a  confined  cavity. 
Malposition  of  the  uterus,  if  the  cause 
of  so  many  troubles  in  ordinary  condi- 
tions of  health,  must  be  a  graver  trouble 
in  the  pregnant  woman,  and  thus  in- 
creases the  vomiting  of  pregnancy  and 
consequent  malnutrition  and  emaciation. 

In  the  absence  of  uterine  troubles  and 
organic  disease,  hysteria  plays  an  impor- 
tant role,  and  usually  defies  all  therapeu. 


BOOKS  AND  MONOGRAPHS  RECEIVED.  47 

tical  remedies.  If  operation  should  be  gastric  irritation  may  be  set  up  and  con- 
deemed  necessary,  it  should  be  carried  tinued  in  consequence  of  the  special  tox- 
out  under  thoroughly  antiseptic  condi-  a?mia  which  at  present  is  only  suspected, 
tions  and  anaesthesia.  but  which  in  further  researches,  the 
It  is  probable  in  pregnancy,  with  its  writer  is  convinced,  will  be  scientifically 
increased  arterial  tension,  and  where  proved.  J.  M.  H.  Martin  (British  Med- 
lung   and    cardiac    complications    exist,  ical  Journal.  December  10,  1904). 


DE.  FEAXK  P.  FOSTER. 


Dr.  Foster  has  just  completed  the  twenty-fifth  year  of  his  labors  as  Editor  of 
the  New  York  Medical  Journal.  Started  as  a  monthly,  the  journal  has  steadily  in- 
creased in  size  and  importance  under  his  able  management  until  it  has  become  what 
it  is  now,  one  of  the  leading  scientific  weeklies  of  our  land.  Dr.  Foster's  generosity 
under  all  occasions,  his  lofty  ideals,  and  the  marked  influence  his  labors  have  had  in 
the  development  of  medical  journalism,  have  given  him  a  place  in  the  estimate  of 
his  colleagues  that  anyone  can  envy.  We  heartily  congratulate  him  and  wish  him 
manv  more  vears  of  success. 


IJooks  and  ponographs  Received. 


The  editor  begs   to  acknowledge,   with   thanks,  the   receipt   of  the  following  books   and 
monographs:  — 

Transactions  of  the  Clinical  Society  of  London.    Volume  Thirty-Seventh,  1904. Transac- 
tions of  the  American  Otological  Society.    Vol.  VIII,  Part  III.     1904. Annual  Report  of  the 

Surgeon-General    of   the   Public   Health   and   Marine-Hospital    Service   of   the    United   States 

for  the  Fiscal  Year  1904. Report  of  the  Secretary  of  Agriculture,  1904. A  Case  of  Supposed 

Primary  Tuberculosis  of  the  Pharyngeal  Tonsil.    By  D.  M.  Barstow,  New  York.     1904. The 

Aseptic   Technic   of   Abdominal   Surgery   with   the   Topographical    and   Visceral    Anatomy   of 

Male  and  Female  Abdomen.    By  H.  0.  Walker,  Detroit,  Mich.     1904. Treatment  of  Anaemic 

Conditions  in  Children  with  Iron.   By  George  Carpenter,  London,  Eng.     1904. Report  of  the 

Committee  on  Prophylaxis  of  Venereal  Diseases.     Ludwig  Weiss,  New  York. Contributions 

to  the  Pathology  and  Treatment  of  Acute  Gonorrhoea.    By  Ludwig  Weiss,  of  New  York.     1904. 

Hereditarv  Abnormitv  of  the  Little  Fineer.    Bv  G.  T.  Mundorff,  New  York.     1904. The 

Kollmann  Five-Glass  Test.     By  G.  T.   Mundorff,  New   York.     1904. Report   of  a   Case   of 

Obstinate  Phosphatic  Diathesis  cured  by  Systematic  Dilatations  of  the  Posterior  Urethra.    By 

G.  T.  Mundorff.  New  York.     1904. A  Case  of  Horeshoe  Kidney  Found  During  an  Operation 

for  Nephrectomy  on  the  Cadaver.     By  G.   T.  Mundorff..   New  York. Bacillus   Pyocyaneus 

Septicaemia  Associated  with  Blastomycetic  Growth  in  Primary  Wound.     By  J.  R.  Eastman 

and  T.  V.  Keene,  Indianapolis,  Ind.     1904. The  Relation  of  Asthma  to  Nose  Disease.     By 

Greville  Mac-Donald,  London,  Eng.     1904. Sarcoma  of  the  Abdominal  Wall,  and  Probably 

of  the  Pelvic  Viscera,  which  has  Disappeared  under  the  Use  of  the  Rontgen  Rays.     By  G.  E. 

Shoemaker.  Philadelphia.     1903. Fibroma  of  the  Uterus,  Complicated  by  Disorders  of  the 

Heart  and  Kidneys.   By  G.  E.  Shoemaker.  Philadelphia.    1904. Immunity  from  Consumption. 

Cause  and  Treatment  of  Consumption.  Massage  Treatment  for  Consumption.  By  C.  L.  Topliff, 
New  York.  1904. Poisoning  by  Wood  Alcohol.  Causes  of  Death  and  Blindness  from  Colum- 
bian Spirits  and  Other  Methylated   Preparations.     By  Frank  Puller.  Montreal.  Canada,  and 

C.  A.  Wood,  Chicago,  111.     19*04. International  Sugar  Situation.     By  F.  R.  Rutter,  United 

States  Department  of  Agriculture,  \\  a>hington,  D.  C.  1904. Varieties  of  Fruits  Recom- 
mended for  Planting.    By  W.  II.  Ragan,  United  Stat,-  Department  of  Agriculture.  Washington, 

D.  C.  1904. The  Chemical  Composition  of  Apples  and  Cider.  By  W.  15.  Alwood.  R.  J.  David- 
son, and  W.  A.  P.  Moncure,  United  State-  Department  of  Agriculture.  Washington.  D.  C.    1904. 

Progress  Report  on  the  Strength  of  Structural  Timber.     By  W.  K.  Hatt,  United  States 

Department  of  Agriculture.  Washington,  D.  C.     1904. The  Use  of  Paris  Green  in  Controlling 

the  Cotton  Boll  Weevil.  Bv  W.  D.  llrnter,  United  state-  Department  of  Agriculture,  Wash- 
ington. D.  C.     1904. 


EDITORIAL  STAFF. 

Sajous's  Analytical  Cyclopaedia  of   Practical  Medicine. 


ASSOCIATE.  EDITORS. 


J.  GEORGE  ADAMI,  M.D., 

Ml  i.N  I  KtJL,  P.  Q. 


LEWIS  H.  ADLER,  M.D., 

PHILADELPHIA. 


JAMES  M.  ANDERS,  M.D.,  LL.D., 

PHILADELPHIA. 


THOMAS  G.  ASHTON,  M.D., 

PHILADELPHIA. 


A.  D.  BLACKADER,  M.D., 

MONTREAL,  P.  U- 


E.  D.  BONDURANT,  M.D., 

MOBILE,  ALA. 


DAVID  BOVAIRD,  M.D., 

NEW  YORK  CITV. 


WILLIAM  BROWNING,  M.D., 

BROOKLYN,  N.  Y. 


WILLIAM  T.  BULL,  M.D., 
NEW  YORK  CITY. 


CHARLES  W.  BURR,  M.D., 

PHILADELPHIA. 


HENRY  T.  BYFORD,  M.D., 

CHICAGO,  ILL. 


HENRY  W.  CATTELL,  M.D., 

PHILADELPHIA. 


WILLIAM  B.  COLEY,  M.D., 

NEW  YORK  CITY. 


FLOYD  M.  CRANDALL,  M.D., 

NEW  YORK  CITY. 


ANDREW  F.  CURRIER,  M.D., 
NEW  YORK  CITY. 


ERNEST  W.  CUSHING.  M.D., 

BOSTON,  MASS. 


GWILYM  G.  DAVIS,  M.D., 

PHILADELPHIA. 


N.  S.  DAVIS,  M.D., 

CHICAGO.  ILL. 


AUGUSTUS  A.  ESHNER,  M.D., 

PHILADELPHIA. 


SIMON  FLEXNER.  M.D., 

PHILADELPHIA. 


LEONARD  FREEMAN,  M.D., 

DENVER,  COL. 


8.  G.  GANT,  M.D. 

NEW  YORK  CITY. 


1.  MoFADDEN  GASTON,  Sr.,  M.D., 

ATLANTA,  GA. 


J.  MoFADDEN  GASTON,  Je.,  M.D., 

ATLANTA,  GA. 


k    B.  GLEASON,  M.D., 
PHILADELPHIA. 


EGBERT  H.  GRANDIN.  M.D., 

NEW  YORK  CITY. 


J.  P.  CROZER  GRIFFITH,  M.D., 

PHILADELPHIA. 


C.  M.  HAY,  M.D., 

PHILADELPHIA. 


FREDERICK  P.  HENRY,  M.D., 

PHILADELPHIA. 

L.  EMMETT  HOLT,  M.D., 
NEW  YORK  CITY. 

EDWARD  JACKSON,  M.D., 

DENVER,  COL. 

W.  W.  KEEN,  M.D., 

PHILADELPHIA. 

EDWARD  L.  KEYES,  Jr.,  M.D., 

NEW  YORK  CITY. 

ELWOOD  R.  KIRBY,  M.D., 

PHILADELPHIA. 

L.  E.  La  FETRA.  M.D., 

NEW  YORK  CITY. 

ERNEST  LAPLACE,  M.D.,  LL.D., 

PHILADELPHIA. 

R.  LEPINE.  M.D., 
LYONS,  FRANCE. 

F.  LEVISON,  M.D., 

COPENHAGEN,  DENMARK. 

A.  LUTAUD,  M.D., 
PARIS,  FRANCE. 

G.  FRANK  LYDSTON,  M.D.. 
CHICAGO,  ILL. 

F.  W.  MARLOW,  M.D., 

SYRACUSE,  N.  Y. 

SIMON  MARX.  M.D., 

NEW  YORK  CITY. 

ALEXANDER  McPHEDRAN.  M.D., 

TORONTO,  ONT. 

E.  E.  MONTGOMERY,  M.D, 

PHILADELPHIA. 

HOLGER  MYGIND.  M.D., 

COPENHAGEN,  DENMARK. 

W.  P.  NORTH  RUP.  M.D.. 
NEW  YORK  CITY. 

RUPERT  NORTON,  M.D.. 

WASHINGTON,  D.  0. 

H.  OBERSTEINER,  M.D., 

VIENNA,  AUSTRIA. 

CHARLES  A.  OLIVER,  M.D., 

PHILADELPHIA. 

WILLIAM  OSLER.  M.D.,     - 

BALTIMORE,  MD. 

LEWIS  S.  PILCHER,  M.D., 

BROOKLYN,  N.   Y. 

WILLIAM  CAMPBELL  POSEY.  M.D.. 
PHILADELPHIA. 


W.  B.  PRITCHARD.  M.D., 
NEW  YORK  CITY. 


JAMES  J.  PUTNAM,  M.D., 

BOSTON. 


B.  ALEXANDER  RANDALL,  M.D., 

PHILADELPHIA. 


CLARENCE  C.  RICE,  M.D., 
NEW  YORK  CITY. 


ALFRED  RUBINO,  M.D., 

NAPLES,  ITALY. 


REGINALD  H.  SAYRE,  M.D., 

NEW  YORK  CITY. 


JACOB  E.  SCHADLE,  M.D., 

ST.  PAUL,  MINN. 


JOHN  B.  SIIOBER,  M.D., 

PHILADELPHIA. 


J.  S0LIS-CO1IEN,  M.D., 

PHILADELPHIA. 


SOLOMON  SOLIS-COHEN,  M.D., 

PHILADELPHIA. 


H.  W.  STELWAGON,  M.D., 

PHILADELPHIA. 


D.  D.  STEWART.  M.D., 

PHILADELPHIA. 


LEWIS  A.  STIMSON,  M.D., 

NEW  YOliK  CITY. 


J.  EDWARD  STUBBERT,  M  D.. 

LIBERTY,  N.  Y. 


A.  E.  TAYLOR,  M.D., 

SAN  FRANCISCO,  CAL. 


J.  MADISON  TAYLOR.  M.D., 

PHILADELPHIA.     . 


M.  B.  TINKER.  M.D., 

PHILADELPHIA. 


CHARLES  S.  TURNBULL,  M.D.. 

PHILADELPHIA. 


HERMAN  F.  VICKERY,  M.D., 

BOSTON,  MASS. 


F.  E.  WAXHAM,  M.D., 

DENVER,    COL. 


J.  WILLIAM  WHITE,  M.D., 

PHILADELPHIA. 


JAMES  C.  WILSON,  M.D.. 

PHILADELPHIA. 


C.  SUMNER  WITHERSTINE,  M.D., 

PHILADELPHIA. 


ALFRED  C.  WOOD,  M.D., 

PHILADELPHIA. 


WALTER  WYMAN,  M.D., 
WASHINGTON,  D.  0. 


[End  of  the  Editorial  Department  of  the  Monthly  Cyclopaedia  for    Jan.,     1904.] 


THE    MONTHLY   CYCLOPEDIA 

OF 

PRACTICAL   MEDICINE 


(Published  the  Last  of  Each  Month) 


PHILADELPHIA,  FEBRUARY,  1905. 


Vol.  VIII,  No.  2. 
New  Series. 


PAGE 

EDITORIALS 

THE     PREBENT     STATUS     OF 

NEUROLOGY.     Joseph  Collins 49 

BUPRARENAL  EXTRACT  IN  THE 
TREATMENT  OF  CARDIO- 
VASCULAR   DISEASE.      James 

Tyson 53 

THE     TEACHING     OF    SPECIALTIES 

IN  MEDICINE.  Charles  A.  Oliver,     55 
MYXEDEMA  IN  ITS  RELATIONS  TO 
THE     ADRENAL      SYSTEM. 
Charles  E.  de  M.  Sajous 55 

CYCLOPEDIA    OF   CURRENT 
LITERATURE 

ACETONURIA    ELBtWHhRE     THAN 

IN    DIABETES.     Beauvv 58 

ALBUMINURIA,        PHYSIOLOGICAL 


TABLE  OF  CONTENTS. 

PAGE  | 

ENURESIS.     Julius  Ullmann 67 

EPILEP8Y,  TREATMENT  OF  BY 
LIGATION  OF  LONGITUDINAL 

SINUS.     Delageniere 68 

EROTOMANIA.    J.  L.  Coining 68 

ERYSIPELAS:     TREATMENT.     F. 

Franke 69 

ERYTHEMA  INFECTIOSUM.       H.   L. 

K.  Shaw (9 

ETHYL  CHLORIDE.     H.  Ililliard 7u 

FRACTURES,  CARE  0  1,  FROM 
STANDPOINT  OF  GENERAL 
PRACTITIONER.      W.   S.   New- 


AND  PATHOLOGICAL.    Senator,     59 
ANESTHESIA,    LOCAL.      A.  E.  Bar- 
ker      59 

ANTISTREPTOCOCCIC    SERUM.  AD- 
MINISTRATION     OF.       J.    W. 

Thomson   Walker 60 

AORTIC  INSUFFICIENCY.  TRAUMA 

AS  CAUSE  OF.     Sinnhuber 61 

ARTERIAL        HYPERTENSION, 

CHRONIC.     II.  W.Cook  61 

BARIUM  CHLORIDE  IN  THERAP1U- 

TICS      E.  Pesci 62 

BLADDER     PRIMARY  SARCOMA  OF 

J.  A  Wilder 62 

CARBONIC      OXIDE      POISONING. 

F.  Strissmann  and  A.  Schnlz 63 

CARDIAC  INSUFFICIENCY.  CAUSIS 

OF.     J.  II.  Pratt 63 

CERVIX     1NTERI,   C  AN  CE  R     OF, 
TREATMENT,   IN     ADVANCED 

STAGES.     J.  Wesley  Bovee 64 

CILIARY    BODY,     SYPHILOMA     OF 

Herman    Knapp 64 

CONJUNCTIVITIS,      PURULENT, 

TREATMENT    OF.     Myles  Stan- 


dish. 


64 


CONVULSIONS  IN  CHILDREN  AND 
THEIR  RELATION  TO  EPI- 
LEPSY.    R.  O.  Moon  65 

CORYZA,      ACUTE,     ABORTIVE 

TREATMENT   OF.     Ruault 65 

DENGUE.     D.  N.  Carpenter  and  R.  E. 

Sutton 66 

DIABETIC  GANGRENE  OF  THE 
LOWER  EXTREMITY.  II.  J. 
Whitaere 66 

DIGE8TIVE     DISORDERS,       TFEAT- 

MENT  OF.     J.  W.  Hunter,  Jr 65 

DISINFECTION  OF  HANDS,  ANTI- 
SEPTIC     OR      MECHANICAL? 

R.  Sehaeffer 67 

ECZEMA,  INFANTILE:  TREAT- 
MENT.    C    Clenet 67 


HEMOPTYSIS:    TREATMENT     II. 

Hyslop   Thomson 71 

HEPATIC    ABSCESS.      N.  W.  Sharpe.     7i 

I0TERU8,  PATHOLOGY  OF.  "Jour- 
nal American  Medical  Associa- 
tion " ; 7i 

INTESTINE,   ROLF.    OF    POISONS  IN 

Charrin  and  Leplay 7:j 

KNEE-JOINT  EFFUSION,  RECUR- 
RENT^   W.  H.  Bennett 73 

LACTIC  ACID  FORMATION,  EX- 
PERIMENTAL STUDY  OF 
ETC.  E.    Palier 47 

LEAD    POISONING,     EYE     LESIONS 

OF  CHRONIC.     L,  Lewin 74 

LEUCOCYT08IS,  NAlURk  AND  SIG- 
NIFICANCE OF.    A.  M.  Holmes,     74 

MALARIA,  HEART  IN.     P.  Galenga.    75 

MASTOID  OPERATIONS,  CHOICE  OF 
TIME  OF  ELECTION  IN  D.  A. 
Kuyk 75 

METAL  FERMENTS,  ACTION  OF, 
ON  METABOLISM  AND  IN 
PNEUMONIA.      A.  Robin 7<| 

NEURASTHENIA,  WORK  AS  A  REM- 
EDY IN.      H.  J.  Hall 77 

OPTIC     NEURITIS    AND     FACIAL 

PARALYSIS.     E.  A.  Shunnvny...     77 

ORTHOPEDIC  SURGERY,  DIAGNOS- 
TIC VALUE  OF  TUBERCULIN 
IN.  W.  S.  Baer  and  H.  W.  Ken- 
nard 7s 

PANCREA8.     LYMPH    FLOW  FROM. 

F.  A.  Bainbridge 7s 

PARAURETHRITIS.  J.  W.  Churchman,  78 
PERTUSSIS  TREATED    BY    ELASTIC 

ABDOMINAL     BELT.       T.    G 


PNEUMONIA,  MANAGEMENT  OF 
O.  T.  Osborne 

PRESBYOPIA,  PBEMATURE,  G.M. 
Gould 

PROSTATECTOMY,     m"  B.  Tinker!!"... 
PUERPERE,    CARE    OF.      J.  D  Voor- 


Kilmer 


PERTU8SIS,  TREATMENT  OF. 
L.    Itzkowitz 

PNEUMONIA:  18  IT  INCREASING? 
J.  S.  Fulton 

PNEUMONIA,  PREVENTION  AND 
TREATMENT  OF  HEART- 
FAILURE  IN.     S.  Solis  Cohen.... 


PUERPERAL    INFECTION,     SALINE 

INFUSION  IN.     J.  Jaworski 84 

PUPILS,  INEQUALITY  OF  IN  DIS- 
EASES OF  THE  LUNGS  AND 
PLEURA.      Dchrain  84 

ROENTGEN  RAYS,  lNILUENCfc  OF 
ON  INTERNAL  ORGANS.  H.' 
Heineke 85 

STOMACH,  DISEASES  OF,  CRITI- 
CISM OF  RECENT  SURGICAL 
LITERATURE  ON.  II.  W.  Bett 
mann 85 

SUPRARENAL  EXTRACT.  INFLU- 
ENCE OF,  UPON  ABSORPTION 
AND  TRANSUDATION  S.  J. 
Meltzer  and  John   Auer 86 

SUPRARENAL  INSUFFICIENCY.     G. 

Bossuet 86 

SYPHILIS,  SCARS  AND  THE  RE- 
TROSPECTIVE DIAGNOSIS  OF 
Arthur  Cooper S6 

TABES,  PAINS  OF.    W.  R.  Goners.         87 

TENOTOMY      OP     THE      TENDO- 

ACHILLES.      J.  P.lWebster 88 

TETANUS.   BLANK  CARTRIDGE.    D 

H.  Dolley 88 

TONSIL,  FUNCTION  OF.    G.  B.  Wood,     8 

TONSILLITIS  AND  ARTICULAR 
RHEUMATISM,         RELATIONS 

BETWEEN.      Gurich S9 

TUBERCULOSIS  AND  MORTALITY 
IN  CHILDHOOD.  W.  P.  S  Bran- 
s'1"      '0 

TUBERCULOSIS,    HEALING    OF.     II. 

M.  King 90 

TUBERCULOSIS     IN     THE     UNITED 

STATES.     S.A.Knopf. !1 

TUBERCUL08IS,    PULMONARY. 


Wl 


rnin 


!1 


TUBERCULOSIS,  PULMONARY, 
FIRST  ANATOMICAL 
CHANGES  IN    A.  J.  Abrikossoff, 

TUBERCULOSIS,  TRANSMISSION  OF. 

S.  Kitasato 92 

TYPHOID  FEVER,     RUPTURE    OF 

THE  MUSCLBS  IN.    Perochaud...     91 

UTERINE       MYOMATA,      EIECTR1C 

TREATMENT  OF.     E.  Witte 94 

UTERINE       RETRODEVIATIONS. 

Lucy  Waite 91 

VOMITING,  RECURRENT,  B.  K. 
Rachford 

BOOKS  AND  MONOGRAPHS  RE- 
CEIVED      95 

STAFF  LIST 96 


VI 


94 


Editorials. 

DEPARTMENT  IN  CHARGE   OF 
J.   MADISON   TAYLOR,   A.M.,   M.D. 

THE  PRESENT  STATUS  OF  NEUROLOGY. 

A  generation  ago  neurology  seemed  to  have  the  most  promising  outlook  of  any 
of  the  departments  of  medical  science.  The  correlated  results  of  the  experimenter, 
the  anatomist,  and  the  clinician  were  so  conclusive  and  so  illuminating,  not  only  of 


50  THE    PEESENT    STATUS    OF    NEUROLOGY. 

many  of  the  obscure  points  in  the  physiology  of  the  nervous  system,  but  of  its  dis- 
eases as  well,  that  many — even  the  most  conservative — hailed  the  advent  of  a  new 
era  in  this  department  of  medicine.  The  stimulus  which  these  results  gave  to  the 
diagnosis  of  diseases  of  the  nervous  system  is  best  evidenced  by  the  progress  which 
has  been  made  in  that  field.  In  no  department  of  clinical  medicine  have  the  results 
been  more  gratifying  and  to-day  the  correct  diagnosis  of  organic  diseases  of  the 
nervous  system  is  more  directly  dependent  upon  the  application  of  rules  of  scientific 
exactitude  than  in  any  other  department  of  internal  medicine.  Despite  this  com- 
mendable state  of  affairs,  there  is  no  denying  that  during  the  past  few  years  a 
remarkable  stagnation  in  neurological  progress  has  come  about.  The  proceedings 
of  the  neurological  societies  of  the  great  cities  of  the  world,  London,  Paris,  Berlin, 
Xew  York,  are  the  best  proof  of  this  statement.  During  this  time  no  contribution 
of  signal  importance  has  been  made  and  not  only  is  there  a  real  dearth  of  epoch- 
making  contributions,  but  the  apathy  and  indifference  manifest  toward  the  subject 
is  shown  in  the  comparatively  few  contributions  in  which  new  points  of  view  are  set 
forth.  In  certain  centers  this  stagnation  of  neurological  progress  has  been  com- 
pensated for  in  a  measure  by  a  renewal  of  interest  in  psychiatry,  and  thanks  to  the 
initiative  of  Kraepelin  and  to  the  persistence  of  Wernicke,  the  clinical  study  of 
mental  diseases  has  had  a  very  decided  impetus  given  to  it  throughout  the  entire 
world.  One  of  the  results  of  this  impetus  is  to  be  seen  in  the  tendency  at  the  present 
time  to  put  many  of  the  cases  of  functional  nervous  disease,  such  as  were  formerly 
classified  under  neurasthenia  and  hysteria,  under  the  caption  of  mental  diseases. 
Another  is  the  frequency  with  which  the  meetings  of  neurological  societies  are 
entirely  given  over  to  the  discussion  of  psychiatric  subjects;  and  a  third  is  the 
immense  number  of  contributions  upon  mental  disorders  that  is  to  be  found  both 
in  the  weekly  medical  journals  and  in  the  special  neurological  periodicals. 

This  revival  of  interest  in  psychiatry  is  most  commendable  and  will  certainly 
lead  to  gratifying  results.  But  at  the  same  time  it  need  not  blind  us  to  the  fact 
that  a  part  of  the  interest  being  manifest  in  psychiatry  is  that  which  was  formerly 
given  to  neurological  subjects,  and  that  the  chief  reason  why  it  is  no  longer  given 
to  the  latter  is  that  neurology  for  the  time  being  seems  to  have  come  to  a  genuine 
standstill.  The  idea  that  the  laboratory  worker  would  reveal  the  pathogenesis  and 
with  it  the  real  etiology  of  many  of  the  organic  and  functional  diseases  of  the  nervous 
system  which  was  held  a  generation  ago  has  been  supplanted  by  one  which  holds 
that  for  this  information  we  must  look  elsewhere.  As  a  matter  of  fact,  the  promise 
which  the  laboratory  held  out  has  not  been  made  good.  We  have  been  profoundly 
informed  as  to  the  structure,  situation,  and  architecture  of  the  nervous  system,  we 
are  deeply  versed,  compared  to  a  generation  ago,  in  the  physiology  of  the  nervous 
system  and  both  of  these  desirable  states  have  been  brought  about  largely  by  the 
worker  in  the  laboratory,  but  we  know  very  little  more  concerning  the  etiology, 


THE    PRESENT    STATUS    OF    NEUROLOGY.  51 

pathogenesis,  and  the  clinical  display  of  the  majority  of  nervous  diseases,  organic 
and  functional,  than  we  did  twenty  years  ago.  We  no  longer  have  any  interest  or 
incentive  in  reporting  one  or  several  cases  of  disseminated  sclerosis  or  tabes  or  pro- 
gressive muscular  atrophy  or  bulbar  paralysis  or  myasthenia  gravis,  even  though 
they  are  accompanied  by  reports  of  most  carefully  performed  histological  work, 
because  we  are  unable  to  add  anything  new  to  what  has  already  been  said  and  said 
very  often.  There  is  no  incentive  to  work  over  the  statistics  of  epilepsy  or  hysteria 
or  brain  tumors,  or  of  tabes  or  of  paralysis  agitans  or  any  of  the  other  well  known 
diseases  of  the  nervous  system.  The  successive  contributions  in  this  direction  brings 
with  them  no  illumination.  Occasionally  a  disease  undergoes  a  clinical  transforma- 
tion in  the  course  of  time,  such  as  general  paresis  and  tabes  seem  to  have  done,  and 
then  the  clinical  course  and  description  of  the  disease  has  to  be  rewritten.  Occa- 
sionally a  clinician  of  large  experience  and  profound  insight  is  able  to  split  up  a 
disease  into  two  or  more  distinct  varieties  or  to  lop  off  from  a  more  or  less  hetero- 
geneous symptom-complex  a  clinical  entity  such  as  Erb  did  when  he  established 
the  reality  of  syphilitic  spinal  paralysis.  Now  and  then  some  new  objective  symptom 
of  real  diagnostic  importance  is  discovered,  such  as  the  toe  phenomenon  of  Babinski 
indicative  of  lesion  of  the  pyramidal  tracts,  but  in  the  main  no  considerable  progress 
in  neurology  has  been  made  during  the  past  few  years,  and  it  is  to  this  absence  of 
progress  that  we  must  attribute  the  widespread  lack  of  interest  in  neurological 
subjects. 

In  a  measure  our  apparent  indifference  is  the  expression  of  our  disappointment 
that  the  laboratory  worker,  experimenter,  and  pathologist  have  not  realized  our 
expectations  that  they  would  contribute  to  the  elucidation  of  the  origin  and  course 
of  nervous  disease.  More  depressing  still  is  the  fact  that  there  are  no  signs  tending 
to  indicate  that  we  can  look  to  them  for  much  help  in  the  future.  As  a  matter  of 
fact  the  neurologist  must  look  to  himself  in  the  interpretation  of  diseases  of  the 
nervous  system  and  not  pin  his  hope  to  the  psychologist,  physiologist,  or  pathologist. 
The  riddles  of  his  branch  of  pathology  are  more  likely  to  be  guessed  by  him  because 
of  his  own  clinical  experience  than  from  any  other  equivalent.  What  neurology 
needs  at  present  more  than  anything  else  is  votaries  who  are  trained  in  the  highest 
degree  to  exact  observation  and  to  exact  recording  of  such  observations. 

The  recognition  of  the  vast  majority  of  the  functional  'and  organic  nervous 
diseases  when  they  have  reached  certain  not  very  advanced  states  of  development  is 
probably  one  of  the  easiest  branches  of  the  medical  art  to  acquire.  The  majority 
of  the  organic  nervous  diseases  are  accompanied  by  objective  symptoms  which  indi- 
cate the  diagnosis  with  absolute  certainty,  and  to  recognize  them  requires  no  con- 
siderable skill  and  no  especial  training,  but  to  detect  the  earlier  symptoms  of  such 
diseases  and  to  give  them  correct  interpretation,  to  determine  the  perversion  of 
function,  particularly  in  the  viscera,  which  such  symptoms  indicate,  and  to  give 


52  THE    PRESENT    STATUS    OF    NEUROLOGY. 

them  their  true  significance  in  contributing  to  the  nervous  disease  is  the  task  which 
is  by  no  means  easy.  It  is  the  absence  of  exactitude  in  observation  and  in  recording 
of  the  earlier  symptoms  of  nervous  disease  or  of  symptoms  that  seem  to  be  remote 
from  the  disease  that  we  are  endeavoring  to  interpret  that  has  helped  to  make 
neurology  the  barren  acre  that  it  seems  to  be  to-day;  and  if  we  propose  to  cultivate 
it  and  expect  to  find  it  fertile  we  must  go  back  to  the  first  principles  that  have  been 
found  useful  in  the  interpretation  of  every  disease.  Facts  are  what  are  needed  in 
neurology  at  the  present  time.  They  are  the  material  from  which  must  be  built  the 
road  upon  which  the  triumphal  march  of  neurology  may  pass.  One  often  hears  it 
said  that  the  day  of  operating  for  brain  tumors  has  passed,  that  surgeons  of  experi- 
ence are  not  keen  to  undertake  these  cases  unless  under  the  most  favorable  circum- 
stances. Despite  this  attitude  it  is  probable  that  when  the  neurologist  acquires-  a 
comprehensive  insight  into  the  symptomatology  of  intracranial  neoplasms;  when 
he  can  come  forward  with  the  facts  of  these  cases,  the  surgical  treatment  of  them 
will  not  only  take  the  place  which  it  was  thought  it  had  taken  ten  years  ago,  but  it 
will  be  an  adequate  treatment  in  perhaps  a  majority  of  cases. 

The  urgent  necessity  is  for  an  enlargement  of  our  clinical  horizon  by  careful 
and  exact  observation  and  record,  not  only  of  phenomena  which  are  already  recog- 
nized as  symptomatic,  but  of  all  phenomena  whether  it  has  or  has  not  apparent 
bearing  upon  the  disease,  which  will  eventually  permit  of  logical  analysis  and  inter- 
pretation of  objective  phenomena.  Many  examples  might  be  cited  to  show  the  exist- 
ence of  a  hiatus  in  our  neurological  knowledge.  Take,  for  instance,  the  question 
of  ankle  clonus.  A  most  important  question  is,  does  it  or  does  it  not  exist  in  func- 
tional nervous  disease  such  as  hysteria?  One  will  answer  the  question  in  the  affirma- 
tive, another  in  the  negative,  but  where  are  the  facts  that  should  stand  out  with  the 
distinctness  and  splendor  of  jewels  in  an  imperial  crown?  This  is  not  an  isolated 
example,  a  half  score  might  be  cited  quite  as  easily.  Neurology  has  missed  the 
fructifying  impetus  and  rejuvenating  effect  of  bacteriology  which  have  been  given 
so  bounteously  to  surgery  and  internal  medicine  during  the  present  generation,  and 
consequently  the  pace  which  has  been  set  by  them  along  the  high  road  of  progress 
would  seem  to  be  too  rapid  for  the  offshoot  neurology  which  appeared  so  lusty  at  its 
birth  and  during  its  youthful  days. 

The  tranquil  stage  through  which  neurology  is  passing  does  not  mean  that  it 

has  forfeited  its  claim  to  be  considered  a  competitor  in  the  race.     On  the  contrary, 

the  new  bearings  that  are  being  taken,  the  deep  consideration  that  is  being  given 

to  the  problems  that  present  themselves,  the  continual  seeking  for  new  avenues  that 

will  reach  the  goal  more  directly  and  surely,  are  bound  to  win  in  the  end  large  rewards 

for  her  patient  devotees. 

.Joseph  Collins.* 
New  York. 


*Professor  of  Nervous  and  Mental  Diseases,  Post-Clraduate  Medical  School. 


SUPRARENAL  EXTRACT  IN  THE  TREATMENT   OF   CARDIO- 
VASCULAR DISEASE. 

Some  recent  experience  has  led  the  writer  to  examine  more  closely  into  the 
results  reported  from  the  use  of  suprarenal  derivatives — viz.:  suprarenal  extract 
and  adrenalin— in  the  above  mentioned  class  of  diseases.  Such  examination  has 
resulted  in  the  conclusion  that  they  are  sufficiently  encouraging  to  justify  further 
trial,  with  a  view  to  determining  the  actual  value  of  these  agents.  While  we  have  in 
digitalis,  strophantus,  nitroglycerin,  caffeine  and  its  derivatives  valuable  remedies 
in  these  affections,  we  are  not  embarrassed  by  their  number. 

The  clinical  effect  claimed  for  suprarenal  extract  is  a  strengthening  of  the 
cardiac,  muscle  resulting  in  increased  force  and  restored  rhythm,  if  the  latter  has 
been  lost.  The  roborant  effect  is  so  far  recognized  that  the  hypodermic  injection 
of  adrenalin  in  the  treatment  of  shock  has  become  quite  common,  but  its  use  in 
cardiac  disease  as  a  substitute  for  other  cardiac  tonics  has  not  become  general. 

It  may  aid  us  to  a  better  understanding  to  review  the  modus  operandi  of 
suprarenal  extract  and  its  active  principle,  adrenalin.  One  of  the  earliest  discov- 
ered effects  is  their  local  action  on  blood-vessels,  as  the  result  of  which  they  became 
early  valuable  for  the  control  of  local  haemorrhages  and  hyperemias;  whence,  too, 
their  employment  in  nasal  therapeutics.  To  this  knowledge  was  soon  added  a  like 
effect  when  administered  by  the  mouth,  presumably  due  to  vasomotor  stimulation 
of  the  muscular  coat.  Herein  is  the  first  stimulus  to  the  energy  of  the  heart, — 
i.e.,  an  increased  resistance  to  the  movement  of  the  blood  which  up  to  a  certain 
degree  stimulates  and  strengthens  cardiac  contraction. 

It.  is  not,  however,  through  its  effect  as  a  vasoconstrictor  stimulant  alone  that 
suprarenal  extract  increases  the  strength  of  the  heart.  It  is  acknowledged  that  it 
produces  more  forcible  contraction  of  the  cardiac  muscle  itself  either  through  direct 
stimulation  of  the  muscular  substance  or  by  a  specific  action  of  the  poison  on  the 
intracardial  motor  ganglia.  The  former  view  is  held  by  Oliver  and  Shafer  and  the 
latter  by  Gottlieb  of  Heidelberg.  Thus  it  would  seem  that  the  effect  of  suprarenal 
extract  is  like  that  of  digitalis — coincidently  a  stimulus  to  the  heart  muscle  and  vessel 
muscle. 

It  may  be  said,  if  the  action  of  suprarenal  products  is  like  that  of  digitalis,  it 
is  not  an  actual  addition  to  our  cardiac  materia  medica.  But  though  these  operations 
may  be  similar,  they  are  probably  never  identical.  Strophantus,  at  first  thought 
to  differ  from  digitalis,  in  its  absence  of  contracting  effed  on  the  muscular  coat 
of  the  blood-vessels,  was  soon  found  to  act  similarly  on  both  muscles.  But  further 
studies  reiterate  the  earlier  conclusion,  at  least  to  this  extent:  that  the  effect  on 
the  muscular  coat  of  the  blood-vessels  is  not  as  strong  as  that  of  digitalis.  lie  this 
as  it  may,  we  are  often  glad  to  substitute  strophantus  for  digitalis,  for  a  time  at 
3  (53) 


54  TREATMENT  OP  CARDIOVASCULAR  DISEASE. 

least.  The  same  may  be  true  of  the  suprarenal  extract,  the  effect  of  which  may  be 
found  sufficiently  different  from  that  of  the  better  known  heart  tonics  to  make  it 
a  desirable  substitute. 

An  objection  to  suprarenal  extract  and  adrenalin  is  their  temporary  and  fleet- 
ing action.  The  same  may  be  said  of  nitroglycerin,  which  has  come  to  be  acknowl- 
edged, nevertheless,  as  a  useful  agent  in  cardio-renal  therapeutics  in  the  hands  of 
clinicians.  It  may  be,  too,  that  the  operation  of  suprarenal  extract  is  slower 
than  that  of  its  active  principle,  adrenalin,  and  that  therefore  it  is  more  suitable  in 
chronic  cardiac  diseases,  and  adrenalin  better  suited  in  sudden  heart  failure  and 
shock  because  of  its  more  rapid  action. 

As  to  authorities  and  doses,  S.  Florsheim  regards  the  suprarenal  extract  in 
doses  of  from  2  l/2  to  3  grains  a  powerful  cardiac  tonic.  E.  A.  Gray  gave  the 
extract  for  the  same  purpose  in  pneumonia  in  doses  of  from  1 1/2  to  3  grains  every 
two  or  three  hours.  H.  C.  Wood  gives  the  dose  at  5  grains.  Yet  120  grains  of  the 
fresh  gland  have  been  administered  daily  without  effect.  Doubtless  the  suprarenal 
active  principle  must  be  in  a  measure  destroyed  in  gastric  digestion.  That  it  is  not, 
however,  completely  destroyed,  is  shown  by  the  fact  that  Griinbaum  obtained  a  rise 
of  pressure  of  from  75  to  91  millimeters  of  mercury  with  suprarenal  tabloids  in  a 
pregnant  woman  who  had  very  low  pressure — an  effect  which  disappeared  when  the 
drug  was  discontinued.  Intravenous  injection  is,  of  course,  a  surer  method  of 
obtaining  results,  and  the  evanescent  effect  in  strong  contrast  with  that  of  digitalis 
must  reasonably  limit  its  utility. 

The  writer  has  used  suprarenal  extract  in  myocarditis  with  irregular  and  inter- 
mittent pulse  in  doses  of  2  and  5  grains  every  six  hours  with  seemingly  good  results, 
and  intends  to  enlarge  its  use  and  its  dose. 

Adrenalin  chloride,  the  active  principle  of  suprarenal  extract,  is  described  as 
the  most  active  of  all  vasoconstrictor  agents.  A.  L.  Benedict  administers  adrenalin 
in  doses  of  1/240  grain  as  a  vasomotor  excitant  in  general  atony  of  the  vascular  sys- 
tem attended  with  constipation  and  dyspepsia  and  in  chronic  disease  of  the  heart  in 
general.  The  1  to  1000  solution  of  adrenalin  may  be  conveniently  prescribed,  of 
which  40  minims  equal  1/250  grain.  This  quantity  may  be  added  to  a  pint  of  salt 
solution  and  used  hypodermically.  Much  larger  quantities  are  not  safe.  Thus  I 
have  known  8  ounces  of  a  1  to  50,000  solution  injected  under  the  skin  to  produce 
gangrene  as  far  down  as  the  muscle. 

It  is  with  a  view  to  inviting  the  attention  of  others  to  this  subject  that  this 

editorial  is  written,  and  it  is  hoped  that  a  sufficient  number  of  cases  will  be  collected 

to  permit  a  decision  of  the  question. 

James  Tyson.* 

Philadelphia. 
•Professor  of  Medicine,  University  of  Pennsylvania. 


MYXCEDEMA:  IN  ITS  RELATIONS  TO  THE  ADRENAL  SYSTEM.  55 

THE  TEACHING  OF   SPECIALTIES  IN  MEDICINE. 

Much  that  is  deleterious  to  the  welfare  of  individual  organs  throughout  the 
body  has  been  wrought  by  an  imperfect  understanding  of  the  anatomy  of  the  parts, 
and  inadequate  familiarity  with  the  explanations  of  their  functional  activities.  In 
a  measure,  the  responsibility  for  this  want  of  knowledge  is  dependent  upon  the 
present  prevalent  plan  to  impart  to  the  student  nothing  more  than  a  few  clinical 
empiricisms  which  are  the  fruits  of  individual  practical  experience,  together  with  a 
modicum  of  imperfectly  understood  ideas  that  have  been  cursorily  gathered  together 
by  desultory  reading  and  uninterested  observation  of  the  work  of  others. 

Successful  special  teaching — successful  in  the  sense  of  usefulness — is  com- 
mensurate with  but  a  few  mental  types.  To  secure  such  a  character  of  worker,  the 
first  requisite  of  selection  should  make  it  obligatory  to  confine  the  choice  to  those 
who  possess  large,  active,  and  varied  clinical  experiences  that  are  under  immediate 
guidance  and  control;  the  courses  of  instruction  should  be  vouchsafed  to  only  such 
of  this  selected  type  of  instructor  as  are  constantly  keeping  themselves  in  touch  with 
the  latest  discoveries  in  healthy  and  diseased  anatomical  structures,  and  who  are 
making  themselves  conversant  with  the  most  modern  views  regarding  the  relative 
actions  of  such  organs;  and  as  a  final  test,  the  work  should  be  relegated  to  those 
remaining  few  who,  with  this  knowledge  at  hand,  are  enabled  to  keep  themselves  as 
nearly  abreast  as  possible  with  general  medicine  and  its  applications  to  their  special 
lines  of  study.  These  combined  types  are  alone  able  .to  give  a  proper  teacher  who 
is  capable  of  offering  the  uninformed  mind  a  theoretic  and  practical  training  which 
will  either  provoke  further  study  and  thus  ensure  increased  usefulness  in  the  par- 
ticular line  of  work  which  has  been  chosen,  or  open  the  door  of  the  special  form  of 
knowledge  sufficiently  wide  to  enable  the  observer  to  make  an  intelligent  and 
selective  survey  of  what  is  spread  before  him. 

If  to  all  of  these  requirements  are  added  a  broad,  scientific  training  along  ger- 
maine  lines,  a  literary  ability  for  the  intelligent  and  useful  perusal  of  noted  expres- 
sion of  both  old  and  new  thought  throughout  the  world,  a  constant  search  for  the 
hidden  truths  of  the  laboratory,  and  a  personal  magnetism,  enthusiasm,  and  charm 
of  manner,  the  perfected  exponent  of  specialized  work  has  been  fairly  well  obtained. 

Charles  A.  Oliver.* 
Philadelphia. 

•Attending  Surgeon,  Wills'  Hospital,  Philadelphia. 


MYXCEDEMA:    IN  ITS  RELATIONS   TO   THE  ADRENAL  SYSTEM. 

A  striking  feature  of  all  the  more  recent  physiological  studies  bearing  in  any 
way  upon  diseases  of  the  ductless  glands  is  the  care  with  which  the  pituitary  body, 


56  MYXCEDEMA:  IN  ITS  RELATIONS  TO  THE  ADRENAL  SYSTEM. 

the  thyroid,  and  the  adrenals  are  examined.  Many  important  facts  are  thus  brought 
to  light  which  will  in  due  time  demonstrate  the  truth  of  the  writer's  opinion  in  this 
connection,  namely,  that  the  functions  of  these  organs  furnish  the  keynote  of  the 
medicine  of  the  future. 

Of  value  in  this  connection  is  a  paper  by  J.  Eamsay  Hunt,  in  the  American 
Journal  of  the  Medical  Sciences,  for  February,  1905,— a  pathological  study  of  a  case 
of  myxoedema  associated  with  tuberculosis  of  the  adrenals,  besides  the  thyroid  lesions, 
in  a  woman  of  fifty-one  years.  The  disease  had  begun  four  years  before,  had  pro- 
gressed insidiously,  and  ended  in  death  from  purulent  bronchitis  with  incipient 
broncho-pneumonia. 

The  history  and  habits  of  the  patient  included  nothing  which  might  suggest 
hereditary  or  acquired  predisposition  to  disease.  Occipital  headaches,  vertiginous 
seizures,  weakness,  increasing  loss  of  hair,  swelling  of  the  face,  especially  the  eyes, 
swelling  of  the  legs  on  walking  or  standing,  frequent  micturition,  and  failing  vision 
constituted  the  symptoms  recorded  on  admission  to  hospital.  The  status  prasens 
of  the  case  added  thereto  great  corpulency ;  marked  dullness  and  apathy  and  extreme 
slowness  in  thought  and  action;  coarseness  of  the  hair — which  was  yellowish-brown 
and  very  sparse — dryness,  harshness,  and  scaliness  of  the  skin  in  various  regions; 
impairment  of  the  acuity  of  sight  and  hearing;  slow,  labored,  and  awkward  gait 
almost  to  co-ordination;  slow  and  monotonous  speech;  drowsiness  and  subjective 
sensation  of  cold. 

The  post-mortem  findings,  aside  from  those  peculiar  to  the  intercurrent  disease 
which  killed  the  patient,  were  pallor  of  muscular  elements,  including  those  of  the 
heart.  The  ventricles  of  this  organ  were  also  hypertrophied  and  somewhat  dilated, 
the  free  borders  of  the  mitral  valves  being  somewhat  thickened,  and  the  cusps 
sclerosed  near  their  attachment.  Arteriosclerosis  of  the  coronaries  and  of  the  circle 
of  Willis  was  also  present.  Congestion  of  the  liver  and  spleen,  hypertrophy  of  the 
linguo-pharyngeal  glandular  tissues  completes  the  morbid  conditions  presented, 
aside  from  the  lesions  of  the  ductless  glands. 

The  nervous  system  appeared  to  play  no  part  in  the  morbid  process;  as  stated 
by  the  author,  the  "brain,  spinal  cord,  and  peripheral  nerves,  except  a  moderate 
oedema  of  the  pia  mater,"  and  the  above  mentioned  arteriosclerosis  of  the  circle  of 
Willis  "show  no  gross  pathological  changes."  He  further  refers  to  the  classical 
cases  of  Hun  and  Prudden,  in  which  this  system  was  entirely  normal,  and  to  the 
report  of  the  Committee  of  the  Clinical  Society  of  London,  which  had  recognized 
"no  essential  changes  in  the  cerebrospinal  or  sympathetic  nervous  systems,"  and 
adduces  his  study  as  a  confirmation  of  the  fact. 

After  reviewing  some  of  the  theories  adduced  to  explain  the  origin  and  mech- 
anism of  the  nervous  manifestations  of  myxcedema,  Hunt  says :  -"The  toxic  theory 


MYXCEDEMA:  IN  ITS  RELATIONS  TO   THE  ADRENAL  SYSTEM.  57 

is  that  which  finds  most  favor  at  the  present  day,  but  even  here  authorities  differ 
as  to  the  exact  nature  of  the  toxic  substance  in  question.  While  all  concur  that  the 
symptoms  are  produced  by  an  absence  of  the  secretion  of  the  thyroid  gland,  it  is  still 
one  of  the  mooted  questions  of  chemical  pathology  as  to  whether  this  secretion  is 
itself  essential  to  metabolism,  or  whether  its  beneficial  influence  consists  in  neutral- 
izing products  of  metabolism  otherwise  possessing  toxic  properties   (Ewald)." 

Finally,  he  closes  with  the  following  remarks :  "The  gradual  reawakening 
under  thyroid  therapy  from  this  state  of  extreme  mental  and  physical  torpor,  which 
Charcot  so  aptly  likened  to  that  of  hibernation  in  animals;  the  disappearance  of 
hallucinations  and  delusions  and  the  eventual  complete  restoration  of  mental  and 
bodily  health  after  years  of  partial  dementia,  furnish  strong  clinical  evidence  that 
the  nerve  element  in  myxcedema  is  not-  dependent  upon  organic  changes  in  the  neural 
structures  of  the  body.  If  such  are  present  they  should  rather  be  regarded  as  sec- 
ondary in  nature  or  ascribed  to  some  other  complicating  factor." 

What  conclusions  can  we  draw  from  all  these  statements?  It  is  evident  that 
the  manner  in  which  the  symptoms  outlined  are  produced  is  unknown  to  the  authori- 
ties to  which  the  author  refers,  and  that  the  one  established  fact  is  that  thyroid 
medication  is  capable  of  restoring  the  patients  to  a  comparatively  normal  condition. 
This  one  fact,  however,  is  in  itself  a  beacon — it  seems  to  me — provided  the  so-called 
"toxic  theory"  be  set  aside  as  regards  myxcedema  per  se. 

An  important  difference  between  the  intoxication  that  attends  experimental 
removal  of  the  thyroid  and  the  gradually  developed  symptom  complex  termed 
"myxcedema,"  has  always  been  overlooked,  i.e.,  the  fact  that  symptoms  of  intoxica- 
tion occur  in  the  former  case  which  do  not  appear  in  the  latter  disease.  Tetany  is 
the  foremost  of  these;  muscular  twitchings  first  appear  and  these  subsequently 
develop  into  clonic  and  tonic  convulsions.  No  such  symptoms  occur  in  myxcedema-— 
except  occasionally  as  a  terminal  event — even  in  animals  that  survive  the  operation 
and  which,  after  passing  safely  through  the  convulsive  phase,  become  myxedematous. 
In  other  words,  it  is  only  by  considering  myxcedema  apart  from  the  condition 
brought  about  by  thyroidectomy  that  its  true  identity  asserts  itself.  Why  this  dif- 
ference between  two  conditions  so  nearly  related?  This  finds  a  ready  explanation 
in  the  fact  that  the  sudden  removal  of  the  thyroid  deprives  the  animal  of  an  organ 
which  sustains  the  activity  of  its  oxidation  processes.  Toxic  waste-products  accu- 
mulate in  the  blood-stream  instead  of  being  converted  into  eliminable  products 
by  oxidation  and  other  chemical  processes  in  which  it  takes  part.  The  merest  tyro 
will  not  deny  to-day  that  thyroid  extract  produces  its  effects  by  enhancing  oxidation ; 
thyroid  extract,  we  know,  causes  the  acute  symptoms,  including  the  convulsions,  to 
cease.  It  is  here,  therefore,  that  a  "toxic  theory"  is  applicable;  but  such  a  theory 
does  not  apply  to  myxcedemaf 


58  MYXCEDEMA:   IN  ITS  RELATIONS  TO  THE  ADRENAL  SYSTEM. 

We  are  dealing  in  the  case  of  the  latter  disease  with  manifestations  of  another 
order — a  steady  decline  of  vital  activities  due  to  a  correspondingly  gradual  sub^ 
sidence  of  oxidation  in  all  organs,  manifested  clinically  by  the  "insidious  onset  and 
gradual  progression  of  symptoms"  in  Dr.  Hunt's  case.  There  is  not  here  the  sudden 
deprivation  of  functions  which  extirpation  of  the  thyroid  entails ;  there  is  a  gradual 
loss  of  function  by  this  organ :  "The  important  and  essential  change  consists  of  an 
extensive  atrophy  and  sclerosis  of  the  thyroid  gland,"  says  Dr.  Hunt,  "even  those 
vestiges  of  glandular  substance  still  remaining  are  compressed  or  undergoing  atro- 
phy." Here,  again,  we  know,  thyroid  extract  is  remarkably  efficacious,  owing  again 
to  its  influence  on  all  oxidation  processes.  Need  we  insinuate  a  "toxic  theory"  to 
account  for  the  array  of  symptoms  witnessed? 

But  how  is  oxidation  influenced  by  the  thyroid  extract — the  homologue  as  far 
as  effects  witnessed  are  concerned  of  the  thyroid  secretion?  I  have  submitted  in 
"Internal  Secretions,"  Volume  I,  the  many  reasons  that  have  led  me  to  conclude 
that  this  secretion  had  for  its  purpose  to  sustain  the  functional  activity  of  the  ante- 
rior lobe  of  the  pituitary  body.  Considerable  work  done  since  its  publication  has 
only  served  to  strengthen  this  position.  The  pituitary  body  in  Dr.  Hunt's  case  "was 
not,"  he  says,  "the  seat  of  any  considerable  compensatory  hypertrophy."  Why 
should  it,  since  its  normal  source  of  excitation,  the  thyroid  secretion,  was  steadily 
being  reduced  ?  From  the  pituitary  body  I  have  traced  nerves  by  way  of  the  teg- 
nemtum,  the  bulb,  the  cord,  the  sympathetic  chain,  and  the  splanchnic  to  the 
adrenals — organs  which,  when  diseased,  so  lower  all  functional  activities  as  to  give 
the  patient  sometimes,  as  stated  by  a  writer  in  Allbutt's  Practice,  a  cadaverous  odor. 
Dr.  Hunt  refers  to  "the  co-existence"  in  his  case  "of  a  chronic  tuberculosis  of  the 
adrenal  glands,"  which  must,  he  says,  "be  regarded  as  a  rare  and  curious  example 
of  a  pathological  coincidence" — until,  I  might  add,  pathologists  will  have  realized 
the  true  importance  of  these  organs  as  inherent  parts  of  the  triad  upon  which  all 
our  functions  depend  for  their  pabulum  vitce. 

Charles  E.  de  M.  Sajous. 


Cyclopaedia  of  Current  literature. 


ACETONURIA  ELSEWHERE  THAN  IN  DIA-  diabetic  coma,  still  for  a  long  time  it 

BETES.  has  been  known  to  exist  in  other  condi- 

Althongh    acetonuria    has    for    years  tions.      It   has   been   said   that   a   meat 

been  studied,  especially  in  its  relation  to  regime  causes  acetonuria,  and  it  is  well 


ALBUMINURIA. 


ANAESTHESIA,  LOCAL. 


59 


known  that  diabetic  coma  is  sometimes 
due  to  an  exaggerated  meat  diet,  but  ac- 
cording to  Argenson,  the  acetonuria  of 
meat  diet  is  very  slight.  The  three  char- 
acteristics of  acute  acetonuria  are  the 
peculiar  fruity  odor  of  the  breath,  and 
so  penetrating  at  times  as  to  be  notice- 
able at  a  distance,  the  febrile  urine,  with 
the  characteristic  odor;  and  the  fact 
that  the  reaction  of  Gerhardt  is  generally 
positive,  while  the  reaction  of  Lieben  is 
always  so  (acetonuria  generally  accom- 
panied by  diaceturia).  As  a  rule,  this 
clinical  picture  exists  only  when  the  ace- 
tone amounts  to  about  0.20  grain  to  a 
liter,  a  figure  frequently  reached.  In  the 
condition  of  acetonuria,  acetone  exists  in 
the  blood,  as  Petters  and  Argenson  have 
demonstrated.  The  kidney  plays  the 
role  of  elimination,  and  not  of  forma- 
tion. But  the  breath  eliminates  as  much 
acetone  as  the  saliva,  and  the  perspira- 
tion. The  origin  of  acetone  has  been 
discussed  at  great  length.  Some  author- 
ities believe  it  to  be  derived  from  sugar 
by  alcohol  or  aldehyde ;  others,  from  the 
albuminoids.  Schumann  has  detected 
acetonuria  in  a  healthy  subject  after 
feeding  him  on  fats  exclusively,  and  has 
determined  the  cessation  of  this  condi- 
tion after  adding  carbohydrates  to  this 
regime.  But  all  of  these  diets  cause  so 
marked  an  inanition  that  it  may  itself 
be  the  cause  of  the  acetonuria.  This  is 
the  reason  why  none  of  the  theories  can 
be  considered  as  being  absolutely  demon- 
strated. Although  acetone  is  slightly 
toxic  to  a  healthy  subject,  it  is  not  so 
well  tolerated  by  hepatic  and  diabetic 
patients,  in  whom  it  causes  slight  head- 
ache, and  in  whom  it  passes  easily  into 
the  urine,  as  if  the  liver  were  incapable 
of  arresting  it.  It  is  an  exaggeration  to 
say  that  acetonuria  is  a  phenomenon  con- 
tingent to  the  course  of  diabetic  coma. 


Beauvy    (Revue  Franchise  de  Medecine 
et  de  Chirurgie,  November  7,  1904). 

ALBUMINURIA.       PHYSIOLOGICAL       AND 
PATHOLOGICAL. 

It  is  only  within  comparatively  recent 
times  that  this  condition  has  been  re- 
ceived as  a  possibility,  but  now  it  is  gen- 
erally accepted  that  every  normal  urine 
must  contain  some  albumin,  though  it 
may  be  present  only  in  very  small 
amounts.  3STow,  physiological  albumin- 
uria is  regarded  much  in  the  same  way 
as  physiological  glycosuria,  and  among 
the  causes  that  give  rise  to  it  in  sus- 
ceptible individuals  are  severe  exertion 
of  the  lower  extremities,  eating  and  di- 
gestion of  a  hearty  meal,  menstruation, 
cold  baths,  and  psychical  excitement. 
The  occurrence  of  albuminuria  is  to  be 
regarded  as  pathological  only  when  it 
does  not  take  place  under  unusual  con- 
ditions alone,  and  does  not  disappear 
promptly  on  the  cessation  of  the-  par- 
ticular stimulus  that  caused  it.  Ortho- 
static albuminuria  is  distinctly  patho- 
logical and  most  cases  of  this  or  cyclical 
albuminuria  are  caused  by  a  slight  irri- 
tation or  inflammatory  state  of  the  kid- 
neys which  may  go  on  to  recovery  or 
may  develop  into  a  chronic  diffuse  ne- 
phritis. Physiological  and  allied  forms 
of  albuminuria  are  based  upon  congeni- 
tal or  acquired  predisposition  of  the  in- 
dividual, which  consists  in  an  abnormal- 
ity of  various  organs  such  as  the  kidneys, 
the  digestive  tract,  the  blood-vessels,  or 
the  body  fluids.  Senator  (Deutsche 
medicinische  Wochenschrift,  December 
8,  1904.) 

ANESTHESIA,  LOCAL. 

The  writer  describes  his  method  of 
producing  local  anaesthesia.  He  uses  B- 
eucain,  which  is  far  less  dangerous  than 
cocaine,  while  possessing  analgesic  prop- 


60 


ANESTHESIA,  LOCAL. 


ANTISTREPTOCOCCIC  SERUM. 


erties  little,  if  at  all,  inferior  to  it,  and 
with  the  concurrent  use  of  adrenalin  for 
the  purpose  of  securing  a  retardation  of 
circulation  equivalent  to  constriction  of 
the  part,  he  has  removed  some  of  the  ob- 
jections as  to  the  duration  of  the  anal- 
gesia, the  extent  of  the  area  which  can  be 
dealt  with  and  the  amount  of  the  toxic 
drug  to  be  employed.     It  is  necessary 
to  keep  within  the  safe  dose  of  the  drug, 
and   to   have    at   our    disposal    a    large 
enough     quantity     of     the     fluid     me- 
dium to  render  it  possible  to  spread  the 
analgesic  agent  over  large  areas.     For 
ordinary    surgical    work    the    following 
solution  is  found  by  the  author  to  an- 
swer well:    Distilled   water,   140   cubic 
centimeters;    B-eucain,  0.2  grams;    so- 
sodium  chloride,  0.8  grams;    1  to  1000 
adrenalin  chloride  solution,  10  minims. 
All  this  quantity  of  fluid  can  be  used  in 
an  ordinary  case  if  necessary  and  is  quite 
sufficient  for  most.    Twice  as  much  may 
be    injected    without    ill    results.      The 
duration  of  the  insensibility  is  secured 
by    the    admixture    of    the    adrenalin. 
Without  it  sensation  is  only  abolished  by 
eucain  for  about  fifteen  minutes;    with 
it,   for   three   to   four   hours.     But   the 
analgesia  is  produced  more  slowly  when 
adrenalin  is  employed  with  the  eucain. 
It  is  therefore  well  before  all  larger  op- 
erations   to   wait   some    thirty   minutes 
after  injection  to  allow  time  for  the  in- 
sensibility   to   become    fully    developed. 
After  this  the  effect  appears  to  deepen 
for  a  couple  of  hours.    Waiting  has  an- 
other advantage.    When  eucain  alone  is 
employed  the  operation  must  be  done  at 
,once.    The  tissues  are  still  in  a  state  of 
artificial   oedema   which   masks   the   an- 
atomic details  unpleasantly.     By  adding 
adrenalin    to    the    eucain   solution    and 
waiting,  the  artificial  oedema  has  disap- 
peared and  details  are  very  clearly  seen. 
Eapid  injection  is  to  be  avoided;    sud- 


den distention  of  the  tissues  is  disagree- 
able, if  not  painful.  The  fluid  should 
not  be  used  cold  nor  too  hot,  for  the 
same  reason.  All  dragging  on  the  parts 
is  to  be  avoided,  lest  structures  be  pulled 
upon  which  lie  beyond  the  area  of  infil- 
tration. The  writer  has  never  seen  any 
depressing  effects  follow  the  use  of  B- 
eucain  in  a  long  series  of  operations. 
A  list  of  operations  done  under  B-eucain 
analgesia  is  appended,  and  among  these 
are  the  following:  Abdominal  sections, 
hernia  operations,  amputations,  orchi- 
dectomy,  removal  of  cyst  of  thyroid,  re- 
moval of  silver  wire  from  around  the  pa- 
tella, operations  for  fistulo  in  ano,  vari- 
cose veins,  hydrocele,  varicocele,  etc.  A. 
E.  Barker  (British  Medical  Journal, 
December  24,  1904). 

ANTISTREPTOCOCCIC    SERUM,    ADMINIS- 
TRATION   OF. 

Injection  of  antistreptococcic  serum 
in  cases  of  pure  streptococcal  infection 
has  been  followed  by  strikingly  beneficial 
results.  Variability  in  the  results  of  the 
serum  in  proved  streptococcal  infection 
has  been  due  to  the  selective  activity  dis- 
played by  the  antitoxin  of  each  variety 
of  streptococcus  or  to  the  serum  being 
used  too  late  in  the  case  or  having  lost 
its  activity  from  staleness.  More  uni- 
form results  are  likely  to  be  obtained 
from  the  present  "compound''  antistrep- 
tococcic serum  than  from  the  earlier 
forms,  from  the  prompt  injection  of 
serum  at  the  commencement  instead  of 
near  the  close  of  a  severe  infection,  and 
from  the  use  only  of  serum  which  has 
been  recently  prepared.  The  initial  dose 
may  with  benefit  be  increased  and  a  large 
quantity -spread  over  several  days  causes 
no  ill-effect.  The  administration  of  the 
serum  should  be  continued  for  some  days 
after  tbe  general  symptoms  have  dis- 
appeared    and     a     recrudescence     thus 


AORTIC  INSUFFICIENCY. 


ARTERIAL  HYPERTENSION. 


61 


avoided.       J.     W.     Thomson     Walker 
(Lancet,  December  31,  1904). 

AORTIC     INSUFFICIENCY,     TRAUMA     AS 
THE  CAUSE  OF. 

Traumatic  rupture  of  the  cardiac 
valves  may  be  produced  in  one  of  two 
ways.  The  more  frequent  of  the  two  is 
that  from  a  sudden,  intense  muscular 
effort,  ,such  as  a  great  sudden  effort  after 
a  deep  inspiration.  The  long  inspiration 
and  the  rigidity  of  the  thorax  impedes 
the  venous  flow  and  raises  the  blood- 
pressure;  the  violence  of  the  effort  does 
this  still  more  so  for  the  moment  and  if 
the  blood-pressure  rises  beyond  a  certain 
point  at  the  moment  of  closure  of  the 
valves,  a  tear  may  be  produced.  The 
second  and  less  frequent  cause  of  rupture 
is  direct  violence,  such  as  a  direct  blow, 
kick,  or  crush  applied  to  the  thoracic 
walls.  There  are  also  cases  of  sponta- 
neous laceration  in  the  course  of  a 
chronic  endocarditis,  the  result  of  sud- 
den violent  shock,  and  increase  of  blood- 
pressure;  also  cases  of  endocarditis  de- 
veloping as  the  result  of  an  injury.  Be- 
fore a  diagnosis  of  traumatic  valve  rup- 
ture can  be  made,  we  must  be  certain 
that  no  valvular  disease  existed  before 
the  accident;  the  cardiac  symptoms  must 
first  appear  after  the  traumatism,  and  if 
the  case  ends  fatally,  a  rent  should  be 
found  in  the  valve.  While  such  a  diag- 
nosis therefore  has  many  obstacles,  still 
too  little  attention  is  paid  to  this  cause 
as  a  factor  in  the  production  of  the  dis- 
ease. The  writer,  after  reviewing  the 
cases  recorded  in  literature,  states  that 
he  has  observed  3  cases  in  the  last  eight- 
een months  in  which  the  symptoms  of 
aortic  insufficiency  were  traceable  to  a 
contusion  or  fall  on  the  chest.  Two  of 
the  patients  applied  for  relief  without 
referring  to  any  traumatism  in  their 
antecedents,  and  it  was  only  learned  by 


direct  questioning.  In  the  first  patient 
the  symptoms  came  on  a  month  after 
having  been  struck  on  the  chest  violently 
by  a  football;  immediately  after  the  in- 
jury the  patient  had  fainted.  He  was 
refused  for  military  service  because  of 
heart  disease,  although  after  other  ex- 
aminations held  previously,  no  such  dis- 
ease had  been  discovered  and  the  patient 
had  been  able  to  lead  an  athlete's  life. 
All  the  signs  of  aortic  regurgitation  de- 
veloped rapidly.  The  second  patient 
complained  of  vertigo  the  day  after  he 
had  fallen  backward  off  a  board;  two 
months  later  aortic  regurgitation  was 
diagnosed ;  he  had  been  perfectly  well 
until  the  day  of  the  accident.  The  third 
case  is  somewhat  dubious  on  account  of 
pre-existence  of  malaria  and  gonorrhoea, 
but  as  the  symptoms  came  on  violently 
after  the  accident,  an  eight-foot  fall  and 
striking  of  chest  with  a  heavy  piece  of 
iron,  the  author  considers  himself  jusi- 
fied  in  making  this  diagnosis.  Sinn- 
huber  (Deutsche  medicinische  Wochen- 
schrift,  Bd.  xxx,  No.  32,  1904;  from 
American  Medicine,  December  31, 
1904). 

ARTERIAL   HYPERTENSION,    CHRONIC. 

Chronic  hypertension  may  be  divided 
into  four  classes,  according  to  etiology: 
(a)  arteriosclerotic;  (b)  cardiac,  pul- 
monary, and  cerebral  compensatory;  (c) 
toxic;  (d)  primary.  The  primary  form 
of  hypertension  deserves  recognition  as 
a  distinct  disease.  Early  recognition  of 
the  tendency  toward  a  progressive  in- 
crease in  pulse  tension  should  prevent  or 
delay  the  development  of  certain  forms 
of  cardiovascular  and  renal  disease.  In 
correcting  hypertension  sodium  nitrite 
has  many  advantages  over  nitroglycerin. 
H.  W.  Cook  (Journal  of  the  American 
Medical  Association,  January  28,  1905). 


62 


BARIUM  CHLORIDE. 


BLADDER,  SARCOMA  OF. 


BARIUM    CHLORIDE    IN    THERAPEUTICS. 

The  author  has  been  testing  barium 
chloride  in  40  cases  of  various  affections, 
including  11  of  pleurisy,  8  of  valvular 
defects,  4  of  myocarditis,  3  of  typhoid, 
etc.    He  studied  the  temperature,  pulse, 
respiration,  arterial  pressure,  urine,  and 
ingestion  of  fluids  in  the  various  cases 
while  under  the  influence  of  the  drug. 
The   results   confirm   those   reported   by 
Schedel,  Tabora,  and  others  in  respect 
to  the  efficacy  of  barium  chloride  as  a 
pressure-raising  drug  and  diuretic.    The 
pressure  was  raised  from  a  few  milli- 
meters to  a  maximum  of  60  millimeters 
in  his  experiences,  both  clinical  and  ex- 
perimental.    It  rose  a  few  hours  after 
taking  the  chloride,  and  constantly  in- 
creased to  a  maximum  at  which  it  per- 
sisted for  three  or  four  days,  then  grad- 
ually subsided,  but  still  kept  for  a  time 
longer  above  the  previous  figure.    In  the 
very  severe  cases  the  pressure  sank  after 
the  first  rise — a  sign  of  grave  prognosis. 
In  some  cases  there  was  no  appreciable 
action  on  the  pressure,  but  the  general 
condition  showed  marked  improvement, 
sometimes  with  diuresis.     In  every  case, 
however,  the  pulse  tracings  assumed  a 
more  normal  type,  the  pulse  findings  ex- 
plaining the  general  improvement  that 
followed  the  use  of  the  drug.     No  in- 
jurious  action  was  noted  in  any  case. 
The   prompt   diuresis   that  followed  in 
case  of  pleurisy  was  the  most  gratifying 
result  noted,  in  some  instances  the  bene- 
fit being  truly  marvelous,  the  amount  of 
urine  excreted  increasing  from  1000  to 
4000  cubic  centimeters.    The  dosage  was 
43  centigrams  in  three  days,   60  centi- 
grams in  four  days,  or  32  centigrams  in 
three    days.      The    drug    is    advocated, 
therefore,  as  the  best  diuretic  for  pleu- 
risy, the  benefit  being  prompt,  constant, 
and  superior  to  that  of  any  other  diuretic 
with  which  the  writer  is  familiar.     The 


drug  is  also  indicated  in  the  first  stage 
of  disturbance  of  compensation  in  a  val- 
vular .affection  when  the  circulation  is 
sluggish  and  the  relaxed  walls  of  the 
arteries  allow  infiltration  of  the  tissues. 
Barium  chloride  stimulates  the  mus- 
culature of  the  walls  of  the  arteries.  It 
is  also  useful  for  the  same  reason  in  in- 
fectious disease  when  the  pulse  is  be- 
coming dicrotic  from  relaxation  of  the 
walls  of  the  vessels  and  weakness  of  the 
intoxicated  myocardium.  Barium  chlo- 
ride arrests  these  disturbances  or  pre- 
vents them  by  its  beneficient  influence 
on  the  disease  itself.  Excessively  high 
blood-pressure  with  weak  heart  is  the 
only  contra-indication.  E.  Pesci  (Ei- 
forma  Medica,  vol.  xx,  No.  25;  Journal 
American  Medical  Association,  January 
28,  1905). 

BLADDER,    PRIMARY   SARCOMA    OF   THE. 

Sarcoma  of  the  bladder  is  most  com- 
mon after  middle  life  (26  cases  out  of 
50  occurring  after  the  age  of  40)  and 
during  childhood  (14  cases  out  of  50 
occurring  under  the  age  of  10),  but  it 
may  occur  at  any  age.  It  is  more  com- 
mon in  males  than  females  (34  to  13). 

The  most  constant  symptom  is  hamia- 
turia.  This  symptom  cannot,  .however, 
in  many  cases  be  considered  as  an  early 
sign,  as  the  date  of  its  appearance  is 
probably  significant  in  the  majority  of 
cases  of  beginning  ulceration  of  the  neo- 
plasm. Next  to  hematuria  the  mo.$t 
constant  symptoms  are  those  of  cystitis 
and  vesical  irritation — i.e.,  stranguary; 
frequent  and  difficult  micturition ;  small 
stream ;  retention ;  purulent  urine. 
Emaciation  consecutive  to  the  growth  is 
present  in  advanced  cases  only.  A  cal- 
culus may  or  may  not  be  present.  In 
females  the  growth  may  invade  the  ure- 
thra and  appear  at  the  vaginal  opening. 

The  disease  is  more  rapidly  fatal  in 


CARBONIC  OXIDE  POISONING. 


CARDIAC  INSUFFICIENCY. 


63 


children  than  in  adults.  In  those  cases 
in  which  the  diagnosis  has  been  made 
early  in  the  course  of  the  disease,  the 
neoplasm  has  been  small,  single,  and  ap- 
parently localized. 

The  growth  may  spring  from  the  sub: 
mucosa  of  any  part  of  the  bladder,  but 
the  most  common  location  is  at  the  base, 
in  the  vicinity  of  the  ureteral  orifices. 
The  growth  is  usually  sessile,  with  a 
broad  base;  is  usually  soft  and  friable, 
more  or  less  lobulated,  in  some  cases  has 
a  cauliflower  or  villous  appearance.  The 
growths  are  usually  single,  but  in  the 
later  stages  may  be  multiple.  Meta- 
stases, as  compared  with  sarcoma  of 
other  parts  of  the  body,  seem  rare  except 
in  quite  advanced  cases.  The  varieties 
of  sarcoma  occurring  in  the  bladder  so 
far  recorded  are  round-celled  (large, 
medium,  small,  lymphosarcoma,  and  al- 
veolar) ,  spindle-celled,  mixed-celled, 
giant-celled,  fibrosarcoma,  myosarcoma, 
myxosarcoma,  and  chondrosarcoma. 

At  the  present  time  the  only  hope  for 
the  cure  of  sarcoma  of  the  bladder  ap- 
pears to  lie  in  the  early  detection  of  the 
neoplasm  by  means  of  the  cytoscope  or 
by  exploratory  incision,  and  its  complete 
removal  at  this  stage  of  the  disease.  J. 
A,  Wilder  (American  Journal  Medical 
Sciences,  January,  1905). 

CARBONIC    OXIDE    POISONING. 

The  writers  have  been  studying  to 
learn  if  it  is  possible  to  distinguish  be- 
tween poisoning  from  without  and  poi- 
soning from  within  by  this  agent;  that 
is,  whether  it  was  inhaled  during  life  or 
permeated  the  tissues  after  death.  They 
experimented  with  illuminating  gas, 
using  the  sensitive  palladium  chloride 
test.  The  gas  was  introduced  into  the 
air-tight  coffin  holding  the  eadaver,  and 
sometimes  the  tube  was  placed  in  the 
mouth.    The  results  showed  that  there  is 


no  part  of  the  body  into  which  the  car- 
bon oxide  does  not  penetrate  in  time, 
whether  the  gas  is  pure  or  diluted  with 
air,  stagnating,  or  constantly  renewed. 
A  very  important  sign  that  the  gas  has 
penetrated  from  without  is  the  difference 
in  color  of  the  haemoglobin  in  the  mus- 
cles as  they  are  nearer  or  farther  from 
the  surface  of  the  body.  There  is  no 
qualitative  difference  between  the  find- 
ings after  carbonic  oxide  poisoning  and 
of  post  mortem  diffusion,  but  the  quan- 
titative difference  is  marked  when  the 
body  has  not  been  very  long  exposed  to 
the  gas.  If  completely  saturated  with 
it  there  may  be  no  difference  of  any  kind. 
In  a  recent  case  a  woman  was  found 
dead  with  the  tube  of  her  gas  stove  in 
her  mouth  and  the  stopcock  open.  A 
relative  asserted  that  criminal  abortion 
had  been  forced  on  her  and  that  the  gas 
accessories  were  merely  to  divert  sus- 
picion. No  traces  of  recent  abortion 
could  be  discovered  and  tests  for  car- 
bonic oxide  in  the  blood  aided  in  con- 
firming the  assumption  of  suicide.  F. 
Strassmann  and  A.  Schulz  (Berliner 
klinische  Wochenschrift,  November  28, 
1904,  from  Journal  American  Medical 
Association,  January  7,  1905). 

CARDIAC   INSUFFICIENCY,   CAUSES  OF. 

The  author  refers  to  experiments 
which  show  that  so-called  fatty  degen- 
eration is  only  another  example  of  fatty 
infiltration.  Fat  is  not  visible  in  healthy 
muscle  because  as  fast  as  it  is  taken  up 
by  the  protoplasm  it  is  used  to  supply 
the  energy  of  the  cell.  Tissues  micro- 
scopically fat-free  have  been  found  chem- 
ically to  contain  20  per  cent.  No  rela- 
tion seems  to  exist  between  fatty  heart 
and  cardiac  weakness.  The  normal  heart 
contains  8  per  cent.  In  phosphorus  pois- 
oning there  is  25  per  cent. ;  in  pernicious 
anaemia,  13  per  cent.    In  nephritis,  ma- 


64 


CERVIX  UTERI. 


CILIARY  BODY. 


CONJUNCTIVITIS. 


lignant  tumors,  and  tuberculosis  there  is 
some  increase,  but  in  myocarditis  and 
chronic  valvular  disease  the  amounts 
found  have  been  normal.  Experimental 
researches  fail  to  show  that  fat  inter- 
feres with  muscle  work.  Disease  of  the 
coronary  arteries  is  a  frequent  cause  of 
insufficiency,  but  extreme  sclerosis  has 
been  found  with  absence  of  symptoms. 
Fibrous  myocarditis,  although  many 
times  associated  with  coronary  sclerosis, 
often  occurs  independently.  All  cases 
of  muscle  incompetence,  however,  cannot 
be  explained  on  the  basis  of  anatomic 
changes.  In  obesity  increased  work  is 
thrown  on  the  heart.  Insufficiency  may 
be  due  to  acute  overdistension  from  vio- 
lent bodily  exertion.  There  is  no  justi- 
fication for  attributing  it  to  nervous 
disturbances  or  exhaustion.  Circulatory 
disturbances  in  the  infectious  fevers  are 
probably  due  to  paralysis  of  the  vaso- 
motor center.  J.  H.  Pratt  (Johns  Hop- 
kins Hospital  Bulletin,  October,  1904). 

CERVIX  UTERI,  CANCER  OF,  TREATMENT 
OF,   IN    ADVANCED    STAGES. 

Severe  surgical  operations,  involving 
appreciable  mortality  rates  or  a  marked 
degree  of  additional  suffering  should 
not  be  employed  in  the  treatment  of  car- 
cinoma of  the  cervix  uteri,  except  in  very 
early  cases.  According  to  the  reports  of 
the  exhaustive  microscopic  examinations 
in  serial  sections  of  the  tissue  surround- 
ing the  uterus  in  cancer  of  the  cervix, 
there  is  no  means  of  knowing  before 
operation  that  eradication  is  certain  in 
any  given  case  of  this  disease,  and  hence 
such  attempts  must  be  reserved  for  the 
very  earliest  and  most  promising  ones. 
The  galvanocautery  offers  the  best  pros- 
pects for  prolonging  life,  relieving  pain, 
and  lessening  discharges  in  all  other 
cases.  J.  Wesley  Bovee  (American  Med- 
icine, January  7,  1905), 


CILIARY  BODY,  SYPHILOMA  OF. 

The  first  appearance  of  the  syphiloma 
frequently  is  a  small  nodule  in  the  iris- 
angle  of  the  anterior  chamber,  from 
whence  it  takes  its  way  outward  through 
the  sclerotic  or  into  the  anterior  and 
vitreous  chambers,  with  exudations  in 
the  former  as  hypopyon  spurium.  Only 
9  per  cent,  of  Ewetzky's  series  had  been 
free  from  iritis.  The  pupil  is  mostly 
changed  by  posterior  synechia?  of  the 
iris  and  membranous  exudations,  pre- 
venting more  or  less  the  examination  of 
the  posterior  parts  of  the  eye.  These  are 
frequently  more  or  less  seriously  affected ; 
for  instance,  with  congestion  of  the  ret- 
ina, retinitis  in  white  patches,  and  post- 
neuritic atrophy  of  the  optic  disc.  The 
shape  and  mobility  of  the  globe  are  dam- 
aged in  many  ways.  As  to  sex,  there 
were  47  men  against  215  women;  52 
per  cent,  were  between  20  and  30  years 
old ;  28  per  cent,  ended  in  phthisis  bulbi. 
In  30  per  cent,  the  enucleation  was 
made.  Herman  Knapp  (Journal  of  the 
American  Medical  Association,  January 
14,  1905). 

CONJUNCTIVITIS,  PURULENT,  TREAT- 
MENT OF. 
The  newer  silver  salts  are  more  easily 
applied,  safer  in  use,  and  produce  better 
results  than  nitrate  of  silver.  In  case  of 
ophthalmia  neonatorum  either  protargol 
or  argyrol  is  an  entirely  satisfactory 
agent.  In  cases  of  gonorrhoea!  ophthal- 
mia in  the  adult,  the'  results  obtained 
when  treatment  is  begun  early  are  ap- 
proximately the  same  with  either  prepa- 
ration, but  when  once  the  cornea  is  in- 
volved, protargol  appears,  in  these  cases 
at  least,  "to  have  afforded  a  better  ulti- 
mate outcome.  The  application  of  cold 
during  the  stage  of  swelling  in  gonor- 
rhoeal  ophthalmia  is  a  dangerous  pro- 
.  cedure,  and  should  be  abandoned.    Myles 


CONVULSIONS  IN  CHILDREN. 


CORYZA,  ACUTE. 


65 


Standish  (Journal  of  the  American 
Medical  Association,  December  17, 
1904). 

CONVULSIONS  IN  CHILDREN  AND  THEIR 
RELATION  TO  EPILEPSY. 
The  author  states  that  a  serious  view 
of  all  convulsions  occurring  in  infancy 
is  compulsory  and  there  is  no  justifica- 
tion for  supposing  that  even  a  single  con- 
vulsion in  childhood  will  end  with  itself 
and  have  no  further  evil  influence  on  the 
life  of  the  child.  Most  cases  which  have 
arisen  in  connection  with  an  extrinsic 
cause  have  also  had  a  history  of  heredity 
or  alcoholism  in  the  parents,  which  are 
both  predisposing  causes  of  epilepsy. 
Even  where  there  is  no  such  history,  and 
if  it  is  assumed  that  a  peripheral  irrita- 
tion is  adequate  in  itself  to  produce  a 
convulsion  in  a  perfectly  normal  brain, 
yet  the  mere  fact  of  the  convulsions 
being  often  repeated  makes  the  brain 
cease  to  be  normal  and  creates  a  dis- 
tinct pathological  basis  for  the  pro- 
duction of  epilepsy.  What  the  pre- 
cise relation  of  such  convulsions  to 
epilepsy  may  be  it  is  impossible  to  say, 
and  for  this  reason  it  seems  unfortunate 
that  infantile  convulsions  and  epilepsy 
in  many  text-books  on  diseases  of  chil- 
dren are  dealt  with  in  different  chapters  •, 
for  the  impression  is  conveyed  that  there 
is  a  much  greater  difference  between 
these  two  affections  than,  in  the  author's 
opinion,  the  facts  seem  to  warrant.  It  is 
true  that  there  is  found  the  distinction 
between  the  two  emphasized  by  Koplik, 
who  says  "epilepsy  is  a  true  disease  of 
the  nervous  system  and  has  nothing  in 
common  with,  and  no  demonstrable  re- 
lationship to,  infantile  convulsions." 
Holt  also  speaks  of  both  affections  as 
being  quite  distinct,  and  as  a  result  of 
his  large  experience  among  children,  he 
says,   "in   a  highly  susceptible  nervous 


child  a  convulsion  often  means  no  more 
than  an  attack  of  migraine  in  an  older 
person."  It  might,  however,  be  said  in 
passing  that  many  physicians  consider 
epilepsy  and  migraine  to  be  nearly  re- 
lated. The  serious  view,  however,  here 
taken  of  infantile  convulsions  is  borne 
out  by  Sir  William  Gowers,  who  says, 
"no  convulsion  in  childhood  should  be 
looked  upon  as  of  little  moment,  no 
matter  how  prominent  an  exciting  cause 
may  be  discovered."  And  again,  "even 
a  single  fit  in  childhood  indicates  the 
need  for. careful  supervision."  Finally, 
Dr.  Hughlings  Jackson  says,  "I  find  it 
hard  to  believe  that  eccentric  irritations 
of  any  sort  can  act  on  the  nervous  cen- 
ters, when  they  are  healthy,  so  as  to  pro- 
duce a  convulsion."  E.  0.  Moon 
(Lancet,  December  24,  1904). 

CORYZA,  ACUTE,  ABORTIVE  TREATMENT 
OF. 

Internally,  the  writer  employs  sodium 
benzoate  in  the  dose  of  4  grams  (1 
drachm)  for  a  child,  10  grams  (2 1/2 
drachms)  for  an  adult.  This  remedy 
succeeds  in  aborting  an  acute  coryza  or 
at  least  in  shortening  the  duration  of 
the  disease  in  about  50  per  cent,  of  the 
cases  in  which  it  is  used.  Tincture  of 
belladonna,  tincture  of  aconite  and 
opium  have  been  used,  but  their  action 
is  uncertain.  Locally,  the  application 
of  cocain  in  a  1  per  cent,  solution  or 
a  1  to  1000  solution  of  adrenalin  fre- 
quently gives  relief.  Irrigation  with  a 
pint  of  hot  saline  or  boric  acid  solutions 
morning  and  evening  tends  to  relieve  an 
acute  coryza.  The  abortive  treatment 
should  only  be  used  in  the  first  twenty- 
four,  or  at  the  most,  forty-eight  hours. 
After  this  time,  the  administration  of 
sodium  salicylate  in  the  dose  of  from 
2  grams  to  4  grams  (1/2  drachm  to  1 
drachm)   is  recommended  to  relieve  the 


66 


DENGUE. 


DIABETIC  GANGRENE. 


DIGESTIVE  DISORDERS. 


muscular  pains  and  to  reduce  the  in- 
flammation which  accompanies  this  con- 
dition. Euault  (Journal  des  Praticiens, 
vol.  xviii,  No.  36,  1904.) 

DENGUE. 

Dengue  is  one  of  the  few  fevers  in 
which  a  leucopenia  persists  from  the 
first.  Blood  examinations  are  of  great 
value  in  differentiating  from  malaria  and 
dengue.  Even  though  no  parasites  be 
found  a  slight  leucocytosis  with  decided 
increase  in  the  percentage  of  large 
mononuclears  and  transitionals  is  indi- 
cative of  the  former,  while  a  leucopenia, 
with  a  normal  differential  leucocytic 
count  or  varying  degree  of  a  small 
mononuclear  lymphocytosis  and  a  marked 
eosinophilia  late  in  the  disease  is  char- 
acteristic of  the  latter. 

Albuminuria  is  seldom  seen  in  an 
ordinary  attack  of  dengue,  and  then  only 
in  small  amounts.  The  exact  opposite 
is  true  of  yellow  fever.  The  period  of 
convalescence  in  dengue  is  almost  in- 
variably ushered  in  by  a  pronounced 
small  mononuclear  lymphocytosis  which 
persists  for  several  days.  It  is  suggested 
that  the  causative  agent  is  a  small  diplo- 
coccus  or  a  delicate  bipolar  staining  ba- 
cillus closely  resembling  Pfeiffer's  or- 
ganism. It  is  probably  transmitted  by 
the  respiratory  tract,  and  its  virulence  is 
much  increased  by  the  presence  of  the 
essential  meteorologic  factors  and  by 
overcrowding.  D.  N.  Carpenter  and  E. 
L.  Sutton  (Journal  of  the  American 
Medical  Association,  January  21,  1905). 

DIABETIC    GANGRENE    OF    THE    LOWER 
EXTREMITY. 

An  endarteritis  obliterans  is  the  main 
etiological  factor  in  so-called  diabetic 
gangrene.  In  the  abscene  of  such  arte- 
rial change  it  is  believed  that  gangrene 
of  the  lower  extremity  will  not  often  oc- 


cur in  diabetes.  The  form  of  diabetes 
presented  in  this  type  of  case  varies  con- 
siderably from  true  diabetes  mellitus. 
An  expectancy  line  of  treatment  should 
be  followed  so  long  as  the  gangrene  is 
confined  to  the  toes.  Amputation  above 
the  knee  should  be  done  as  soon  as  the 
gangrene  process  involves  the  dorsum  of 
the  foot.  H.  J.  Whitacre  (New  York 
Medical  Journal  and  Philadelphia  Med- 
ical Journal,  January  28,  1905). 

DIGESTIVE  DISORDERS,  TREATMENT  OF. 

The  prevalent  methods  of  treating 
digestive  disorders  give  unsatisfactory 
results.  An  inability  correctly  to  diag- 
nose digestive  affections,  a  tendency  to 
treat  all  cases  of  indigestion  by  a  routine 
method,  and  the  injudicious  administra- 
tion of  ferments  are  responsible.  The 
author  advocates  a  rational  plan  of  treat- 
ment based  on  a  careful  physical  exami- 
nation, which  should  comprise  all  the 
organs  of  the  body,  and  in  doubtful  cases 
also  include  examination  of  the  stomach 
contents  and  fasces.  Constipation  must 
be  corrected  and  the  teeth  and  mouth 
should  receive  what  treatment  is  neces- 
sary. Proper  mastication  of  the  food 
and  healthful  methods  of  cooking  are 
essential,  as  well  as  moderate  exercise, 
fresh  air,  sunlight,  and  rest.  The  vari- 
ous bitter  tonics  are  useful,  and  antacids, 
such  as  sodium  bicarbonate  or  magne- 
sium carbonate,  in  some  cases  combined 
with  an  intestinal  antiseptic  and  a  mu- 
cous protective,  will  do  much  to  prevent 
flatulence.  Acute  attacks  are  treated  by 
carminatives,  followed  by  a  saline,  an 
emetic,  or  lavage.  A  case  is  described 
which  had '  been  unsuccessfully  treated 
with  enzymes,  and  which  promptly 
yielded  to  rational  measures.  These  con- 
sist in  assisting  nature  without  rendering 
the  functions  dependent  on  medication, 
which   in   the   long   run   reduces   their 


DISINFECTION  OF  HANDS. 


ECZEMA. 


ENURESIS. 


67 


activities  instead  of  stimulating  them. 
J.  W.  Hunter,  Jr.  (Medical  Kecord, 
January  14,  1905). 

DISINFECTION  OF  THE  HANDS,  ANTISEP- 
TIC OR  MECHANICAL? 
From  a  general  consideration  of  the 
subject  and  from  experiments  performed 
by  himself  and  his  assistants,  the  author 
expresses  the  opinion  that  the  use  of 
antiseptics  in  the  disinfection  of  hands 
is  a  pure  waste  of  time ;  that  mechanical 
cleansing  is  the  only  method  which  pro- 
duces any  sort  of  results;  and  that  of 
all  the  mechanical  methods,  the  best  one 
is  the  hot  water  and  alcohol  method 
ascribed  by  Ahlfeld.  The  writer  scrubs 
his  hands  for  ten  minutes  with  hot  water, 
soft  soap,  and  by  means  of  a  sharp  brush ; 
he  rinses  them  in  hot  flowing  water  and 
then  brushes  for  five  minutes  with  alco- 
»  hoi.  The  alcohol  has  three  virtues :  It 
is  bactericidal,  dissolves  fat  and  epithe- 
lial cells  ready  to  be  desquamated,  and 
shrinks  the  surface  structures,  thus  pre- 
venting deeply-seated  bacteria  from  in- 
fecting the  field  of  operation,  just  as 
rubber  gloves  would  do.  During  the 
operation,  he  does  not  rinse  his  hands 
with  water,  antiseptics,  or  saline  solu- 
tion, but  with  25  per  cent,  to  50  per 
cent,  alcohol.  E.  Schaeffer  (Therapeu- 
tische  Monatshefte,  Bd.  xviii,  Nu.  11, 
1904). 

ECZEMA,  INFANTILE,  TREATMENT  OF. 

The  author  considers  this  a  form  of 
auto-intoxication  due  to  disordered  di- 
gestive action,  and  consequently  the  first 
indication  is  to  attempt  to  regulate  the 
caslro-intestinal  tract.  Tf  the  child  is 
breast-fed.  feedings  should  be  at  a  def- 
inite time  and  for  a  definite  period. 
Bottle-fed  children  should  Ik1  given 
properly  modified  milk.  Older  children 
should  be  fed  chiefly  on   milk,  with  a 


limited  amount  of  eggs  and  vegetables. 
If  any  meat  is  given,  white  meat  is  to 
be  preferred.  No  tea,  coffee,  or  alcohol 
should  be  allowed.  The  bowels  must  be 
kept  regular.  Arthritic  infants  should 
be  given  alkalies;  scrofulous  ones  cod- 
liver-oil,  iron,  or  calcium  glycerophos- 
phate. In  the  sluggish  eczema  of  chil- 
dren over  five  years  arsenic  may  be  ad- 
ministered. In  cases  which  resist  die- 
tetic and  internal  treatment  local  appli- 
cations are  necessary.  First  the  skin 
must  be  made  as  aseptic  as  possible  by 
means  of  mild  and  non-irritating  anti- 
septics or  preferably  by  boiled  water. 
The  affected  parts  should  be  washed  with 
cotton  swabs — which  must  be  thrown 
away  after  once  being  used — dipped  in 
the  solution.  This  is  to  be  done  several 
times  a  day  and  is  to  be  followed  by  a 
dressing.  If  crusts  are  present  they  may 
be  loosened  by  a  poultice  of  potato 
starch,  and  later,  if  the  area  is  not  large, 
powders  should  be  applied.  On  the  scalp 
sterile  oil  containing  a  little  salicylic 
acid  is  useful.  Bathing  is  usually  con- 
tra-indicated. Before  using  ointments, 
powders  and  solutions  should  be  tried, 
and  when  these  latter  have  initiated  the 
treatment,  ointment  of  salicylic  acid; 
sulphur,  tar,  or  oil  of  cade  are  indicated. 
In  oily  and  impetigenous  eczemas,  dress- 
ings of  silver  nitrate  have  a  favorable 
action ;  later  tar  or  salicylic  acid  should 
be  used.  Finally,  in  children  who  resist 
the  foregoing  treatments,  weak  pastes  of 
pyrogallic  or  chrysophanic  acid  may  be 
tried.  C.  Clenet  (Eevue  Franchise  do 
Medecine  et  de  Chirurgie,  No.  32, 
1904). 

ENURESIS. 

Hue  author  has  used  massage  in  this 
condition  as  advocated  by  Txrauss.  of 
Vienna,  with  good  results.  The  move- 
ments  are   as  follows:    The  rectum  is 


68 


EPILEPSY,  TREATMENT  OF. 


EROTOMANIA. 


freed  of  faeces  and  massage  is  applied 
by  means  of  the  index  finger  to  the 
sphincter  vesicas.  The  idea  of  this  pro- 
cedure is  based  on  an  assumption  of  a 
relaxed  condition  of  the  sphincter  vesicae. 
The  child  lies  in  the  lithotomy  position, 
and  with  the  index  finger  in  the  rectum, 
the  sphincter  vesicae  is  gently  tapped  by 
the  operator  for  a  half  to  a  minute.  A 
deep  circular  massage  is  applied  over  the 
hypogastric  region  for  two  to  three  min- 
utes. The  patient,  lying  in  the  dorsal 
position,  with  the  knees  tightly  drawn 
together,  is  told  to  resist  while  the  knees 
are  drawn  apart;  and  with  the  knees 
widely  separated,  he  is  asked  to  resist 
while  they  are  drawn  together.  The 
same  resistant  adduction  and  abduction 
movements  are  also  employed  with  the 
legs.  These  movements  occupy  about 
two  minutes.  The  patient,  standing 
against  a  wall  or  door,  crosses  and  re- 
crosses  one  thigh  over  the  other  for  a 
period  of  five  minutes.  The  patient  is 
next  taken  across  the  knee  and  with  the 
side  of  the  hand,  the  lumbar  and  sacral 
regions  are  sharply  tapped  very  fre- 
quently by  the  operator,  thus  giving  a 
vibratory  sensation.  In  addition,  as  an 
excellent  adjuvant,  especially  for  its 
mental  effect,  electricity  may  be  used. 
These  movements,  together  with  a  solu- 
tion of  atropin,  1  grain  to  2  ounces  of 
water,  5  drops  at  4  p.m.  and  10  p.m., 
have  given  excellent  results  in  the  hands 
of  the  writer.  Julius  Ullmann  (New 
York  Medical  Journal  and  Philadelphia 
Medical  Journal,  December  31,  1904). 

EPILEPSY,  TREATMENT  OF,  BY  LIGATION 
OF  LONGITUDINAL  SINUS. 

In  operating  on  an  epileptic  of  54  the 
longitudinal  sinus  was  accidentally  in- 
jured and  was  tamponed  to  control  the 
haemorrhage.  The  patient  was  freed  at 
one  stroke  from   his   epileptic  seizures 


and  has  had  no  recurrence  during  the 
two  years  since.  The  benefit  derived 
suggests  that  the  seizure  may  be  the  re- 
sult of  a  permanent  dilatation  of  the 
veins  on  the  surface  of  the  hemispheres, 
causing  irritation  of  the  cortex.  If  the 
circulation  in  the  cortex  could  be  modi- 
fied, the  epilepsy  would  be  cured.  The 
author  has  acted  on  this  assumption  in 
another  case  since,  applying  a  double 
ligature  to  the  longitudinal  sinus  near 
its  end.  The, technique  is  similar  to  that 
of  ligation  of  the  saphena  for  superficial 
varices.  The  results  were  almost  as  per- 
fect as  in  the  first  case.  The  patient  was 
a  man  of  23  who  has  had  no  seizures 
during  the  three  months  since  the  simple 
intervention,  the  particulars  of  which 
are  described  in  detail.  Delageniere 
(Semaine  Medical,  vol.  xxiv,,  No.  50, 
1904). 

EROTOMANIA. 

Erotomania,  like  other  manifestations 
of  paranoia,  is  due  to  degeneration.  It 
may  occur  in  either  men  or  women,  but 
is  more  common  in  the  former.  Broadly, 
it  is  an  affection  of  the  imagination,  a 
morbid  extravagance  of  the  ideal.  In  its 
individual  manifestations  it  presents  the 
characters  of  a  love,  pathologic  -  and  es- 
sentially psychic  and  devoid,  moreover, 
of  carnal  appetite.  There  is  nearly  al- 
ways, though  not  invariably,  a  tendency 
to  personification,  the  subject  foists  his 
ideality  upon  a  living  person,  or  upon  an 
inanimate  object  (statue,  picture).  In 
the  latter  case,  his  apostrophes  and  ges- 
tures disclose  the  personifying  propen- 
sity. 

The  delirious  idea  of  the  erotomaniac, 
like  others  of  the  same  class  traceable  to 
degeneracy,  is  impulsive,  obsessional, 
irresistibly  compelling.  Though  his  in- 
telligence may  show  him  the  consequence 
of  yielding  to  his  obsession,  he  is  power- 


ERYSIPELAS,  TREATMENT  OK 


ERYTHEMA  INFECTIOSUM. 


69 


less  to  resist  it.  He  should,  therefore, 
not  be  held  to  a  legal  responsibility  for 
his  acts,  but  should  be  restrained,  and, 
if  necessary,  committed  to  a  hospital  for 
the  insane. 

Erotomania  may  occasionally  co-exist 
with  nymphomania  or  some  other  form 
of  sexual  aberration,  or  with  mysticism. 
The  obsession  of  the  erotomaniac  is  usu- 
ally for  an  individual  of  the  opposite  sex. 
While  erotomania  may  disclose  itself  in 
youth,  it  is  really  a  disease  of  adult  life, 
coming  on  after  puberty,  and  ending  not 
seldom  in  dementia.  J.  L.  Corning 
(American  Medicine,  January  21,  1905). 

ERYSIPELAS,   TREATMENT   OF. 

The  following  modification  of  the 
well-known  ichthyol  treatment  for  ery- 
sipelas is  recommended  by  the  author: 
In  the  case  of  the  limbs,  a  narrow  piece 
of  adhesive  plaster  is  fastened  several 
centimeters  ahead  of  the  eruption;  it 
extends  around  four-fifths  of  the  limb, 
the  open  place  being  in  front  of  the  por- 
tion least  affected;  a  second  strip  is 
fastened  2  centimeters  nearer  the  trunk, 
the  open  place  being  on  the  other  side 
of  the  limb;  a  third  portion  is  fastened 
still  nearer  the  center  portion  of  the 
body.  In  very  few  cases  did  the  ery- 
sipelas extend  even  beyond  the  first  strip 
of  adhesive,  and  in  no  case  beyond  the 
second  strip.  In  the  case  of  the  face, 
collodion  is  employed  instead  of  plaster. 
It  is  brushed  across  the  forehead  and  in 
front  or  behind  the  ears  down  to  the 
neck,  depending  upon  the  extent  of  the 
disease.  Both  applications  produce  a 
firm  pressing  together  of  the  skin  and 
underlying  structures,  thus  keeping  the 
organisms  and  their  toxins  from  freely 
circulating  through  the  lymph-paths. 
The  affected  area  itself  is  thickly  covered 
with  ichthyol.  Before  applying  either 
plaster  or  ichthyol,  it  is  necessary  to 
4 


wash  the  surface  with  benzine.  The  au- 
thor claims  to  have  had  much  better  re- 
sults with  this  modified  method  than 
with  the  ordinary  treatment.  F.  Franke 
(Therapeutische  Monatshefe,  Bd.  xviii, 
Nu.  11,  1904). 

ERYTHEMA  INFECTIOSUM. 

The  author  calls  attention  to  a  disease 
which  he  says  has  been  described  inde- 
pendently by  several  well  known  pediat- 
rists  and  which  has  clinical  features  dis- 
tinct enough  to  justify  its  classification 
with  the  acute  exanthemata.  The  prior- 
ity of  recognition  as  a  separate  disease 
entity  belongs  to  Escherich.  Erythema 
infectiosum  is  a  feebly  contagious  dis- 
ease, occurring  chiefly  in  children  be- 
tween the  ages  of  4  and  12  years,  with 
very  slight  subjective  symptoms,  and 
characterized  by  a  maculopapular,  rose- 
red  rash,  pronounced  on  the  cheeks,  legs, 
and  outer  surface  of  the  arms.  The 
specific  agent  is  unknown.  The  disease 
occurs  in  epidemics  and  often  follows  an 
outbreak  of  measles  or  rotheln.  Both 
sexes  are  equally  affected.  It  occurs 
most  frequently  in  the  spring  and  sum- 
mer months.  The  period  of  incubation 
varies  from  six  to  fourteen  days.  The 
disease  may  be  ushered  in  by  a  slight 
feeling  of  malaise,  weakness,  and  sore 
throat,  but  in  the  majority  of  cases  the 
first  symptom  noticed  is  the  eruption. 
This  is  the  most  important  and  often  the 
only  symptom.  It  appears  invariably 
on  the  external  skin,  usually  first  on  the 
face,  chiefly  the  cheeks.  The  skin  is 
hot  to  the  touch,  is  swollen,  but  is  not 
sensitive;  nor  does  it  itch.  The  whole 
appearance  is  suggestive  of  erysipelas. 
The  eruption  is  confluent  over  the  cheeks, 
and  the  edges  are  well  defined,  slightly 
raised  and  distinct  from  the  normal  skin. 
The  area  of  confluent  eruption  is  rather 
sharply  limited  in  front  by  the  nasolabial 


70 


ETHYL  CHLORIDE. 


FRACTURES,  CARE  OF. 


folds  and  above  by  the  temples.  Later- 
ally, it  extends  to  the  angles  of  the  jaws. 
Discrete  spots  are  often  seen  on  the  fore- 
head and  chin.  The  rash  fades  from  the 
face  after  four  or  five  days.  On  about 
the  second  day  the  eruption  makes  its 
appearance  on  the  body,  where  it  is  most 
marked  on  the  outer  surface  of  the  legs 
and  arms.  The  trunk  is  involved  to  a 
much  less  degree,  and  may  be  almost 
free.  The  hands  and  feet  are  the  last 
portions  of  the  body  to  be  affected.  An 
evanescence  is  often  observed  which  is 
perhaps  peculiar  to  the  disease.  The 
eruption  is  not  followed  by  desquama- 
tion. No  haemorrhage  results  on  pinch- 
ing the  skin.  The  lymph  glands  are  not 
enlarged.  The  subjective  symptoms  are 
conspicuous  by  their  absence.  Measles 
can  be  excluded  by  the  absence  of  in- 
volvement of  the  mucous  membranes,  of 
all  constitutional  sypmtoms  and  of  Kop- 
lik's  spots.  In  rotheln  the  rash  spreads 
rapidly  over  the  entire  body  and  is  of  a 
different  character  from  that  seen  in 
erythema  infectiosum.  There  are  also 
constitutional  symptoms.  H.  L.  K. 
Shaw  (American  Journal  Medical  Sci- 
ences, January,  1905). 

ETHYL   CHLORIDE. 

The  writer  is  strongly  in  favor  of 
ethyl  chloride  as  an  anaesthetic,  provid- 
ing its  dangers  are  recognized.  It  is 
portable,  of  stable  composition  if  it  is 
kept  in  the  dark,  easy  of  administration, 
acts  rapidly,  and  provides  a  narcosis  of 
several  minutes  after  the  removal  of  the 
inhaler,  which  narcosis  is  quiet  and 
sleep-like.  But  if  complete  muscular 
flaccidity  is  required  the  anaesthetic  must 
be  pushed  to  the  limit  of  safety.  The 
writer  prefers  Braine's  modification  of 
Ormsby's  inhaler.  The  same  preparation 
of  the  patient  is  necessary  as  for  ether 
narcosis.      Almost   any   position   of   the 


patient  is  safe,  but  the  recumbent  posture 
is  best  for  children.  The  head  should 
not  be  either  too  far  backward  or  for- 
ward. A  good  average  dose  for  an  aver- 
age adult  is  five  cubic  centimeters.  It  is 
better  to  give  a  full  and  rapidly  induced 
anaesthesia  than  to  admit  air  and  econo- 
mize the  drug.  Ethyl  chloride  should 
not  be  administered  in  the  following 
conditions :  diseases  of  the  larynx ;  in- 
flammatory lesions  or  tumors  in,  or  ad- 
jacent to,  the  respiratory  passages;  goi- 
tre; all  conditions  giving  rise  to  urgent 
dyspnoea;  and  in  long  operations.  H. 
Hilliard   (Lancet,  December  17,  1904). 

FRACTURES,  CARE  OF,  FROM  STAND- 
POINT OF  THE  GENERAL  PRACTI- 
TIONER. 

Fractures  cause  the  physician  more 
trouble  than  any  other  trial  in  his  pro- 
fessional life.  In  such  cases,  if  the 
proper  precautions  were  always  taken, 
many  of  the  difficulties  would  be  avoided. 
The  x-ray  is  of  great  value  in  giving  a 
graphic  description  of  the  exact  amount 
of  damage.  A  green-stick  fracture  is 
often  unrecognized.  Although  such  an 
error  is  not  likely  to  lead  to  any  serious 
consequences,  the  patient  is  made  more 
comfortable  when  the  proper  dressings 
are  applied.  <  A  most  troublesome  class 
of  fractures  are  those  which  occur  about 
the  joints,  as  at  the  wrist,  elbow,  shoul- 
der, or  ankle.  In  these  cases  a  small  bit 
of  the  bone  is  torn  off,  and  is  often  bound 
so  firmly  by  the  ligaments  that  the  ordi- 
nary signs  of  fracture  are  absent.  These 
injuries  are  often  treated  as  sprains. 
Such  an  injury  causes  more  inconven- 
ience to  the  patient  on  account  of  the 
joint  involvement  than  does  a  fracture 
of  the  shaft  of  the  long  bones  with  con- 
siderable displacement^  The  writer  calls 
attention  to  a  bad  method  of  dressing 
which    should   be    avoided.      When   the 


HEMOPTYSIS. 


HEPATIC  ABSCESS. 


ICTERUS. 


71 


bone  is  placed  in  position,  the  dressings 
are  applied,  and  are  allowed  to  remain 
on  for  three  or  four  weeks.  If  in  that 
time  they  become  loose,  a  new  bandage 
is  simply  wrapped  around  the  old  dress- 
ings. This  is  extremely  dangerous,  and 
one  that  will  always  give  a  poor  result. 
Whenever  doubt  exists  as  to  the  nature 
of  the  injury,  the  mystery  should  be 
cleared  up  at  once,  before  the  bones  have 
become  united,  which  may  result  in  a 
deformity  that  lasts  the  rest  of  the  pa- 
tient's life.  W.  S.  Newcomet  (Medical 
News,  December  10,  1904). 

HEMOPTYSIS,   TREATMENT   OF. 

As  soon  as  haemorrhage  begins,  the 
head  and  shoulders  should  be  raised  and 
a  hypodermic  injection  of  morphine 
given,  the  dose  varying  from  1/a  to  1/3 
of  a  grain.  Thirty  to  forty  grains  of 
calcium  chloride  dissolved  in  a  little 
water  should  be  injected  high  into  the 
rectum,  and  an  iceberg  applied  to  that 
part  of  the  chest  immediately  underlying 
which  is  the  most  active  tuberculous 
focus.  Heat  should  be  applied  in  order 
that  blood  may  be  drawn  to  the  lower 
limbs.  The  value  of  morphine  in  hsem- 
orrhage  depends  upon  its  power  of  stim- 
ulating the  inhibitory  center,  by  means 
of  which  the  cardiac  action  is  slowed. 
As  to  the  value  of  the  administration  of 
calcium  chloride,  it  may  be  said  that 
active  fibrin  ferment  is  rich  in  calcium, 
and  wherever  coagulation  takes  place, 
calcium  in  some  form  or  other  is  pres- 
ent; and  the  conditions  which  favor 
coagulation  in  the  lungs  are  feeble,  for 
blood,  after  circulating  several  times 
through  the  pulmonary  vessels  without 
being  allowed  to  enter  the  systemic  cir- 
culation, loses  its  power  of  clotting.  IT. 
Hyslop-Thomson  (Lancet,  December  17, 
1904) . 


HEPATIC   ABSCESS. 

Hepatic  abscess  is  a  pathologic  condi- 
tion that  has  been  recognized  for  many 
centuries.  It  is  widespread  in  its  occur- 
rence. The  so-called  "tropic  liver  ab- 
scess" occurs  most  frequently  in  the  hot 
countries.  Sporadic  cases  of  tropic  liver 
abscess  are  encountered  as  exotic  mani- 
festations in  the  temperate  zones.  It  is 
impossible  to  tabulate  definitely  a  gen- 
eral ratio  of  frequency  of  occurrence. 
Hepatic  abscess  is  at  times  the  result  of 
trauma;  usually,  however,  the  result  of 
invasion  of  the  hepatic  tissue  by  various 
forms  of  parasites,  protozoa,  and  pyo- 
genic organisms.  That  form  commonly 
known  as  "amoebic  abscess  of  the  liver," 
is  in  reality  not  an  abscess,  but  rather  a 
necrosis  and  liquefaction  of  hepatic  tis- 
sue. When  pus  is  encountered,  it  is  the 
result  of  contamination  by  pyogenic  or- 
ganisms. -N.  W.  Sharpe  (American 
Medicine,  January  28,  1905). 

ICTERUS,  PATHOLOGY  OE. 

In  a  condition  like  icterus,  which  is  a 
symptom  of  many  different  diseases, 
there  is  always  a  desire  to  find  a  com- 
mon factor  underlying  all  cases.  In  the 
early  days  of  pathology  it  was  assumed 
that  in  all  instances  this  common  under- 
lying factor  was  a  mechanical  obstruc- 
tion of  some  sort,  but  it  very  soon  be- 
came evident  that  in  many  cases  no  such 
mechanical  obstruction  could  be  found. 
In  such  cases  the  signs  of  biliary  stasis 
in  the  liver  itself,  dilatation  and  over- 
filling of  the  bile  ducts,  stasis  of  bile  in 
the  interlobular  bile  passages  and  de- 
position of  bile  pigment  in  the  liver  cells, 
are  entirely  lacking.  Inability  to  ac- 
count for  such  cases  on  mechanical 
grounds  led  to  the  conception  of  hema- 
genous  as  opposed  to  hepatogenous  ic- 
terus. It  was  i bought  that  bile  could  be 
manufactured  not  only  in  the  liver,  but 


72 


ICTERUS,  PATHOLOGY  OF. 


also  in  the  blood.  The  latter  form  of 
bile  formation  was  thought  to  occur  '  in 
toxic  and  infectious  conditions  in  which 
a  large  number  of  blood  corpuscles  were 
broken  up  in  the  circulation.  As  a  result 
of  this  conception  all  cases  of  icterus 
which  could  not  be  classed  as  obstructive 
were  ranged  under  hematogenous  icterus, 
or  as  ISTaunyn  and  Minkowski  called  it, 
icterus  from  polycholia.  Later  it  was 
shown  that  something  more  than  ex- 
cessive blood  destruction  was  needed  to 
account  for  such  cases  when  the  liver 
was  acting  normally,  and  in  recent  years 
many  have  held  that  the  second  necessary 
factor  was  a  disturbance  in  the  function 
of  the  liver  cells  themselves.  This  change 
in  the  liver  cells  has  been  compared  to 
the  disturbance  in  the  kidney  cells  which 
produces  albuminuria.  This  hypothesis 
explained  especially  well  the  icterus  of 
infections  or  intoxications,  and  that  of 
circulatory  or  nervous  disturbances,  be- 
cause in  just  such  conditions  it  was  easy 
to  imagine  that  the  secretory  powers  of 
the  liver  cells  might  be  affected.  Some 
writers  went  so  far  at  this  time  as  to 
almost  deny  to  mechanical  factors  any 
importance  at  all. 

The  recent  work  of  Eppinger,  which 
was  based  on  painstaking  histologic  ex- 
aminations and  a  method  which  rendered 
the  walls  of  the  bile  capillaries  easily 
visible,  has  led  back  once  more  to  a  me- 
chanical theory  of  icterus.  He  found  in 
various  forms  of  icterus  a  dilatation  of 
the  bile  capillaries  with  elongation,  sinu- 
osity, varicose  swellings,  and  even  rup- 
ture of  the  walls.  As  a  result,  the  bile 
was  able  to  gain  entrance  into  the  peri- 
vascular lymph  spaces.  The  obstruction, 
though  mechanical,  was  not  in  the  larger 
bile  passages,  but  in  the  capillaries,  which  ' 
were  either  compressed  by  new-formed 
connective  tissue  or  blocked  by  bile 
thrombi.     These  observations  have  been 


confirmed  in  the  main  by  Abramow  and 
Samoilowicz.  Eecently  Winckelmann 
(Zeitschrift  fiir  kliu.  Medicin.,  vol.  lv), 
working  at  Minkowski's  suggestion,  has 
gone  over  the  work  afresh.  The  point 
in  which  Eppinger's  conception  differs 
most  radically  from  the  preceding  theo- 
ries of  icterus  is  in  the  role  played  by 
the  lymph  spaces  surrounding  the  bile 
capillaries.  Doubt  has  been  cast  on  the 
existence  of  such  spaces,  and  even  Ep- 
pinger himself  does  not  describe  them 
as  definite  vessels,  but  merely  as  spaces 
between  the  walls  of  the  bile  capillaries 
and  the  liver  cells.  According  to  Min- 
kowski, there  is  little  doubt  that  such 
spaces  exist.  Eppinger  seems  to  think 
that  in  icterus  the  bile  must  reach  the 
blood  by  means  of  the  lymph  channels, 
and  there  is  some  support  to  this  view 
in  the  old  observations  of  Harley  and 
von  Frey,  who  showed  that  if  the  thoracic 
duct  be  ligated  at  the  same  time  as  the 
ductus  communis  choledochus  no  icterus 
would  occur.  This  of  course  necessitates 
the  view  that  while  the  blood  capillaries 
of  the  liver  are  permeable  for  some  sub- 
stances they  are  not  permeable  for  bile, 
an  idea  which  is  by  no  means  unthink- 
able in  the  light  of  our  present  knowl- 
edge of  cell  specificity.  Another  point 
in  which  Eppinger's  conception  differs 
from  preceding  ones  is  the  recognition  of 
the  bile-stained  plugs  in  the  capillaries 
as  bile  thrombi.  These  are  not  made  up 
of  pure  bile,  but  are  bile-stained  con- 
crements  which  form  when,  as  a  result 
of  disturbances  in  the  liver  cells,  abnor- 
mal substances  are  excreted  with  the  bile. 
These  bodies  can,  perhaps,  more  reason- 
ably be  compared  to  the  urinary  casts 
than  to  thrombi. 

While  this  work  of  Eppinger  explains 
the  pathology  of  many. cases  of  icterus, 
Minkowski  points  out  that  all  cases  ex- 
amined  since   its   publication  have  not 


INTESTINES,  ROLL  OF  POISONS  IN. 


KNEE-JOINT  EFFUSION. 


73 


shown  these  lesions.  This  is  especially 
true  of  cases  of  infectious  icterus.  In 
just  such  cases  it  has  been  shown  that  the 
bile  is  often  abnormal,  and  may  contain 
albumin.  Such  cases  are  probably  clue 
primarily  to  the  liver  cell  changes, 
though  the  bile  thrombi  and  mechanical 
stasis  may  occur  as  secondary  phenom- 
ena. Minkowski  thinks  that  though  the 
work  of  Eppinger  has  greatly  extended 
our  knowledge  of  the  pathology  of  ic- 
terus, we  must  still  recognize  two  forms 
— the  true  obstructive  icterus,  in  which 
mechanical  obstruction  plays  the  main 
part,  and  the  toxic,  cyanotic,  and  nerv- 
ous forms,  in  which  the  disturbance  in 
the  function  of  the  liver  cells  is  the 
important  factor.  Editorial  (Journal 
of  the  American  Medical  Association, 
January  21,   1905). 

INTESTINE,    THE    ROLE    OF    POISONS    IN 
THE. 

The  writers  conclude  from  their  in- 
vestigations that  in  the  normal  condition 
of  the  digestive  tube  innumerable  poi- 
sonous substances  are  constantly  present. 
In  addition  there  are  toxic  substances, 
the  diastases,  for  example,  which  are  in- 
dispensible  to  the  nutritive  changes  of 
the  body.  The  organism  has  various 
means  for  defending  itself,  and  the  tend- 
ency of  disease  is  to  break  flown  such 
moans  of  defense.  Tf  the  views  of  patho- 
genesis advanced  by  the  authors  are  true, 
they  signify  that  general  therapeutical 
measures  are  inadequate.  Tliev  indicate 
that  the  enemy  is  to  bo  attacked  directly 
and  also  that  the  moans  of  defense  must 
not  bo  broken  down.  Normal  organic 
products  are  often  morbific  and  the  phys- 
iological digestive  secretions  themselves 
arc  such  at  times.  TWoro  destroying 
them  it  is  necessary  to  allow  them  to 
accomplish  their  proper  functions  and 
maintain  intact  all  the  means  of  defense 


with  which  the  body  is  provided.  Char- 
rin  and  Leplay  (Semaine  Medicale, 
November  23,  1904. 

KNEE-JOINT  EFFUSION,  RECURRENT. 

In  a  series  of  750  cases  of  recurrent 
knee-joint  effusion,  the  effusion  was  re- 
current either  spontaneously  or  after  an- 
other injury,  usually  very  slight.  In  all 
the  cases  an  interval  had  elapsed  during 
which  the  joint  was  apparently  entirely 
independent  of  any  constitutional  con- 
ditions. Of  these,  in  428  the  symptoms 
of  internal  derangement  was  very  pre- 
cise. The  proportion  of  male  to  female 
cases  was  as  sixteen  to  one.  Eighty  cases 
were  treated  by  operation — removal  of 
pedunculated  bodies,  and  of  internal  and 
external  semilunar  cartilages.  From  his 
experience  the  author  concludes  that 
when  the  usual  methods  of  treatment 
have  failed  to  effect  a  cure,  exploratory 
operation  is  indicated.  Further,  that 
extensive  displacement  of  one  or  even 
both  semilunar  cartilages  may  take  place 
without  the  recurrence  of  any  of  the 
symptoms  which  are  commonly  regarded 
as.  characteristic  of  the  lesion.  The  cases 
in  which  the  displacement  is  greatest 
give  rise  to  the  fewest  symptoms.  Con- 
stitutional conditions  seemed  to  play  a 
part  in  241  cases.  Osteoarthritis  was 
present  in  107  cases.  Radiant  boat 
baths,  massage,  and  electric  vibration 
were  the  only  modes  of  treatment  which 
seemed  to  have  more  than  a  palliative 
effect.  In  23  recent  cases  they  appeared 
to  effect  an  actual  cure.  Rheumatism 
and  gout  were  present  in  30  cases,  and  as 
a  rule  the  usual  constitutional  measures 
gave  relief.  Tn  42  syphilitic  cases  no 
permanent  benefit  was  obtained  until  a 
course  of  antisyphilitic  treatment  was 
adopted.  .  Tn  28  cases  there  -was  a  history 
of  flronorrhooa,  17  of  the  patients  having 
obvious    gleet.      Operations    were    per- 


74 


LACTIC  ACID  FORMATION.    LEAD  POISONING.     LEUCOCYTOSIS. 


formed  to  relieve  tension,  aspiration  ef- 
fecting the  purpose  as  perfectly  as  in- 
cision. An  interesting  class  of  cases 
were  the  ones  where  there  was  a  history 
of  malaria,  mostly  contracted  in  South 
Africa.  Eighteen  such  cases  were  seen. 
There  were  thirteen  instances  of  quiet 
effusion  in  young  people,  a  condition  to 
which  the  author  has  previously  called 
attention.  W.  H.  Bennett  (Lancet, 
January  7,  1905). 

LACTIC  ACID  FORMATION,  EXPERIMEN- 
TAL STUDY  OF,  WITH  SPECIAL  REF- 
ERENCE  TO   THE    STOMACH. 

Lactic  acid  develops  in  all  organic 
substances  containing  carbohydrates, 
whether  sugar  or  starch;  and  in  some 
instances  even  while  yet  in  solid  form, 
such  as  bread  and  meat,  for  instance, 
at  certain  seasons  which  are  especially 
favorable  for  bacterial  development, 
some  lactic  acid  exists  already;  and  on 
dissolving  such  substances  in  water  the 
lactic  acid  reaction  can  soon  be  detected. 

Lactic  acid  formation  is  due  in  all 
cases  to  bacterial  development,  even  the 
so-called  sarcolactic  acid  of  meat.  Fur- 
thermore, many  kinds  of  bacteria  can 
by  their  development  bring  about  the 
formation  of  lactic  acid  in  substances 
containing  carbohydrates;  but  the  bac- 
teria usually  vary  in  the  different  sub- 
stances. 

Lactic  acid  does  not  give  the  usual 
reaction  with  the  usual  tests  when  an 
inorganic  acid  is  also  present  in  suffi- 
cient strength. 

The  lactic  acid  development  is  hin- 
dered  when  there  is  an  antiseptic  present, 
such  as  HC1,  for  example,  acting  against 
those  bacteria  which  bring  about  the  lac- 
tic acid  development ;  but  the  lactic  acid 
that  had  been  formed  before  HC1  was 
added  is  not  destroyed  when  the  latter 
is  added.    It  is  only  masked  as  far  as  the 


ordinary  reactions  are  concerned  and  its 
further  development  arrested;  but  it 
can  be  separated  by  means  known  to 
chemistry. 

HC1  enters  in  combination  with  albu- 
minoids, and  after  some  time  it  does  not 
give  the  usual  reaction,  though  it  was 
marked  when  it  was  first  added;  and 
then  bacteria  appear,  and  also  lactic  acid 
begins  to  form,  the  latter  in  substances 
containing  carbohydrates.  E.  Palier 
(American  Medicine,  January  7,  1905). 

LEAD      POISONING,      EYE      LESIONS      OF 
CHRONIC. 

Substances  likely  to  be  dangerous  to 
workers  are  carbon  disulphide  in  the  vul- 
canization of  rubber,  ethyl  bromide,  mer- 
cury in  all  forms,  wood  alcohol,  arsenic, 
dinitro-benzol,  anilin  and  anilin  colors, 
carbonic  oxide,  hydrogen  sulphide,  lime, 
chinon  compounds,  and  lead.  The  last 
of  these  is  often  underestimated  in  im- 
portance but  forms  a  most  treacherous 
and  dangerous  foe  to  the  workman.  The 
author  cites  thirty  different  trades  in 
which  the  use  of  lead  was  followed  by 
damage  of  greater  or  less  degree  to  the 
eyes  of  130  patients.  The  gravity  of  the 
condition  is  shown  by  the  statistics  of 
114  cases  in  which  cure  could  be  effected 
in  only  40,  while  atrophy  of  the  optic 
nerve  was  noted  36  times.  The  ocular 
symptoms  caused  may  be  of  many  sorts 
and  degrees  of  intensity,  but  even  when 
cured  always  leave  the  patient  with  a 
susceptibility  to  the  poison  which  makes 
a  continued  exposure  very  hazardous.  L. 
Lewin  (Berh'ner  klinische  Wochen- 
schrift,  December  12  and  19,  1904). 

LEUCOCYTOSIS,    NATURE     AND     SIGNIFI- 
CANCE OF. 

Poverty  in  small  lymphocytes  exists  in 
connection  with  a  great  impairment  in 
body  nutrition  and  cell  metabolism. 
This  condition  exists  in  typhoid  fever, 


MALARIA,  HEART  IN.     MASTOID  OPERATION. 


75 


tuberculosis,  and  a  variety  of  debilitated 
conditions.  It  cannot,  therefore,  be  in- 
terpreted as  being  characteristic  of  any 
particular  disease.  Whenever  it  exists  it 
is  always  to  be  considered  a  potent  factor 
when  estimated  in  connection  with  the 
history  of  the  case  and  the  associated 
clinical  symptoms. 

On  the  other  hand,  the  lymphocytosis 
that  so  frequently  accompanies  a  well- 
marked  convalescence,  from  a  condition 
in  which  poverty  of  lymphocytes  pre- 
viously existed,  would  seem  to  indicate  a 
condition  of  increased  physiologic  ac- 
tivity, thus  corroborating  Virchow's 
theory  of  a  nutritive  and  formative  hy- 
peracidity of  a  convalescent  organism. 
A.  M.  Holmes  (Journal  of  the  American 
Medical  Association,  January  28,  1905). 

MALARIA,  THE  HEART  IN. 

Report  of  three  cases  of  malarial  in- 
fection in  which  symptoms  of  cardiac 
insufficiency  were  observed  which  resem- 
bled closely  those  seen  in  acute  endocar- 
ditis and  myocarditis  accompanying  in- 
fectious diseases.  A  study  of  these  cases 
convinced  the  writer  that  the  cardiac 
disturbances  were  not  merely  the  result 
of  changes  in  the  innervation  of  the 
heart,  but  were  indications  of  a  severe 
involvement  of  the  myocardium.  There 
is  no  doubt  that  the  myocardium  may  be 
affected  in  severe  cases  of  malarial  in- 
fection, especially  in  the  aestivoautumnal 
type.  These  changes  are  usually  func- 
tional only  at  first,  but  later  on  they  may 
become  anatomical,  and  more  permanent. 
If  tbe  proper  treatment  be  applied  to  the 
malarial  infection,  however,  these  cases 
may  be  favorably  influenced.  The  func- 
tional disturbances  of  the  heart  may, 
however,  continue  for  a  long  time  after 
the  malaria  has  been  cured,  and  it  is 
common  in  such  cases  to  find  a  weak  and 
irregular    pulse,    weak    cardiac    sounds, 


cyanosis,  etc.  The  practical  conclusion 
is  that  malarial  patients  with  cardiac 
complications  should  not  merely  be 
treated  as  malarial  cases,  but  should  also 
receive  the  proper  treatment  for  their 
cardiac  condition.  They  should  be 
treated  as  convalescents  from  an  endo- 
carditis, and  the  proper  cardiac  reme- 
dies should  be  employed.  The  condition 
described  is  often  taken  for  the  effect  of 
anaemia,  but  this  is  a  mistake.  Another 
important  point  is  that  too  large  or  too 
frequent  doses  of  quinine  should  be 
avoided  in  the  treatment  of  malaria, 
especially  when  the  heart  is  involved. 
Moderate  doses  of  quinine  at  intervals  of 
three  hours  (1/2  gram  hypodermically, 
for  example)  are  just  as  efficient  and  less 
dangerous  than  the  enormous  doses  some- 
times given.  P.  Gallenga  (Gazetta  degli 
Ospedali  e  delle  Cliniche,  November  20, 
1904;  from  New  York  Medical  Journal 
and  Philadelphia  Medical  Journal,  Jan- 
uary 28,  1905). 

MASTOID  OPERATIONS,  CHOICE  OF  TIME 
OF  ELECTION  IN. 

Delay  in  operation  of  cases  of  mas- 
toiditis complication  or  as  a  sequel  of 
the  exanthemata  or  influenza  should 
not  be  permitted  beyond  from  thirty-six 
to  forty-eight  hours,  if  profuse  discharge 
from  the  middle  ear  by  incision  or  rup- 
ture, with  ice  to  tbe  mastoid  and  general 
antiphlogistic  measures  do  not  markedly 
improve  the  condition.  Even  with  nor- 
mal or  slightly  elevated  temperature,  if 
there  is  oedema  over  the  mastoid  and 
sagging  of  the  posterosuperior  wall  of 
the  external  canal,  operation  should  not 
be  delayed,  for  with  what  seems  to  be 
an  improved  general  state,  in  the  ma- 
jority of  cases  operation  will  eventually 
be  needed. 

Tn  cases  showing  infection  with  strep- 
tococci, while  at  times  for  days  the  symp- 


76 


MASTOID  OPERATIONS.    METAL  FERMENTS. 


toms  lie  in  abeyance,  such  cases  should 
not  be  treated  tentatively  on  appearance 
of  pronounced  symptoms  of  aggravated 
pain  about  the  ear,  fresh  rise  of  tempera- 
ture, lessened  or  suppressed  discharge 
from  middle  ear,  but  should  be  operated 
on  without  delay  in  order  to  prevent  the 
extensive  caries  which  occurs  in  from 
two  to  three  days  in  such  infection. 

In  cases  of  slow,  painful  recovery,  even 
if  promising  in  the  end  to  be  complete, 
it  would  be  wise  to  operate  after  a  reason- 
able period  of  observation,  in  order  to 
assist  Nature  in  her  task. 

Since  this  paper  deals  with  private 
patients  who  are  seen  without  undue  de- 
lay, and  who  have  usually  had  the  benefit 
of  good  care  of  a  palliative  kind,  it  may 
be  stated  that  as  a  rule  applying  to  these 
cases  of  chronic  otitis  media,  that  the 
radical  operation  with  its  disfiguring  re- 
sults may  quite  often  be  replaced  by 
the  simple  operation  conjoined  with  care- 
ful curettage  of  the  middle  chamber. 

Cases  of  chronic  otitis  media  may  be 
permitted  more  latitude  if  there  arise  no 
signs  pointing  to  intracranial  involve- 
ment. However,  if  there  be  present  con- 
stant otorrhcea,  neuralgic  pains  over  the 
part,  lowered  general  health,  with  nerv- 
ous irritability,  perhaps  vertigo,  opera- 
tion should  be  undertaken  after  from 
two  to  six  weeks,  if  treatment  has  failed 
to  relieve  the  condition.  J).  A.  "Kuyk 
(Journal  of  the  American  Medical  Asso- 
ciation, January  21,  1905). 

METAL      FERMENTS.      ACTION      OE,      ON 
METABOLISM    AND    IN   PNEUMONIA. 

The  author  announces  that  a  solution 
of  a  metal,  in  a  proportion  of  .00009  to 
.0002  grams  to  the  cnbic  centimeter, 
has  a  most  remarkable  action  when  in- 
jector! subcutaneous! v.  Tt  displays  a 
phvpiolocrir  notion,  like  that  of  a  true  fer- 
ment, out  of  all  proportion  to  the  minute 


amount  of  the  metal  employed.  The 
amount  of  urea  may  be  increased  by  30 
per  cent.,  in  consequence,  while  there  is 
liable  to  be  a  copious  discharge  of  indoxyl 
in  the  urine  and  the  uric  acid  may  triple 
its  former  figure.  The  respiratory  quo- 
tient is  increased  and  the  blood-pressure 
transiently  raised.  The  injection  is  fol- 
lowed also  by  leucocytosis.  As  certain  of 
the  vital  processes  are  thus  stimulated 
by  these  metal  ferments,  as  the  author 
calls  these  extremely  weak  solutions  of 
metals,  he  has  tried  to  utilize  them  in 
the  clinic.  In  pneumonia  the  phenom- 
ena observed  during  the  crisis  resemble 
those  that  follow  injection  of  the  metal 
ferment.  In  14  cases  of  pneumonia  an 
injection  of  from  5  to  10  cubic  centi- 
meters of  the  metal  solution  hastened  the 
crisis,  the  temperature  dropping  to  nor- 
mal before  the  seventh  day,  but  the  phys- 
ical signs  were  not  apparently  modified. 
The  metal  ferments  evidently  stimulate 
the  reaction  of  the  organism,  re-enforcing 
the  natural  resisting  powers  and  super- 
posing on  the  vital  and  personal  reac- 
tions a  parallel  activity  revealed  by  the 
more  rapid  disappearance  of  the  correla- 
tive symptoms  of  the  infection.  Fifteen 
cases  of  pneumonia  were  treated  with 
antidiphtheria  serum,  normal-  horse 
serum,  lactoserum  or  with  yeast  extracts, 
and  their  action  seemed  to  be  along  the 
same  lines  as  that  of  the  metal  ferments. 
The  writer  regards  it  as  probable  that 
the  effect  of  these  serums  and  of  the 
metal  ferments  is  practically  identical. 
The  latter  may  possibly  substitute  the 
former  when  more  is  learned  in  regard 
to  their  physical  phenomena  and  biologic 
action. 

The  therapeutic  use  of  the  metal  fer- 
ments is  an  attempt  to  apply  in  the  clinic 
the  new  data  furnished  by  physics  and 
chemistry  in  the  last  #ew  years  in  re- 
gard   to    radioactivity,    ionization    and 


NEURASTHENIA. 


OPTIC  NEURITIS. 


77 


atomic  energy,  diastases,  zymases,  mi- 
nutely divided  metals  and  catalytic  phe- 
nomena. The  solutions  are  obtained  by 
passing  a  small  electric  arc  between 
metal  electrodes  submerged  in  distilled 
water.  The  metal  passes  into  the  fluid 
in  the  proportion  of  .09  to  .2  millimeters 
of  the  metal  used  to  each  cubic  centi- 
meter of  the  fluid.  A  solution  thus  made 
displays  a  number  of  the  reactions  sup- 
posed to  be  peculiar  to  the  organic  dia- 
stases, and  these  reactions  can  be  accel- 
erated or  inhibited  by  agents  capable  of 
influencing  the  diastases  in  the  same 
way.  The  kind  of  metal  used — silver, 
gold,  or  platinum — did  not  seem  to 
make  any  difference  in  regard  to  the  re- 
sults. The  author  suggests  that  the  ef- 
fect may  be  due  to  a  condition  of  the 
metal  atoms  similar  to  that  noted  in  the 
vacuum  of  the  Crookes  tube,  the  so- 
called  "radiant  state,"  in  which  the 
atoms  are  separated  to  the  extremest- 
limits,  liberated,  autonomous  in  their 
activity  and  susceptible  of  developing 
more  energy.  This  hypothesis  may 
explain  the  vital  action  of  arsenic  and 
iodine  found  normally  in  the  tissues 
and  also  the  remarkable  therapeutic  effi- 
ciency of  certain  mineral  waters.  A. 
Robin  (Bulletin  de  l'Academie  de  Me- 
dicine, December  6,  1904). 

NEURASTHENIA,    WORK    AS    A    REMEDY 
IN. 

The  author  offers  a  protest  against  the 
almost  universal  treatment  of  neurasthe- 
nia by  rest.  The  neurasthenic  suffers 
fatigue  or  irritability  beyond  the  reason- 
able results  of  mental  or  physical  exer- 
tion, and  is  thereby  incapacitated  for  his 
ordinary  occupation  or  for  enjoyment  of 
life.  Neurasthenics  load  faulty  lives; 
in  many  cases  thorn  is  a  tendency  to 
overestimate  the  importance  of  small 
things  or  to  worry.     Worry  is  closely 


associated  with  a  sense  of  fatigue,  often 
not  distinguishable  from  that  which  fol- 
lows arduous  labor,  except  that  it  is  not 
relieved  by  physiologic  rest.  Some  of 
the  profoundest  neurasthenics  have  never 
over-functioned  in  any  discoverable  way. 
A  feeling  of  fatigue  is  brought  on  by 
the  mere  thought  of  exertion.  Things 
that  the  patient  likes  to  do  are  less 
fatiguing  than  distasteful  activities. 
When  there  is  lack  of  fat  and  blood,  the 
rest  cure  may  do  good,  but  the  great 
need  in  most  cases  is  to  bring  about 
gradually  the  conditions  of  a  normal 
life  by  pleasant  and  progressive  occu- 
pation. Most  neurasthenics  are  adapt- 
able people,  with  artistic  taste  and  crit- 
ical ability,  and  there  is  an  inborn  love 
in  man  for  making  beautiful  things  out 
of  crude  elements.  The  writer  has  estab- 
lished a  shop  for  the  manufacture  of 
pottery  and  woven  fabrics,  having  a  com- 
petent teacher  and  assistants.  The  pa- 
tient after  a  few  days'  rest,  and  without 
warning,  is  required  to  do  something, 
and  a  gradually  progressive  program  is 
written  out  for  each  day  and  entrusted 
to  the  nurse.  This  eliminates  anticipa- 
tory fatigue.  When  the  patient  turns  out 
work  of  value  it  is  sold  and  the  pro- 
ceeds credited  to  the  maker.  The  accu- 
mulated indications  point  to  the  prob- 
ability  of  fairly  quick  results.  H.  J. 
Hall  (Boston  Medical  and  Surgical 
Journal,  January  12,  1905). 

OPTIC    NEURITIS    AND    FACIAL    PARAL- 
YSIS. 

T'eport  of  a  case  of  postpapillitic  optic 
atrophy  with  a  history  of  prior  right- 
sided  facial  paralysis  with  pain  in  iaw 
and  with  a  noticeable  flat  toning  of  the 
right  side  of  Ibo  face  from  loss  of  sub- 
cutaneous fat,  together  with  enoph- 
thalmus.  all  on  the  right  side,  while 
the  optic  atrophy  wq£  bilateral,  most 


78 


ORTHOPEDIC  SURGERY. 


PANCREAS. 


PARAURETHRITIS. 


marked  on  the  left.  He  finds  in  the 
literature  only  seven  similar  cases  of 
this  association  of  facial  paralysis  and 
optic  neuritis,  though  a  number  of  cases 
of  optic  neuritis  have  been  reported  in 
connection  with  polyneuritis.  The  atro- 
phy and  sinking  of  the  eyeball  is  evi- 
dently rarer,  as  he  has  found  no  reports 
of  a  similar  case.  He  has,  however, 
been  able  to  examine  a  case  of  Dr. 
Spiller's  with  flattening  of  the  face  and 
enophthalmus  following  rheumatic  fa- 
cial paralysis  and  implying,  he  thinks, 
as  in  his  own  case,  some  involvement 
of  the  seventh  nerve.  There  were  chlo- 
roansemic  and  disordered  menstrual 
symptoms  in  Shumway's  case,  but  he 
does  not  attribute  to  them  the  optic 
atrophy.  His  conclusions  are  given  as 
follows :  "1.  Optic  neuritis  is  occasionally 
associated  with  facial  paralysis,  either 
alone  or  as  part  of  a  multiple  neuritis; 
the  etiologic  factor  may  be  rheumatism, 
but  at  times  appears  to  be  infection, 
the  nature  of  which  is  as  yet  undeter- 
mined. The  optic  neuritis  is  usually  of 
the  retrobulbar  type,  but  a  decided 
papillitis  may  be  present,  and  be  fol- 
lowed by  more  or  less  marked  atrophy. 
In  cases  of  multiple  neuritis  of  the 
cranial  nervevs,  the  eye  grounds  should 
be  examined  for  possible  optic  nerve 
complication.  2.  In  facial  paralysis, 
flattening  of  the  face  and  enophthal- 
mus may  appear,  and  are  to  be  consid- 
ered as  due  to  a  neuritis  of  the  fifth 
nerve,  and  not  to  involvement  of  pos- 
sible sensory  fibers  in  the  facial  nerve/' 
E.  A.  Shumway  (Journal  of  the  Amer- 
ican Medical  Association,  February  11, 
1905). 

ORTHOPAEDIC    SURGERY.    THE    DIAGNOS- 
TIC VALUE  OF  TUBERCULIN  IN. 

Tuberculin  is  the  best  and  most  re- 
liable diagnostic  agent  for  incipient  tu- 


berculosis of  bones  and  joints.  Its 
proper  administration  is  attended  by  no 
permanent  harmful  effects.  The  dosage 
is  variable  and  it  is  rarely  necessary  to 
exceed  a  dose  of  6  milligrams.  The 
local  signs  are  of  equal,  if  not  greater, 
importance  than  the  general  reaction  in 
bone  and  joint  tuberculosis.  Tubercu- 
losis practically  always  reacts  to  tuber- 
culin. Diseases  other  than  tuberculosis 
may  possibly  react  to  tuberculin,  but  the 
evidence  on  this  point  is  not  conclusive. 
The  diagnosis  of  tuberculosis  can  be 
made  earlier  and  with  more  certainty  by 
means  of  tuberculin  than  by  radiography. 
The  tuberculin  test  is  applicable  to  pri- 
vate and  dispensary  as  well  as  to  hospital 
practice.  W.  S.  Baer  and  H.  W.  Ken- 
nard  (Johns  Hopkins  Hospital  Bulletin, 
January,  1905). 

PANCREAS,  LYMPH  FLOW  FROM  THE. 

The  injection  of  secretion  or  ileum 
extract  causes  an  increased  flow  of  lymph 
from  the  thoracic  duct.  After  ligature 
of  the  portal  lymphatics  secretion  still 
causes  an  increased  flow  of  lymph, 
whereas  ileum  extract  has  no  effect. 
The  increased  lymph  flow  produced  by 
secretion  is  not  caused  by  the  depressor 
substance,  but  by  secretion  itself.  There 
is  a  close  relation  between  the  secretion 
of  pancreatic  juice  and  the  increased 
flow  of  lymph.  The  lymph  is  derived 
entirely  from  the  pancreas,  and  is  prob- 
ably formed  as  a  result  of  metabolic 
changes  occurring  in  the  pancreas  during 
the  secretion  of  juice.  F.  A.  Bainbridge 
(British  Medical  Journal,  December  31, 
1904). 

PARAURETHRITIS. 

Gonorrhceal  infection  of  paraurethral 
ducts  "occurs  in  the  male,  and  it  may 
manifest  itself  either  during  the  course 
of  an  ordinary  urethritis  or  before  ure- 
thral symptoms  have  appeared.     Para- 


PERTUSSIS. 


TREATMENT  OF. 


PNEUMONIA. 


79 


urethritis  may,  in  very  early  stages, 
simulate  inflammatory  lesions  of  the 
surface  .of  the  glans,  notably  beginning 
chancre,  chancroid,  or  herpes.  Para- 
urethral infection,  once  it  has  become 
established,  can  -be  destroyed  only  with 
great  difficulty,  the  organisms  reappear- 
ing in  abundance  even  after  cauteriza- 
tion of  the  duct.  The  infection  can  be 
overcome  without  surgical  intervention, 
and  the  continual  existence  of  a  neigh- 
boring focus  of  infection  does  not  neces- 
sarily mean  a  bad  urethral  invasion  if 
careful  prophylactic  measures  are  taken. 
J.  W.  Churchman  (Journal  of  the  Amer- 
ican Medical  Association,  January  14, 
1905). 

PERTUSSIS    TREATED    BY    THE    ELASTIC 
ABDOMINAL   BELT. 

The  belt  employed  by  the  writer  is 
thus  described :  A  stockinette  band  is 
placed  on  a  baby  with  whooping  cough, 
in  the  same  manner  as  is  done  by  ortho- 
paedists before  applying  the  plaster  of 
Paris  jacket.  This  band  extends  from 
the  axillas  to  the  pubes  and  fits  the  baby 
snugly.  Two  muslin  shoulder  straps  are 
used  to  prevent  the  band  from  slipping 
down.  On  this  stockinette  band  a  single 
width  of  silk  elastic  bandage  is  sewn, 
extending  entirely  around  the  body  and 
covering  the  abdomen.  This  silk  elastic 
bandage  is  of  the  same  quality  as  that 
used  for  elastic  stockings.  If  the  child 
is  under  a  year  old.  it  will  be  found 
necessary  to  use  but  one  width  (five 
inches)  of  this  elastic  bandage;  in  an 
older  child,  two  widths  will  often  be 
found  necessary  to  entirely  cover  the  ab- 
domen. This  silk  elastic  bandage  is 
pinned  in  place  when  very  slightly  on 
the  stretch.  After  it  is  pinned  in  place, 
it  should  bo  sewn  to  the  stockinette  band 
underlying  it,  all  around  its  entire  edge; 
this  procedure  keeps  the  silk  elastic  belt 


flat  and  prevents  its  rolling  up  or  becom- 
ing creased.  The  lower  projecting  por- 
tion of  the  stockinette  band  should  be 
pinned  down  to  the  outside  of  the  diaper, 
or  other  clothing,  thus  keeping  the  elas- 
tic belt  smooth  over  the  abdomen.  The 
author  states  that  out  of  eighteen  pa- 
tients on  whom  this  belt  was  used,  cough 
was  relieved  in  twelve  and  vomiting  in 
all  but  one.  T.  G.  Kilmer  (Journal  of 
the  American  Medical  Association,  De- 
cember 10,  1904). 

PERTUSSIS,  TREATMENT  OF. 

In  the  treatment  of  pertussis,  the  au- 
thor uses  vapor  from  the  following- 
mixture  :  Naphtalin,  180  parts ;  pow- 
dered camphor,  20  parts;  essence  of 
eucalyptus  and  terebinthine,  of  each  3 
parts.  This  preparation  is  mixed  with 
boiling  water,  and  the  patient  is  so  placed 
that  he  breathes  its  vapor  for  one  hour  a 
day.  Of  15  early  cases  treated  thus,  a 
rapid  diminution  in  the  number  and  in- 
tensity of  the  attacks  was  noticed.  Mild 
cases  were  cured  in  three  to  four  weeks; 
severe  ones'  in  four  to  six  weks.  Cases 
without  complications  received  no  other 
treatment  except  proper  diet  and  hy- 
giene. No  bad  effects  following  the  in- 
halations were  noted.  L.  Itzkowitz 
(Allgemeine  Wiener  medicinisehe  Zeit- 
ung,  No.  30,  1904;  from  American 
Journal  Medical  Sciences,  January. 
1905). 

PNEUMONIA:     IS  IT  INCREASING? 

The  returned  mortality  of  the  United 
States  for  ages  between  15  and  60  dur- 
ing the  past  twenty  years  shows  a  dimin- 
ishing mortality  from  the  class  of  res- 
piratory diseases  commonly  returned  as 
pneumonia.  Of  the  pneumonias  occur- 
ring in  this  age  period  a  large  majority 
are  true  lobar  pneumonia.  Fifty-eight 
and  a  half  per  cent,  of  the  population  of 


80  PNEUMONIA,  PREVENTION  AND  TREATMENT  OF  HEART-FAILURE  IN. 


the  United  States,  and  66.5  per  cent,  of 
the  population  of  cities  are  between  the 
ages  of  15  and  60.  The  incidence  of 
lobar  pneumonia  on  a  major  part  of  the 
population  is  therefore  diminishing. 

The  return  mortality  of  the  United 
States,  for  ages  above  60,  indicate  that 
the  mortality  from  the  class  of  respira- 
tory diseases  commonly  returned  as  pneu- 
monia has  increased  from  21.9  per  cent, 
to  22.6  per  cent,  in  ten  years,  the  popu- 
lation at  the  same  age  in  the  same  period 
having  increased  from  6.2  to  6.6  per 
cent.  The  urban  mortality  for  the  same 
age  has  grown  in  ten  years  from  16.1 
to  19.5,  and  has  been  accompanied  by  an 
increase  of  population  in  that  age  period 
laterally  from  5.23  to  5.27  per  cent. 
Several  pathologic  conditions  added  to 
the  group  of  pneumonias,  and  not  pro- 
vided for  in  statistics,  are  included  in 
the  returned  mortality  of  pneumonia  for 
ages  above  60.  For  6  per  cent,  of  the 
total  population  lobar  pneumonia  may 
have  increased  in  the  past  ten  years, 
though  satisfactory  evidence  of  an  in- 
crease has  not  been  offered. 

The  return  mortality  of  the  United 
States  for  ages  under  15  (about  one- 
third  of  the  total  population)  shows  an 
apparent  rise  of  mortality  for  the  group 
of  respiratory  diseases  commonly  classed 
as  pneumonia.  The  acute  respiratory 
diseases  of  children  were  in  former  years 
commonly  mistaken  for  affections  of  the 
nervous  system.  Year  by  year  for  thirty 
years  increasing  numbers  of  deaths 
formerly  found  in  the  indefinite  ac- 
counts and  in  the  class  of  nervous  dis- 
eases have  been  transferred  to  the  class 
of  respiratory  diseases,  and  especially  to 
the  pneumonia  account.  Of  the  mortal- 
ity recorded  as  due  to  pneumonia  under 
the  age  of  15  years  not  more  than  10 
per  rent,  is  due  to  lobar  pneumonia.  A 
small  though  considerable  incidence  of 


lobar  pneumonia  in  children  under  the 
age  of  5  has  come  into  view  of  late  years, 
but  there  is  no  evidence  that  lobar  pneu- 
monia has  increased  in  this  age  period. 
The  remaining  90  per  cent,  of  the  re- 
corded mortality  ascribed  to  pneumonia 
includes  the  conglomerate  group  of  bron- 
cho-pneumonias, nearly  all  of  which  are 
secondary  or  complicating  causes  of 
death,  and  should  be  referred  in  the  mor- 
tality tables  to  the  primary  causes  of 
death. 

Since  1890  a  new  cause  of  infantile 
mortality  has  come  into  view,  an  acute 
respiratory  infection,  attacking  infants 
of  two  years  old  and  under,  commonlv 
returned  under  the  diagnosis  or  pneumo- 
nia, sometimes  returned  as  due  to  a  dis- 
ease of  the  nervous  sj'stem,  and  probably 
due  to  influenza.  J.  S.  Fulton  (Journal 
of  the  American  Medical  Association, 
January  14,  1905). 

PNEUMONIA,    PREVENTION   AND    TREAT- 
MENT OF  HEART-FAILURE  IN. 

According  to  the  author,  there  are 
three  principal  and  many  secondary 
causes  of  heart  failure  in  this  disease. 
The  principal  causes  are,  first  the  tox- 
aemia; second,  the  mechanical  obstruc- 
tion to  the  circulation  in  the  lung,  caus- 
ing overburdening  and  dilatation,  espe- 
cially of  the  right  heart;  third,  the 
alteration  in  the  physical  and  chemical 
constitution  of  the  blood,  which,  apart 
from  the  toxic  effect  on  nervous  and 
muscular  action,  central  and  cardiac, 
predisposes  to  the  formation  of  ante- 
mortem  clot.  Among  the  most  impor- 
tant of  rare  causes  are  hyperpyrexia  and 
a  sudden  paralysis  of  inexplicable  origin. 

Two  great  classes  of  drugs  are  at  our 
disposal.  One  may  be  used  to  support 
the  heart  and  circulation  during  the 
progress  of  the  disease,  and  the  other 
reserved  for  emergencies.    The  first  class 


PNEUMONIA,  MANAGEMENT  OF. 


PRESBYOPIA,  PREMATURE. 


81 


includes  digitalis,  barium  chloride; 
strychnine,  and  atropine.  Digitalis  may 
be  used  as  soon  as  hepatization  is  present. 
Before  this,  aconite  and  veratrum  are 
indicated.  For  emergency  service  the 
author  recommends  adrenalin,  camphor, 
and  musk.  For  administering  the  first 
named  he  prefers  to  employ  suprarenalin 
triturates  containing  1/20  grain  active 
principle  in  a  very  small  quantity  of 
sugar  of  milk.  These  are  preferable  to 
solution  for  lingual  administration. 
They  dissolve  quickly  and  do  not  fill  the 
mouth  with  liquid.  Such  a  tablet  may 
be  given  every  ten  minutes,  if  needed; 
as  a  rule,  one  every  one-half  hour  to  two 
hours  suffices.  The  drug  likewise  raises 
vascular  tone — a  great  advantage.  Cam- 
phor may  be  injected  hypodermically  in 
a  10  per  cent,  solution  in  sterilized  olive 
oil  or  in  10  per  cent,  solution  in  ether. 
Exact  dosage  is  unnecessary,  about  a 
syringeful,  say  from  20  to  30  minims, 
can  be  used.  The  effect  is  prompt  and 
usually  lasts  for  some  hours.  The  in- 
jection is  to  be  repeated  as  needed.  Five 
or  10  drops  of  tincture  of  musk  given 
hypodermically  exert  a  powerful  influ- 
ence in  overcoming  the  tendency  to  car- 
diac collapse,  and  the  action  of  musk  is 
even  more  sustained  than  that  of  cam- 
phor. Care  should  be  taken  to  secure  a 
reliable  preparation  of  musk.  Much  on 
the  market  is  useless.  S.  Solis-Cohen 
(Journal  of  the  American  Medical  Asso- 
ciation, December  10;  1904). 

PNEUMONIA,     THE     MANAGEMENT     OF. 

The  author  insists  on  the  ventilation 
of  the  sick-room,  and  the  frequent  mov- 
ing of  the  patient  from  side  to  side,  so 
as  to  prevent  hypostatic  congestion  of 
the  unaffected  lung.  Venesection  may 
abort  the  disease  in  plethoric  patients. 
Antipyrine  may  be  given  in  one  dose  of 
a  gram,  followed  by  a  brisk  purge,  with 


some  morphine  to  stop  the  pain.  Dry 
cuping  may  be  used  at  this  stage.  The 
old  treatment  with  aconite  or  veratrum 
will  probably  have  just  as  good  an 
abortifacient  effect.  The  patient  should 
not  be  overfed.  One  quart  of  milk  with 
two  raw  eggs  furnishes  sufficient  nutri- 
ment for  twenty-four  hours.  Expressed 
beef  juice  is  a  good  heart  muscle  stimu- 
lant. Bowels  should  be  moved  once 
daily.  High  fever  may  be  reduced  by 
sponging  with  tepid  water  the  abdomen 
and  extremities,  but  not  the  chest.  If 
the  leucocytosis  is  deficient,  some  nuclein 
preparation  should  be  given.  Poultices 
are  permissible  if  desired.  Codeia  is  the 
best  sedative  for  an  irritable  cough;  for 
a  stimulant  expectorant  ammonium  mu- 
riate with  a  little  ipecac  in  syrup  of 
citric  acid  may  be  given.  Alcohol  should 
be  used  only  when  the  circulation  calls 
for  it.  One  to  3  drachms  every  three 
hours  is  probably  enough.  Nitroglyc- 
erine will  equalize  the  circulation; 
strychnine  restores  a  flagging,  tensive. 
and  irregular  pulse.  Adrenalin  should 
be  used  cautiously  at  this  stage  if  at  all. 
Camphor  and  olive  oil  may  relieve  an 
acute  heart  failure.  Oxygen  should  be 
used  in  severe  cases.  It  keeps  the  patient 
more  comfortable,  though  in  no  way 
curative.  Chloral  and  ergot  may  quiet 
delirium,  morphine  to  be  used,  if  at 
all  here,  with  the  greatest  caution.  The 
ice  cap  may  relieve  headache.  The  value 
of  serum  treatment  is  as  yet  unproved. 
O.  T.  Osborne  (New  York  Medical  Jour- 
nal and  Philadelphia  Medical  Journal, 
January  7,  1905). 

PRESBYOPIA,   PREMATURE. 

Subnormal,  paretic,  or  insufficient  ac- 
commodation, or  premature  presbyopia, 
even  paralysis  of  the  accommodation,  of 
a  functional  or  reflex  nature,  not  depend- 
ent upon  organic  disease,  exists  in  a  cer- 


82 


PRESBYOPIA,  PREMATURE. 


tain,  probably  much  larger  than  sus- 
pected, proportion  of  young  or  middle- 
aged  persons.  The  youngest  of  the  au- 
thor's patients  was  20,  the  oldest  50. 
Several  cases  show  that  the  subnormal 
accommodation  existed  during  adoles- 
cence. That  18  were  women  and  9  men 
has  only  the  significance  that  women  are 
more  subject  to  eye-strain  than  men  be- 
cause they  do  more  near  work  with  the 
eyes,  are  less  resistant,  etc.  It  is  usually 
permanent  or  ingravescent,  although 
there  was  complete  recovery  in  one  case. 
It  may  be  caused  by  such  degrees  and 
kinds  of  ametropia  as  compel  the  re- 
nunciation of  the  accommodative  func- 
tion, especially  high  hyperopia  or  astig- 
matism, etc.;  monocularity ;  glare  of 
foot-lights;  the  use  of  magnifying 
glasses  in  engraving,  etc. ;  long-continued 
abuse  of  the  eyes;  a  direct  inhibiting 
reflex  to  the  accommodational  mechan- 
ism. Seventeen  of  the  writer's  patients 
had  unsymmetric  astigmatism,  and  most 
of  the  others  an  ametropia  or  anisome- 
tropia unconquerable  by  the  visual  mech- 
anism. In  many  cases  there  may  be  no 
discoverable  or  pathologic  cause,  the  de- 
termining factor  being  a  personal  and 
physiologic  peculiarity.  It  is  apt  to  be 
forgotten  that  presbyopia  really  begins 
with  the  beginnig  of  life,  as  the 
recession  of  the  near  point  commences 
in  infancy,  and  is  continuous  through- 
out life  up  to  the  age  of  60  or  more. 
In  the  normal  progress,  and  when 
uncomplicated  by  ametropia,  this  re- 
cession, at  about.  45,  reaches  a  degree 
which  makes  reading  wearying  at  four- 
teen inches  with  ordinary-sized  type,  be- 
cause the  book  and  writing  cannot  be 
held  further  away;  because  the  letters 
are  so  small,  and  because  the  macular 
image  is  too  minute.  The  crystalline 
lens  of  the  eye  loses  its  inherited  and 
high  elasticity  with  each  year  of  life. 


As  it  has  no  neurologic  connection  with 
the  brain,  and  is  not  nourished  by  red 
blood-corpuscles,  this  loss  of  elasticity  is 
most  natural.  It  is  consequently  as  nat- 
ural and  inevitable  that  its  inherited 
and  primary  elasticity  should  differ  in 
different  individuals  and  that  local  ocu- 
lar and  also  systemic  disease  and  denu- 
tiition,  eye-strain,  etc.,  should  still  fur- 
ther make  the  ingravescent  inelasticity 
of  varying  degrees  of  progress.  The  re- 
sultant symptoms  will  depend  upon  the 
amount  and  morbidity  of  the  near  work 
demanded  of  the  accommodation.  The 
number  of  those  under  45  with  subnor- 
mal accommodation  is  thus  probably 
much  higher  than  supposed,  and  this 
fact  gives  the  suggestion  to  be  constantly 
upon  guard  as  to  its  presence. 

It  is  of  all  degrees  and  varieties,  and 
may  even  differ  in  amount  in  the  two 
eyes.  It  may  complicate  the  condition  of 
head  tilting,  torticollis,  etc.,  with  sec- 
ondary spinal  curvature,  due  to  a  pecul- 
iar axis  of  astigmatism  in  the  dominant 
eye.  The  pathogenic  results  of  dextrocu- 
larity  and  sinistrocularity  should  not  be 
forgotten. 

The  pathognomonic  symptoms  are  the 
persistence  of  common  eye-strain  reflexes 
(such  as  migraine,  headache,  indigestion, 
intestinal  fermentation,  constipation, 
nervous  disorders,  dermatoses,  etc.)  after 
proper  correction  of  the  ametropia  and 
muscle  imbalance,  and  especially  an  in- 
ability to  carry  on  continuous  near  work. 

The  diagnosis  is  impossible  by  any  of 
the  ordinary  tests.  The  loss  of  power 
has  come  on  so  slowly  or  has  been  so 
long  present  that  the  patients  have  no 
suspicion  that  the  print  is  not  clear,  and 
it  is  usually  possible  for  them  to  read 
even  the  finest  letters  with  ease,  for 
a  short  time.  The  comparative  rarity 
of  the  cases  also  throws  the  oculist  off  his 
guard,  and  routine  begets  carelessness. 


PROSTATECTOMY. 


PUERPERiE,  CARE  OF. 


83 


Abnormally  wide  pupils  of  one  or  both 
eyes,  the  demand  of  high  corrections  for 
distant  vision,  certain  occupations,  cer- 
tain forms  of  ametropia  and  anisome- 
tropia, high  heterophoria,  unrelieved  re- 
flexes, photophobia,  etc.,  are  suggestions 
that  there  may  be  accommodation  weak- 
ness. 

It  is  an  active  cause  of  heterophoria, 
adding  to  the  proof  of  the  common  de- 
pendence of  muscle  imbalance  upon 
ametropic  and  optical  causes.  It  is 
therefore  an  added  demonstration,  if  it 
were  needed,  of  the  mistake  of  the  ten- 
otomists  who  operate  for  heterophoria. 
In  the  vast  majority  of  cases,  hetero- 
phoria is  ametropic  in  origin,  innerva- 
tional  in  Nature,  and  is  an  effort  of 
Nature  to  lessen  eye-strain.  The  results 
of  operation  are  therefore  evil,  and  make 
the  cure  more  difficult  by  physiologic 
methods. 

The  treatment  is  by  means  of  bifocal 
spectacles  which  accurately  neutralize 
the  error  of  refraction  for  distant,  and 
the  deficiency  in  accommodational  power 
for  near  vision.  As  in  all  treatment 
whatsoever,  success  here  also  depends 
upon  the  amount  of  irreparable  damage 
done  before  the  appropriate  therapeutic 
measure  is  found.  Usually  relief  is  sud- 
den and  striking.  G.  M.  Gould  (Ameri- 
can Medicine,  January  21,  1905). 

PROSTATECTOMY. 

In  the  weakest  and  most  run-down 
cases  the  author  has  employed  perma- 
nent suprapubic  drainage.  This  is  rap- 
idly performed  under  oueain,  and  he 
thinks  it  is  the  safest  of  all  procedures. 
Except  in  absolutely  desperate  cases,  he 
believes  prostatectomy  under  local  an- 
aesthesia is  safe  as  compared  with  the 
operation  under  general  anaesthesia. 
The  use  of  adrenalin  with  the  ordinary 
local   anaesthesia  greatly  prolongs   and 


adds  to  its  efficiency,  prevents  the  pain 
and  congestion  following,  and  renders 
the  operation  almost  bloodless.  The 
knowledge  of  the  nervous  anatomy  of 
the  parts  is,  of  course,  absolutely  es- 
sential, and  the  course  of  the  pudic 
nerve  and  the  long  pudendal  nerve 
close  to  the  base  of  the  tuberosity  of 
the  ischium  are  important.  He  favors 
the  use  of  Young's  tractor,  and  recom- 
mends allowing  sufficient  time  for  the 
anaesthetic  to  act  before  making  the  in- 
cision. With  sensitive  or  nervous  pa- 
tients he  finds  it  often  better  to  use  a 
little  nitrous  oxid  gas  or  primary  ether 
anaesthesia,  as  the  infiltratirig  solution 
cannot -reach  the  parts  involved  in  the 
deeper  enucleation.  These  parts,  how- 
ever, are  supplied  by  the  hypogastric 
plexus  of  the  sympathic  and  the  dis- 
comfort is  not  necessarily  great.  He 
reports  a  case  in  which  he  thinks  this 
method  of  operation  was  directly  life 
saving.  M.  B.  Tinker  (Journal  of  the 
American  Medical  Association,  Febru- 
ary 11,  1905). 

PUERPER^:,  CARE  OF. 

Continued  asepsis  is  advised  after  de- 
livery. For  the  first  two  or  three  days 
a  piece  of  gauze  wet  with  a  1  to  10,000 
bichloride  solution  is  placed  over  the 
vulva  beneath  the  sterile  vulva  pad. 
Early  vaginal  examination  and  douch- 
ing is  condemned.  After  from  ten  to 
twelve  days  hot  douches  undoubtedly 
help  the  involution  of  the  uterus.  In 
some  cases  where  the  uterus  continues  to 
relax  immediately  after  delivery,  an  in- 
trauterine douche  of  acetic  acid  is  given 
with  good  result.  The  author  says  he 
often  doubts  the  efficacy  of  the  abdomi- 
nal binder,  although  for  the  first  two  or 
three  days  it  does  keep  down  the  gas  and 
supports  the  abdominal  walls.  And  in 
short-waisted  women,  who  have  carried 


84 


PUERPERAL  INFECTION. 


PUPILS,  INEQUALITY  OF. 


the  child  high  and  well  out  in  front,  it 
prevents  an  anterior  relaxation  of  the 
abdominal  walls.  But  for  women  who 
carry  the  child  low  and  well  backward, 
they  are  more  or  less  unnecessary.  Con- 
sequently, if  such  cases  are  bothered  by 
the  binder  after  the  third  to  fifth  day,  it 
is  to  be  discarded.  To  insure  as  complete 
involution  as  possible,  it  is  advised  that 
on  the  second  day  the  patient  should  be 
turned  first  on  one  side  and  then  on  the 
other;  on  the  fifth  day  she  should  com- 
mence to  lie  on  her  abdomen  for  shorter 
or  longer  periods  and  be  encouraged  to 
sleep  in  this  position,  if  possible.  This 
change  in  posture  favors  the  escape  of 
the  lochia  and  allows  the  uterine  liga- 
ments to  contract,  so  favoring  normal 
anteflexion.  The  writer  advises  keeping 
the  patient  in  bed  at  least  two  weeks  and 
longer  if  any  signs  of  subinvolution  per- 
sist. If  involution  is  delayed,  hot  vag-' 
inal  douches,  boroglyceride  tampons,  er- 
got, quinine,  and  strychnine  are  of  serv- 
ice. The  routine  vaginal  examination 
should  be  made  before  any  case  is  dis- 
charged to  determine  the  possible  exist- 
ence of  erosions,  inflammations,  dis- 
placements, etc.  J.  D.  Voorhees  (Med- 
ical News,  January  14,  1905). 

PUERPERAL    INFECTION,    SALINE    INFU- 
SION IN. 

The  author  presents  data  which  un- 
mistakably establish  the  favorable  action 
of  saline  infusion  in  puerperal  infection, 
showing  that  the  course  is  modified  for 
the  better  and  the  patient  displays  slow- 
but  constant  improvement.  In  order  to 
be  effectual  the  emunctories  must  be  still 
functioning.  When  the  kidneys  and  the 
glands  are  no  longer  working  properly, 
then  saline  infusion  can  do  compara- 
tively little  good.  A  large  amount  of 
fluid  should  be  removed  from  the  intes- 
tines or  the  blood  pressure  should  be  re- 


duced by  venesection.  In  this  way  the 
body  is  freed  from  a  certain  amount  of 
toxins,  the  blood-pressure  reduced,  and 
the  diffusion  of  the  artificial  serum 
through  the  vascular  system  favored 
when  it  is  injected  later.  In  the  chronic 
forms  of  puerperal  infection,  saline  in- 
fusion is  especially  valuable,  on  account 
of  its  stimulating,  cleansing,  and  elimi- 
nating action.  J.  Jaworski  (Central- 
blatt  f .  Gynakologie,  Bd.  xxviii,  Nu.  45 ; 
Journal  of  the  American  Medical  Asso- 
ciation, December  31,  1904). 

PUPILS,    INEQUALITY    OF    THE,    IN    DIS- 
EASES OF  THE  LUNGS  AND  PLEURA. 

In  a  series  of  cases  of  diseases  of  the 
respiratory  system  in  which  inequality 
of  the  pupils  was  a  symptom,  it  has  been 
noticed  that  mydriasis  may  occur  on  the 
same  side  as  a  pneumonia  consolidation. 
This  is  believed  by  the  writer  and  others 
to  have  some  connection  with  the  malar 
flush  of  that  disease  and  to  be  due  to 
vasomotor  disturbances.  The  writer's 
observations,  while  confirming  the  occur- 
rence of  pneumonic  mydriasis,  do  not 
bear  out  the  statement  that  it  occurs 
on  the  same  side  as  the  disease,  as,  ac- 
cording to  his  observations,  it  is  fre- 
quent on  the  opposite.  In  a  period  of 
six  months  he  met  with  3  cases  of  acute 
bronchitis  showing  inequality  of  the  pu- 
pils. When  the  acuteness  of  the  symp- 
toms subsided  the  pupils  became  equal. 
Pupiline  quality  is  more  frequent  in  em- 
physema complicated  with  chronic  bron- 
chitis; 11  cases  were  collected  in  six 
months  showing  this  phenomenon.  In 
120  cases  of  pulmonary  tuberculosis  in- 
equality of  the  pupils  was  present  in  26. 
The  writer  refers  to  similar  observations 
made  by  Souques,  who  believed  that 
apical  disease  caused^  this  inequality. 
This  statement  is  not  borne  out  by  the 
writer's    observations,    as    his    26    cases 


ROENTGEN  RAYS. 


STOMACH,  DISEASES  OF. 


showed  all  varieties  of  tuberculosis  of 
the  lungs;  at  the  same  time  he  believes 
that  only  cases  presenting  actual  infil- 
tration are  likely  to  show  inequality  of 
pupils.  There  is  no  connection  between 
the  side  affected  and  the  mydriatic  pupil. 
Persistence  of  this  symptom  in  tuber- 
culous patients  is  remarkable,  lasting 
sometimes  for  months.  There  may  be 
remission  of  the  symptom,  but  it  reap- 
pears on  the  same  side.  Inequality  of 
the  pupils  does  not  produce  any  subjec- 
tive result.  In  4  cases  of  pleurisy  there 
was  pupil  inequality  lasting  several 
weeks;  all  these  cases  showed  serous 
effusion.  The  suggestion  offered  by  the 
writer  is  that  a  mediastinal  gland  irri- 
tates some  branch  or  branches  of  the 
sympathetic.  Deherain  (Presse  Medi- 
cate, No.  79,  1904). 

ROENTGEN  RAYS,  INFLUENCE  OF,  ON 
INTERNAL  ORGANS. 
The  writer's  research  on  mice,  rabbits, 
guinea-pigs,  and  dogs  has  confirmed  the 
statements  of  others,  in  regard  to  the 
action  of  the  Eoentgen  rays  on  the  in- 
ternal organs.  The  effect  observed  is 
entirely  independent  of  that  noted  on 
the  skin.  With  the  exception  of  the 
testicles,  the  deep  action  of  the  Eoentgen 
ray's  seems  to  be  exclusively  restricted  to 
the  organs  concerned  in  the  making  of 
blood.  The  action  is  manifested  in  two 
ways :  in  the  annihilation  of  the  lym- 
phoid tissue  and  in  the  destruction  of 
the  cells  of  the  bone  marrow  and  spleen 
pulp.  This  reaction  of  the  lymphoid  tis- 
sue is  specific.  It  occurs  long  before  any 
other  organ  or  system  of  organs  shows 
any  changes  from  the  exposure,  and  the 
dosage  can  be  calculated  to  limit  the 
action  of  the  rays  to  this  tissue  alone. 
The  reaction  is  further  distinguished  by 
the  lack  of  any  latent  stage,  by  its  sudden 
onset,  its  stormy  course,  its  early  termin- 


ation, the  abscence  of  any  after-effects, 
and  by  the  rapid  restriction  of  what  has 
been  destroyed.  In  all  these  points  the 
reaction  is  directly  the  reverse  of  what  is 
observed  in  regard  to  the  action  of  the 
Eoentgen  rays  on  other  material.  This 
destruction  of  the  lymphocytes  must  al- 
ways be  reckoned  with  as  an  inevitable 
accompaniment  of  any  exposure.  It 
does  not  seem  to  entail  any  undesired 
or  dangerous  by-effects.  H.  Heineke 
(Mitteilungen  a.  d.  Grenzgebieten,  Bd. 
xiv,  Nos.  1  to  2;  from  Journal  of  the 
American  Medical  Association,  January 
21,  1905). 

STOMACH,  DISEASES  OF  THE,  CRITICISM 
OF  RECENT  SURGICAL  LITERATURE 
ON. 

In  America  about  1  per  cent,  of  the 
population  present  a  gastric  ulcer  or  scar 
in  the  autopsy-room.  As  a  clinical  dis- 
ease, not  more  than  2  per  cent,  of  all 
patients  (not  medical  patients  only) 
suffer  from  gastric  ulcer.  Under  appro- 
priate treatment  the  severer  complica- 
tions of  gastric  ulcer  can  be  largely  pre- 
vented. 

The  mortality  from  gastric  ulcer  is 
grossly  exaggerated  in  surgical  literature, 
and  under  proper  medical  treatment  will 
not  exceed  4  per  cent,  in  all  classes  of 
private  patients.  That  gastric  ulcer  pre- 
disposes to  gastric  cancer  to  any  marked 
degree  is  improbable.  That  the  majority 
of  cancers  are  preceded  by  ulcers  is  cer- 
tainly untrue.  That  gastro-enterostomy 
would  prevent  such  metamorphosis  has 
not  been  demonstrated.  Gastro-enteros- 
tomy has  a  certain  mortality.  It  often 
fails  to  relieve  gastric  disorders  due  to 
ulcer.  It  should  be  followed  by  careful 
dietetic  treatment.  It  may  lead  to  fatal 
complications  irrespective  of  the  primary 
(lis  case. 

Pyloric  obstruction  is  not  in  itself  an 


86 


SUPRARENAL  EXTRACT.       SUPRARENAL   INSUFFICIENCY. 


SYPHILIS. 


indication  for  surgical  interference. 
Many  cases  recover  under  medical  treat- 
ment. Patients  will  be  best  served  if 
they  submit  to  proper  medical  treatment 
and  seek  surgical  advice  only  at  the  sug- 
gestion of  their  medical  attendant.  H. 
W.  Bettmann  (Cincinnati  Lancet-Clinic, 
January  21,  1905). 

SUPRARENAL  EXTRACT,  INFLUENCE  OF, 
UPON  ABSORPTION  AND  TRANSUDA- 
TION. 

Intravenous  injections  of  suprarenal 
extract  retard  invariably  the  processes 
of  absorption  and  transudation.  Sub- 
cutaneous injections  also  often  show  a 
retardation  of  these  processes ;  the  effect, 
however,  is  neither  strong  nor  constant. 
In  frogs  the  retardation  of  absorption  of 
some  substances  was  recognizable  only 
when  suprarenal  extract  was  previously 
mixed  with  that  substance,  or  when  both 
substances  were  injected  into  one  and 
the  same  lymph  sac.  It  is  assumed  that 
the  suprarenal  extract  increases  the  ton- 
icity of  the  protoplasm  surrounding  the 
pores  of  the  endothelia  of  the  capillaries, 
thereby  reducing  the  facility  for  the  in- 
terchange between  the  blood  and  the  tis- 
sue fluid.  S.  J.  Meltzer  and  John  Auer 
(American  Journal  Medical  Sciences, 
January,  1905). 

SUPRARENAL  INSUFFICIENCY. 

The  author  has  observed  9  cases  of 
acute  suprarenal  insufficiency  of  vari- 
able intensity,  ending  not  in  death,  but 
in  recovery.  The  syndrome  that  has 
been  noted  in  these  cases  is  no  other 
than  that  known  classically  as  charac- 
teristic of  suprarenal  insufficiency,  the 
only  peculiarity  consisting  in  its  manner 
of  development.  The  symptoms  develop 
very  rapidly,  and  besides,  they  can  dis- 
appear spontaneously,  at  the  same  time 
with  the  illness  which  they  accompany. 


For  this  acute  suprarenal  insufficiency  is 
due  to  an  infection  or  an  intoxication. 
The  writer  has  always  noted  that  the 
insufficiency  occurs  in  the  course  of  a 
toxic  or  infectious  malady,  medical  or 
surgical.  The  longest  duration  of  this 
acute  suprarenal  insufficiency  that  the 
writer  has  observed  was  one  month  and 
a  half,  in  a  woman  who  was  suffering 
from  an  outbreak  of  syphilis.  This  af- 
fection has  yielded  to  the  employment  of 
suprarenal  extract.  The  patients  treated 
by  the  author  recovered  from  the  supra- 
renal insufficiency  in  a  few  clays.  In 
eight  of  the  nine  patients  the  cure  ap- 
pears to  be  definite,  for  the  symptoms, 
which  disappeared  with  the  casual  ill- 
ness, have  not  returned  after  an  interval 
of  several  months.  In  one  case  of  recur- 
rent bronchitis,  however,  with  every  at- 
tack, the  patient  became  asthenic  and  the 
skin  became  dark.  But  when  the  attack 
of  bronchitis  passed,  so  did  the  insuffi- 
ciency. It  would  be  very  difficult  to  des- 
ignate to  what  lesion  of  the  capsule  the 
syndrome  corresponds.  The  fact  that 
this  insufficiency  is  secondary  to  an  in- 
toxication or  infection  is  the  character- 
istic which  gives  it  a  true  clinical  im- 
portance. G.  Bossuet  (Gazette  Heb- 
domadaire  des  Sciences  Medicales  de 
Bordeaux,  October  30,  1904). 

SYPHILIS,   SCARS  AND   THE   RETROSPEC- 
TIVE DIAGNOSIS  OF. 

Genital  scars  are  more  common  and! 
more  marked  in  hospital  than  in  private 
practice.  In  many  cases  of  nervous  or 
other  late  forms  of  internal  syphilis  the 
genital  region  is  free  from  scars.  A  sin- 
gle scar  on  the  skin  of  the  penis  suggests 
syphilis.  A  single  scar  on  the  mucous 
membrane  also  suggests  syphilis  as  a  rule 
— occasionally  the  local  chancre.  Multi- 
ple scars  on  the  mucous  surface  of  the 
penis    only    suggest    the    local    chancre. 


TABES,  THE  PAINS  OF. 


87 


Multiple  scars  on  both  mucous  mem- 
brane and  skin  also  suggest  the  local 
chancre.  Inguinal  scars,  together  with 
scars  on  the  penis,  suggest  the  local 
chancre.  An  inguinal  scar  without  any- 
penile  scar  (if  venereal  at  all)  suggests 
gonorrhoea.  Extensive  scarring  of  penis 
or  groin,  or  both,  suggests  phagedena. 
Genital  scars,  with  scars  on  other  parts 
of  the  body,  suggest  an  ulcerating  syph- 
ilids Arthur  Cooper  (British  Medical 
Journal,  January  21,  1905). 

TABES,   THE   PAINS   OF. 

Pain  is  a  frequent  symptom  of  tabes — 
far  more  common  than  ataxy  and  begin- 
ning earlier  in  the  course  of  the  disease. 
The  symptoms  of  tabes  are  probably  due 
to  a  chemical  toxin,  which  results  from 
syphilis.  A  ferment  is  produced  which 
slightly  influences  the  albuminous  bodies 
in  the  process  of  their  production,  yet 
enough  to  convert  them  into  nerve  poi- 
son instead  of  a  food.  This  toxin  in- 
fluences chiefly  the  elements  of  the  lower 
sensory  spinal  neuron.  The  pains  of 
tabes  are  an  early  and  distressing  symp-. 
torn :  they  are  often  thought  to  be  rheu- 
matic. They  may  be  classified  as  fol- 
lows: A.  Brief  momentary  pains,  suc- 
ceeding each  other  after  a  short  interval 
in  the  same  place.  (1)  Superficial. 
These  seem  to  be  on  or  just  under  the 
surface,  and  are  usually  felt  at  one  spot. 
They  are  most  common  on  the  limbs, 
especially  tbe  lower  logs  and  feet.  They 
are  extremely  brief  but  recurring;  from 
their  character  arose  th.e  aame  "light- 
ning pains."  They  have  the  remarkable 
effect  of  leaving  the  skin  very  tender, 
and  thus  may  occur  where  sensibility  to 
,  pain  has  been  lost.  (2)  Deep  seated. 
These  pains  cannot,  as  a  rulo.  bo  defin- 
itely local od,  but  sometimes  arc  referred 
to  the  joints.  They  have  the  same  char- 
acters as  the  superficial  pains,  but  arc 


not  so  momentary,  usually  lasting  sev- 
eral seconds.  They  are  chiefly  felt  in 
the  limbs,  and  they  are  not  followed  by 
hyperesthesia.  B.  Prolonged  pains,  last- 
ing for  days  or  hours  in  the  same  place. 
They  are  most  common  in  the  trunk,  and 
are  usually  deep  seated,  an  exception 
being  the  girdle  pain  or  sensation.  They 
sometimes  closely  simulate  sciatic  neu- 
ritis. A  common  variety  is  a  sense  of 
distressing  tension  on  the  tendons  or 
muscles.  Very  intense  pains  have  often 
a  burning  character.  There  is  very  sel- 
dom any  exciting  cause.  Widely  diffused 
distressing  sensations  also  occur,  such  as 
numbness,  tingling,  swelling,  etc.  In 
one  form  of  the  disease  the  pains  so 
dominate  the  scene  as  to  justify  a  sepa- 
rate classification  of  such  cases.  The 
author  has  seen  11  such  cases,  all  in 
adult  men,  and  with  a  specific  history  in 
9  cases.  The  pains  were  the  symptom 
for  which  relief  was  sought.  They  were 
severe  and  neuralgic  in  character.  The 
danger  of  ataxy  in  such  cases  is  small. 

The  extremities  of  the  peripheral 
nerves  are  thought  to  be  the  source  of 
the  pains.  Only  the  superficial  pains 
can  be  relieved  by  local  measures.  Chlo- 
roform sprinkled  on  lint  and  covered 
with  oiled  silk,  is  often  useful.  Cocaine 
administered  electrically  is  sometimes 
beneficial.  Deep  injections  of  cocaine 
are  of  little  service  in  pains  in  the  softer 
substance  of  a  limb.  As  regards  internal 
medication  the  coal  tar  products  stand 
above  all  others.  Phenacetin,  antipyrine, 
and  antifebrine  are  the  ones  most  used 
and  of  the  highest  merit.  Antifebrine  is 
certainly  the  most  effective.  Sometimes 
the  suffering  is  so  intense  as  to  require 
morphine.  Chloride  of  aluminium, . in 
doses  of  5  to  10  grains  thrice  daily  seems 
to  lessen  the  tendency  to  recurrence  and 
the  severity  of  the  pains.  Salicylates 
sometimes   have   the   same   effect.      The 


88 


TENOTOMY. 


TETANUS. 


TONSIL. 


use  of  iodides  and  mercury  belong  to  the 
treatment  of  the  disease  rather  than  of 
the  pains.  W.  E.  Gowers  (British  Med- 
ical Journal,  January  7,  1905). 

TENOTOMY  OF  THE  TENDO-ACHILLES  IN 
PARTIAL  AMPUTATIONS  OF  THE 
FOOT,  ALSO  IN  OBLIQUE,  COMPOUND, 
AND  COMMINUTED  FRACTURES  OF 
THE  TIBIA  AND  FIBULA. 
It  is  a  well-established  clinical  fact 
that  after  a  tenotomy  of  the  tendo- 
Achilles  (when  the  foot  is  kept  at  rest) 
a  process  of  repair  does  take  place  and 
satisfactory  functional  use  of  the  foot 
is  the  result.  It  is  much  easier  to  main- 
tain the  foot  in  the  exaggerated  flexed 
position  after  the  tenotomy  of  the  tendo- 
Achilles  than  with  any  form  of  splint, 
anterior  or  posterior,  metallic  or  plaster. 
There  is  much  less  pain,  as  the  foot  and 
ankle  joints  are  placed  at  absolute  rest. 
When  the  patient  commences  to  walk 
none  of  the  resistance  of  the  contracted 
heel  cord  is  present,  so  there  is  but  a 
slight  limp.  In  oblique  and  comminuted 
fractures  of  the  tibia  there  is  much  less 
danger  of  overriding  of  the  fragments  of 
bone  after  a  tenotomy.  This  greatly 
simplifies  the  care  of  the  leg  and  helps 
to  prevent  deformity.  J.  P.  Webster 
(Cincinnati  Lancet-Clinic,  January  21, 
December,  1901). 

TETANUS,  BLANK  CARTRIDGE. 

The  writer  has  investigated  blank 
cartridges  from  several  makers  with 
special  reference  to  their  bacteriolog- 
ical contents,  employing  cultural  and 
incubation,  as  well  as  microscopical 
methods.  The  findings  were  rather 
negative  as  regards  the  tetanus  bacillus, 
but  ilio  Bacillus  cerogenes  capsulatus 
(Welch)  was  present  in  a  large  propor- 
tion of  the  cartridges  examined.  Not- 
withstanding   this    fact    tetanic    symp- 


toms developed  in  a  number  of  the  ani- 
mals inoculated,  and  in  still  other  ani- 
mals inoculated  from  cultures  from 
these.  His  conclusions  are :  B.  cerogencs 
capsulatus  (Welch)  is  present  in  a  large 
proportion  of  the  wads  of  the  three 
makes  of  the  cartridges  examined.  The 
wads  of  the  Peters  Company,  inoculated 
in  rats,  guinea-pigs,  and  rabbits,  pro- 
duced characteristic  symptoms  of  teta- 
nus. The  powder  of  the  three  varieties 
of  cartridges  examined  were  nagative 
for  B.  tetani  and  B.  cerogenes  capsulatus. 
His  efforts  at  isolation  of  B.  tetani 
from  the  wads  have  so  far  been  unsuc- 
cessful. There  is  abundant  evidence, 
from  clinical  observations  and  animal 
experiments,  that  the  wads  of  certain 
blank  cartridges  contain  B.  tetani.  D. 
H.  Dolley  (Journal  of  the  American 
Medical  Association,  February  11, 
1905). 

TONSIL,  FUNCTION  OF  THE. 

The  author  has  made  careful  histo- 
logical studies  and  brings  forward  three 
propositions  for  discussion.  These  are : 
1.  The  older  forms  of  leucocytes  are 
derived  by  a  continuous  development 
from  the  younger  lymphocytes.  He 
thinks  the  lymphoid  cell  must  be  con- 
sidered to  be  a  young  form  of  leucocyte 
capable  of  growing  and  undergoing  cer- 
tain morphological  changes.  2.  The 
lymphocyte  is  originally  derived  from 
the  epithelial  structure.  In  this  connec- 
tion the  thymus  gland  plays  the  most 
important  role..  Eecent  research  has 
practically  established  the  fact  that  there 
is  a  direct  conversion  of  the  epithelial 
cells  into  lymphocytes  in  the  center  of 
the  ingrowing  sprout  of  epithelium  in 
the  thymus,  before  any  outside  structures 
could  have  influenced  this  metamorpho- 
sis. 3.  There  exists  a  strong  histological 
evidence   that   lymphocytes   are   directly 


TONSILLITIS    AND   ARTICULAR    RHEUMATISM. 


89 


derived  from  the  epithelium  of  the  ton- 
sillar crypts.  In  the  development  of  the 
tonsil  there  is  an  ingrowth  of  epithelium 
into  the  mesodermic  tissue  before  any 
lymphoid  cells  can  be  seen  in  this  region. 
The  first  lymphocytes  in  the  tonsil  are 
found  directly  around  this  epithelial  in- 
growth and  are  characterized  by  tine 
anastomosing  processes  of  protoplasm. 
A  careful  histological  study  has  con- 
vinced the  author  that  the  epithelium 
of  the  crypts  exhibits  a  marked  tendency 
toward  constant  growth.  This  is  shown 
by  the  penetration  of  the  epithelial  cells 
into  the  parenchyma  of  the  tonsil  and 
the  formation  of  keratoid  masses  in  the 
lumen  of  the  crypt.  There  also  exist 
transitional  cells  by  which  all  stages  may 
be  traced  between  the  epithelial  cell  and 
the  lymphocyte  and  the  variation  of  types 
in  the  latter  is  most  marked  in  the  re- 
gion of  the  cryptal  epithelium.  The  de- 
gree in  infiltration  of  the  epithelium 
holds  no  relation  to  the  cryptal  con- 
tents. On  the  other  hand,  the  ingrow- 
ing sprouts  of  epithelium  possessing  no 
lumen  show  as  much,  if  not  more,  infil- 
tration than  the  true  crypts.  The  com- 
plete destruction  of  the  cryptal  epithe- 
lium is  a  rare  occurrence,  almost  al- 
ways a  sufficient  number  of  epithelial 
cells  being  left  to  provide  an  intact  bar- 
rier along  the  surface  toward  the 
cryptal  lumen. 

The  author  thinks  he  is  justified  in 
saying  that  the  truth  of  his  three  propo- 
sitions has  been  established,  and  that  an 
affirmative  answer  must  be  given  the 
question,  "Is  the  tonsil  a  primogenial 
source  of  leucocytosis  ?"  If  to  the  ton- 
sils is  accorded  the  function  of  leuco- 
cytic  primogenesis,  their  presence  in  the 
human  economy  is  explained.  The  leu- 
cocytes are  intimately  connected  with 
various  tissue  changes,  and  the  tonsils 
are  the  largest  and  most  fully  developed 


at  the  time  of  life  when  tissue  changes 
are  most  active, — in  childhood.  The 
tonsils  take  up  the  function  of  the  thy- 
mus gland  after  this;  atrophies  earlier 
in  life.  Furthermore,  the  author  thinks 
that  the  adenoid  tissue  in  the  adult  may 
be  carrying  on  the  same  work  which  was 
accorded  the  tonsils  in  childhood.  G-.  B. 
Wood  (University  of  Pennsylvania  Med- 
ical Bulletin,  October,  1904). 

TONSILLITIS  AND  ARTICULAR  RHEUMA- 
TISM, RELATIONS  BETWEEN. 
During  the  last  four  years  the  author 
has  had  occasion  to  treat  17  cases  of 
articular  rheumatism,  and  noted  evi- 
dences of  tonsillitis  in  all  but  1.  and  in 
these  there  was  a  peritonsillar  abscess. 
The  special  form  of  tonsillitis  was  al- 
ways the  chronic,  desquamating,  inflam- 
mation with  the  yellowish-white,  bad 
smelling  "tonsil  plugs"  which  form  in 
the  follicles.  This  follicular  tonsillitis 
is  responsible  for  many  cases  of  articular 
rheumatism,  and  this  disease  can  be 
warded  off  or  recurrences  prevented  by 
incising  and  cauterizing  the  follicles  and 
eventually  excising  part  or  all  of  the 
tonsil.  The  virus  of  articular  rheuma- 
tism finds  its  way  into  the  tonsils  and 
induces  acute  tonsillitis,  which  may  oi 
may  not  be  specially  noticed  by  the  sub- 
ject. The  virus  then  lurks  in  the  re- 
cesses, latent  but  still  virulent.  It  in- 
duces, alone  or  with  other  agents,  a 
chronic  follicular  angina  with  or  with- 
out the  formation  of  plugs.  When  an 
exacerbation]  of  tins  follicular  angina 
occurs  the  door  is  thrown  wide  for  the 
invasion  of  the  body  by  the  rheumatism 
virus.  The  tonsil  plugs  being  very  in- 
fectious foreign  bodies,  are  liable  to  help 
on  the  disease  process,  and  at  any  time 
assisl  in  the  development  of  a  recurrence. 
Griirich  (Munchener  medicinische  Woch- 
enschrift,  November  22,  1904). 


90 


TUBERCULOSIS  AND  MORTALITY. 


TUBERCULOSIS,  HEALING  OF. 


TUBERCULOSIS      AND      MORTALITY      IN 
CHILDHOOD. 

Among  the  children  of  the  poor  in 
London  tuberculosis  is  absolutely  most 
fatal  during  the  first  two  years  of  life, 
but,  relatively  to  all  other  causes  of 
death,  becomes  progressively  more  fatal 
until  the  fourth  year.  There  is  no  spe- 
cific relationship  between  measles  and 
whooping-cough  on  the  one  hand  and 
tuberculosis  on  the  other.  Catarrhal  le- 
sions of  mucous  membranes  are  the  para- 
mount predisposing  causes  of  tuberculo- 
sis in  early  life,  and  measles  and  whoop- 
ing-cough are  potent  in  this  regard 
only  through  the  catarrhs  accompanying 
them.  About  50  per  cent,  of  children 
dying  of  tuberculosis  in  childhood  have 
had  neither  measles  nor  whooping- 
cough.  While  the  infection  of  tuber- 
culosis in  childhood  is  mostly  airborne, 
primary  infection  of  the  abdomen  is  by 
no  means  a  rarity.  W.  P.  S.  Branson 
(British  Medical  Journal,  January  14, 
1905). 

TUBERCULOSIS,  HEALING  OF. 

The  writer  asks  why,  if  all  are  sub- 
jected to  the  infection,  does  the  vast  ma- 
jority escape  and  only  a  comparatively 
small  proportion  develop  a  recognizable 
tuberculous  lesion?  The  painstaking 
and  exhaustive  inquiry  into  the  past 
history  of  a  tuberculous  invalid  is  often 
full  of  surprises.  One  feature,  for  in- 
stance, recurs  with  such  persistent  fre- 
quency that  it  merits  some  attention, 
and  that  is  the  striking  difference  in  time 
between  the  presumptive  evidence  of  dis- 
ease  and  the  first  demonstrable  evidence, 
so  that  at  tbe  onset  of  the  recrudescence 
tbe  original  outbreak  has  been  forgotten 
or  regarded  as  having  no  relation  to  tbe 
present  trouble.  So  that  it  is  extremely 
probable  that  the  initial  lesion  following 


a  tuberculous  infection  is  often  obscure 
in  its  clinical  manifestations  and  fre- 
quently escapes  identification.  There  is 
nearly  always  a  prompt  and  very  often 
successful  tendency  on  the  part  of  the 
organism  to  a  more  or  less  complete  re- 
pair followed  by  an  interval  of  apparent 
health.  Following  this  interval,  which 
may  extend  into  a  period  of  years,  there 
is  a  strong  tendency  to  relapse.  More 
often  than  is  supposed  tbe  real  incipiency 
of  the  disease  is  marked  by  sharp  consti- 
tutional disturbance.  Attention  is  called 
to  the  frequency  with  which  it  is  possible 
to  trace  in  the  history  of  a  tuberculous 
patient  a  first  presumptive  evidence  of 
disease,  followed  by  a  more  or  less  ex- 
tended interval  of  apparent  health  before 
arriving  at  the  demonstrable  onset, 
which,  in  the  light  of  the  history,  must 
be  considered  a  recrudescence.  Whatever 
may  be  the  facts  in  an  individual  case, 
the  safest  and  most  practical  policy  lies 
in  regarding  every  apparent  recovery 
from  tuberculosis  as  merely  an  arrest  of 
the  disease  brought  about  by  an  acquired 
immunity  which  suitable  conditions  are 
very  prone  to  destroy.  If  the  presence 
of  tubercle  during  the  period  of  arrest 
following  the  first  and  unrecognized 
onset  is  ever  to  be  recognized,  it'  is  most 
likely  to  be  done  through  the  discovery 
of  definite  reactions  in  the  blood  serum 
of  the  infected.  The  generally  accepted 
prognostic  significance  of  a  Diazo  reac- 
tion in  tuberculosis  has  application 
chiefly,  if  not  solely,  to  the  last  stages 
of  the  disease,  and  when  temporarily 
present  in  the  early  acute  manifestations, 
or  in  acute  exacerbations  of  chronic  le- 
sions, need '  not  necessarily  indicate  an 
unfavorable  termination.  Its  disappear- 
ance, if  present,  would  be  one  of  the  first 
clinical  evidences  of  improvement.  H. 
M.  Xing  (Medical  Record,  January  7. 
1905). 


TUBERCULOSIS  IN  UNITED  STATES. 


TUBERCULOSIS,  PULMONARY. 


91 


TUBERCULOSIS  IN  THE  UNITED  STATES. 
The  author  reports  progress  in  the 
organization  of  the  medical  profession 
and  the  public  against  tuberculosis  in 
the  last  few  years,  including  a  list  of 
the  special  sanatoria  for  patients  suffer- 
ing from  this  disease  in  the  United 
States  and  Canada.  These  appear  un- 
der various  names — hospital,  sanato- 
rium, sanitarium,  home,  etc.  The 
proper  designation,  he  holds,  is  sana- 
torium, derived  from  the  Latin  word 
sanare,  "to  heal/'  while  sanitarium 
evidently  comes  from  the  Latin  word 
sanitas,  "health,"  and  is  usually  em- 
ployed to  designate  some  specially 
healthful  locality  suitable  for  convales- 
cent patients  or  an  institution  for  the 
care  of  nervous  and  mental  diseases. 
That  this  is  coming  to  be  the  general 
understanding  of  the  term  is  shown  by 
the  adoption  of  the  word  sanatorium 
by  all  the  more  recent  establishments 
and  some  of  the  old  ones.  The  term 
"home"  suggests  an  asylum,  a  place 
which  the  patient  will  enter  and  never 
leave,  and  from  his  observation  he  does 
not  think  that. these  institutions,  as  a 
rule,  are  as  well  equipped  for  curative 
purposes  as  are  the  regular  sanatoria. 
One  institution  on  his  list  is  a  seaside 
sanatorium  for  tuberculous  children,  an 
institution  of  special  value  for  this  class 
of  cases.  Multiple  institutions  for 
scrofulous  children  will  be  required  in 
the  fight  against  consumption.  He 
speaks  highly  of  special  tuberculosis 
dispensaries,  a  number  of  which  have 
been  established  in  the  large  cities,  and 
he  thinks  that  special  wards  in  general 
hospitals  for  this  class  of  cases  are  next 
best,  though  not  equal  to  special  insti- 
tutions. Isolation  of  consumptives  in 
asylums  and  prisons  is  desirable,  and 
Dr.  Knopf  commends  the  Agricultural 
Colony  connected  with  the  Texas  prison 


as  a  worthy  example.  He  holds  also 
that  such  establishments  would  be  of 
great  advantage  to  indigent  convales- 
cents discharged  from  sanatoria,  espe- 
cially those  who  had  formerly  followed 
unhealthy  occupations.  He  pleads  for 
the  co-operation  of  the  various  boards 
throughout  the  country  in  combating 
the  ravages  of  tuberculosis.  S.  A. 
Knopf  (Journal  of  the  American  Med- 
ical Association,  February  11,  1905). 

TUBERCULOSIS,    PULMONARY. 

The  writer  reports  several  cases  to 
show  that  pulmonary  tuberculosis  orig- 
inates in  the  apex  by  way  of  the  lymph 
channels  in  the  neck,  which  transmit  the 
infection  to  the  parietal  pleura  of  the 
upper  part  of  the  chest,  which  forms  ad- 
hesions with  the  visceral  pleura.  The 
appearance  of  stitches  in  the  apical  re- 
gion is  significant  of  this  mode  of  infec- 
tion. The  author  condemns  massage  of 
enlarged  cervical  glands,  and  believes  in- 
fection on  the  right  side  more  frequent 
on  account  of  the  greater  mobility  of  that 
side  of  the  chest,  M.  Wassermann  (Ber- 
liner klinische  Wochenschrift,  Novem- 
ber 28,  1901). 

TUBERCULOSIS,   PULMONARY,  FIRST  AN- 
ATOMICAL CHANGES  IN. 

It  is  difficult  to  determine  what  patho- 
logical lesions  initiate  a  tuberculosis  of 
the  lungs,  since  the  changes  are  already 
far  advanced  in  most  cases  which  come 
to  autopsy.  Thus  the  author  found  only 
two  cases  suitable  for  study  in  several 
hundred  autopsies.  He  concludes  as 
follows:  Pulmonary  phthisis  in  adults 
is  generally  due  to  a  recent  infection 
with  tubercle  bacilli  and  not  a  result  of 
an  exacerbation  of  a  latent  process  ac- 
quired during  infancy,  as  is  held  by  so 
many.  In  most  cases  the  lungs  them- 
selves are  the  starting  point  of  the  proc- 


92 


TUBERCULOSIS,  TRANSMISSION  OF. 


ess;  in  other  words,  pulmonary  tuber- 
culosis is  a  primary  and  independent 
lesion.  The  disease  begins  as  a  rule  in 
the  intralobular  bronchi  of  the  apex  of 
one  lung,  in  the  form  of  a  productive, 
tuberculous  peribronchitis.  Owing  to 
loss  of  elasticity,  as  a  result  of  caseation 
of  the  primary  neoplastic  tissue,  a  cir- 
cumscribed dilatation  of  the  bronchial 
lumen  will  follow.  The  process  spreads 
from  its  primary  sites  in  different  ways. 
It  travels  both  in  centripetal  and  centri- 
fugal direction  along  the  bronchus  and 
its  branches,  giving  rise  to  a  tuberculous, 
peribronchial  lymphangitis.  The  neo- 
plastic tissue  surrounding  the  bronchus 
may  readily  break  through  the  bronchial 
lumen,  both  at  the  primarily  and  sec- 
ondarily infected  sites  and  the  symptoms 
of  a  specific  tuberculous  bronchitis  will 
soon  appear.  Cheesy  bronchitis  and  peri- 
bronchitis of  the  intralobular  bronchus 
and  its  immediate  branches  are  thus  the 
first  stage  of  the  tuberculous  lesion.  The 
process  may  also  extend  to  the  adjacent 
tissue,  when  it  generally  retains  its  pro- 
ductive character  arid  presses  together 
the  alveoli  of  the  lung.  As  soon  as 
cheesy  masses  have  ruptures  into  the 
bronchus,  an  aspiration  occurs  into  pe- 
ripherally situated  areas,  and  several 
patches  of  broncho-pneumonia  will  ap- 
pear, each  one  of  which  corresponds  to 
the  terminal  end  of  a  bronchus.  This 
may  be  called  the  second  act  of  the  proc- 
ess. Most  recent  cases  examined  were 
in  this  broncho-pneumonia  stage  with 
beginning  central  caseation  as  far  ad- 
vanced that  an  idea  of  the  original  struc- 
ture could  only  be  obtained  by  staining 
elastic  fibers. 

The  blood-vessels  are  not  rarely  af- 
fected by  a  productive  process  which  sur- 
rounds them  like  a  belt  and  coos  hand  in 
hand  with  a  proliferation  of  the  intinia. 
Vesspl?   of   larger   caliber   are,  however, 


free.  The  elastic  fibers  are  destroyed 
late  and  then  in  a  purely  mechanical 
way.  The  broncho-pneumonia  distribu- 
tion of  the  initial  foci  may  also  be  seen 
in  hematogenous  miliary  tuberculosis 
and  in  the  experimental  tuberculosis  of 
animals;  it  argues,  however,  strongly  in 
favor  of  a  primary  infection  of  the  lungs 
in  most  cases. 

There  can  be  no  doubt  that  bacilli  are 
often  inhaled  and  the  fact  that  they 
settle  so  frequently  in  the  apices  is  best 
explained  by  diminished  powers  of  over- 
coming an  infection  here.  In  children 
the  bronchial  nodes  are  generally  af- 
fected, first,  from  the  respiratory  pas- 
sages and  the  lungs  are  involved  second- 
arily. Bronchial  tuberculosis  of  children 
has  a  tendency  to  remain  latent  for  a 
long  period  and  encapsulation  is  never 
perfect,  but  with  adult  age  the  dangers 
of  propagation  become  less,  owing  to 
calcification  and  proliferation  of  connec- 
tive tissue.  At  this  stage,  the  bacilli  are 
no  longer  transported  to  the  glands,  but 
to  the  lung  itself.  Secondary  involve- 
ment of  the  lungs  in  children  is  due  to 
rupture  of  cheesy  material  through  the 
walls  of  the  bronchus  nearest  the  node 
or  else  by  extension  of  the  process  into 
the  perivascular  lymph-channels  of  the 
bronchus.  The  secondary  foci  within  the 
lungs  do  not  develop  in  a  typical  way, 
like  the  primary,  unless  they  spread  by 
way  of  the  bronchi.  A.  J.  Abrikossoff, 
(Virchow's  Archiv,  Vol.  178,  No.  2; 
Medical  News,  December  31,  1904). 

TUBERCULOSIS,    THE    TRANSMISSION    OF. 

The  author's  paper  shows  that,  in 
Japan  at  least,  the  chief  if  not  only 
source  from  which  tuberculosis  is  spread 
is  man.  The  native  Japanese  cattle  are 
practically  free  from  the  disease,  while 
human  tuberculosis,  including  the  intes- 
tinal variety,  has  been  known  since  the 


TYPHOID  FEVER,  RUPTURE  OF  MUSCLES   IN. 


93 


beginning  of  medical  history.  The  au- 
thor presents  the  following  formal  con- 
clusions: Human  tuberculosis  is  as  fre- 
quent in  Japan  as  in  the  civilized  coun- 
tries of  Europe  and  America.  Primary 
intestinal  tuberculosis  is  relatively  com- 
mon in  adults  and  children,  although 
cow's  milk  plays  no  role  at  all  in  the 
feeding  of  children.  There  are  large 
districts  in  Japan,  where,  in  spite  of  the 
existence  of  human  tuberculosis  the  cattle 
remain  absolutely  free  from  the  disease. 
In  these  regions  it  is  not  customary  to 
consume  either  meat  or  milk  from  bo- 
vines.  This  is  very  important  proof  of 
the  fact  that  under  ordinary  conditions 
human  tuberculosis  is  not  infectious  for 
bovines,  as  the  opportunities  for  infec- 
tion certainly  cannot  be  lacking.  Among 
Japanese  in  general  very  little  cow's 
milk  is  used  and  especially  is  it  employed 
but  little  for  the  dietary  of  children. 
Under  natural  conditions  the  native  ani- 
mals show  but  very  little  susceptibility 
for  perlsucht.  If  large  doses  of  perl- 
sucht  bacilli  are  inoculated  into  them 
either  intravenously  or  intraperitoneal!}7, 
they  become  tuberculous  to  a  certain  de- 
gree; they  do  not  seem  to  be  at  all  sus- 
ceptible to  subcutaneous  infection.  The 
imported  and  mixed  race  animals  are 
very  susceptible  to  perlsucht.  Human 
tuberculosis  is  not  infectious  for  native 
and  mixed  race  animals.  S.  Kitasato 
(American  Medicine,  January  7,  1905). 

TYPHOID      FEVER,      RUPTURE      OF      THE 
MUSCLES  IN. 

Considering  the  frequency  of  mus- 
cular lesions  in  typhoid,  it  is  curious 
that  rupture  should  seldom  occur.  Vio- 
lent movements,  such  as  take  place  in 
delirium,  appear  to  be  the  chief  cause, 
the  muscle  most  usually  affected  being 
the  rectus  abdominalis.  As  a  matter  of 
fact    the    real    cause    is    not    accurate!'' 


known.  The  male  sex  is  most  usually 
affected.  Muscular  rupture  occurs  in  the 
third  week  or  during  convalescence,  and 
sometimes  accompanies  degeneration  of 
the  bony  structures.  The  author  de- 
scribes a  most  exceptional  case  in  which 
rupture  occurred  between  the  fifth  and 
sixth  day  of  the  disease.  The  patient's 
mind  is  usually  clear ;  he  is  conscious  of 
a  feeling  of  prostration,  and  at  the  time 
of  rupture  of  sudden  pain  and  tenderness 
sufficiently  severe  to  cause  him  to  cry 
out.  Examination  at  this  time  reveals 
an  irregular  depression  outlined  in  the 
substance  of  the  abdominal  rectus.  The 
size  varies.  A  little  later  swelling  due  to 
hemorrhage  is  noticed;  the  condition 
may  be  unsuspected  until  the  hematoma 
is  noticed,  which  forms  an  ovoid  tumor 
with  the  lesser  extremity  pointing  to  the 
pubes.  It  is  rare  for  it  to  exceed  the 
size  of  an  orange.  The  skin  is  movable, 
and  it  is  even  possible  to  slightly  dis- 
place the  tumor  laterally.  In  due  time 
an  ecchymotic  tinge  appears  in  the  skin, 
varying  in  its  intensity  according  to  the 
thickness  of  the  muscle  and  the  imper- 
meability of  its  sheath.  Sometimes 
hemorrhagic  discoloration  is  first  no- 
ticed below  the  pubes  and  at  the  upper 
part  of  the  thighs.  Absorption  may  take 
place,  but  it  is  not  so  usual  as  suppura- 
tion, which  occurred  sixteen  times  in  35 
cases,  and  appears  to  be  due  to  the  pres- 
ence of  Eberth's  bacillus.  The  prognosis 
is  grave,  chiefly  because  muscular  rup- 
ture occurs  in  cases  of  severe  typhoid, 
death  being  due  to  myocarditis  or  some 
other  complication  of  the  disease.  But 
even  in  those  cases  where  death  is  not 
due  to  one  of  the  usual  complications  of 
the  disease  suppurating  hematoma  is 
serious,  as  the  resulting  abscess  may  point 
internally,  and  set  up  septic  peritonitis. 
So  soon  as  the  diagnosis  is  made  surgical 
interference  is  called   for,  as  delay  may 


94 


UTERINE  MYOMATA. 


UTERINE  DEVIATIONS. 


VOMITING. 


expose  the  patient  to  risk.  Perochaud 
(Gaz.  Med.  de  Nantes,  No.  38;  from 
British  Medical  Journal,  January  14, 
1905). 

UTERINE    MYOMATA,    ELECTRIC    TREAT- 
MENT OF. 

In  spite  of  the  shortcomings  of  this 
method,  it  has  been  further  studied  by 
the  writer,  who  has  perfected  a  method 
which  apparently  gives  satisfactory  re- 
sults. His  plan  is  to  produce  firm  uter- 
ine contractions  by  strong  faradization, 
with  the  idea  of  causing  the  blood-vessels 
to  contract,  and  thus  to  check  haemor- 
rhage, while  at  the  same  time  the  nutri- 
tion of  the  tumor  is  interfered  with,  and 
it  diminishes  in  size  by  a  process  of  ab- 
sorption. One  electrode  is  passed  through 
the  cervix  into  the  uterus,  while  the 
other  is  applied  to  the  abdomen.  If  pos- 
sible the  treatment  is  continued  daily  for 
from  twenty  to  thirty  minutes,  and  the 
current  is  used  as  strong  as  the  patient 
can  stand  it.  Both  the  strength  of  cur- 
rent and  the  frequency  of  application 
must  be  carefully  regulated  at  the  begin- 
ning of  treatment  in  order  not  to  over- 
tax the  patient.  The  author  has  never 
observed  any  bad  effects  from  the  treat- 
ment, and  has  found  that  the  metror- 
rhagia is  entirely  controlled  and  the  tu- 
mors are  greatly  reduced  in  size.  E. 
Witte  (Deutsche  medicinische  Wochen- 
schrift,  November  3,  1904). 


of  her  clinic,  39  per  cent,  were  found 
with  retrodeviation.  In  15  per  cent,  of 
these  there  were  no  gynecological 
symptoms.  The  remainder  were  re- 
corded as  eomplicated  with  definite 
pathological  conditions,  tumors,  pyo- 
salpinx,  chronic  disease  of  ovaries, 
myometritis,  etc.  She  notes  the  effects 
of  fixation  on  an  organ,  the  interfer- 
ence with  circulation,  etc.,  and  from  all 
the  data  in  her  observation  and  from 
what  she  has  found  in  the  literature, 
she  concludes  that  a  normal  uterus  may 
lie  in  any  position  in  the  pelvis  with- 
out causing  symptoms,  and  that  when 
these  occur  they  are  due  to  other  patho- 
logical complications.  This  answers 
her  first  question.  As  regards  the 
safety  of  the  operation  of  ventrofixa- 
tion, she  quotes  from  numerous  authori- 
ties showing  its  effects  on  the  progress; 
of  pregnancy  and  delivery,  and  the 
clangers  of  strangulation,  ileus,  etc. 
Vaginal  fixation  is  almost  as  bad  in  its 
results  as  ventrosuspension,  and  the 
best  that  can  be  said  of  the  methods 
of  shortening  the  round  ligaments  is 
that  they  are  not  dangerous  except 
by  weakening  the  abdominal  wall  and 
increasing  the  risk  of  hernia.  On  the 
other  hand,  they  are  unsuccessful  in  a 
large  percentage  of  cases  and,  in  view 
of  the  answer  to  the  first  question,  are 
unnecessary.  Lucy  "Waite  (Journal  of 
the  American  Medical  Association, 
February  11,  1905). 


UTERINE    RETRODEVIATIONS. 

The  writer  discusses  whether  opera- 
tions for  these  conditions  are  neces- 
sary; whether  they  are  safe  surgical 
procedures,  and  whether  they  have 
been  sufficiently  successful  to  warrant 
their  advocacy  in  the  future.  She  an- 
swers each  question  in  the  negative. 
In  1000  cases  taken  from  the  records 


VOMITING,  RECURRENT. 

The  author  defines  recurrent  vomiting 
as  a  symptom  group  closely  related  to 
migraine.  It  is  autotoxic  in  origin  and 
characterized  by  recurrent  attacks  of 
nausea,  persistent  vomiting,  and  great 
prostration;  heredity-  is  the  most  im- 
portant predisposing  factor.     Both  auto- 


BOOKS  AND  MONOGRAPHS  RECEIVED. 


95 


toxins  and  intestinal  toxins  may  play  a 
role  in  producing  this  symptom  group, 
but  the  author  does  not  believe  it  is  al- 
ways produced  by  the  same  toxins.  The 
largest  percentage  of  cases,  however,  is 
produced"  by  toxins  very  closely  related 
to,  or  identical  with,  the  purin  bodies. 
Functional  incompetency  of  the  liver 
is  an  all-important  factor.  As  to  the 
pathology  of  the  disease,  little  is  known. 
The  belief  is  justified  that  the  disease 
is  an  auto-intoxication  produced  by  tox- 
ins closely  related  or  identical  with  the 
purin  bodies,  followed  by  a  secondary 
cyto-intoxication,  which  may  contribute 
to  the  symptoms  in  the  latter  stages  of 
the  attack. 

In  the  treatment  of  the  attack,  normal 
saline  solution  and  benzoate  of  soda  are 
the  important  remedies.  For  curative 
treatment,  change  of  climate  is  of  great 


importance,  if  only  for  a  few  months 
during  the  year.  Diet  should  be  care- 
fully restricted,  particularly  as  children 
suffering  from  recurrent  vomiting  have, 
as  a  rule,  abnormally  large  appetites  in 
the  intervals  between  the  attacks.  They 
must  be  carefully  guarded  against  tak- 
ing an  excess  of  food  of  any  kind,  and 
are  to  be  made  to  cultivate  the  habit  of 
drinking  water  between  meals.  Medical 
treatment  consists  in  relief  of  constipa- 
tion. The  drugs  giving  the  most  satis- 
faction are  wintergreen,  sodium  salicy- 
late and  sodium  benzoate,  put  up  in  es- 
sence of  pepsin  and  peppermint  water. 
In  the  more  severe  cases  such  a  pre- 
scription must  be  continued  for  months 
at  a  time,  and  after  this  is  to  be  given 
once  a  day  for  an  indefinite  period.  B. 
K.  Eachford  (Archives  of  Pediatrics, 
December,  19CU); 


5ool<s  and  /Vionographs  Received. 


The  editor  begs  to  acknowledge,  with  thanks,  the  receipt  of  the  following  books  and 
monographs  : — 

Transactions  of  the  American  Octological  Society,  Thirty-seventh  Annual  Meeting.     Volume 

VIII,  Part  III.    1904. Massachusetts  State  Pharmaceutical  Association  Proceedings.    1904. 

Suppuration  of  the  Nasd  Accessory  Sinuses.  By  J.  A.  Stucky,  Lexington,  Ky.  1904 Mas- 
toiditis in  General  Practice.     By  J.  A.  Stucky,  Lexington,  Ky.     1904. Lithemic  Nasopharyn- 

gits  due  to  Systemic  Disturbance.    By  J.  A.  Stucky,  Lexington,  Ky.    1904. Annual  Address  of 

the  President (College  of  Physicians  of   Philadelphia).     By  Arthur  V.   Meigs,  Philadelphia. 

1905. ■  >n  Adenoid  Vegetations  in  the  Naso-Pharyngeal  Cavity.     Their  Pathology,  Diagnosis. 

and  Treatment.     Dr.  Wilhelm  Meyer's  Original  Paper,   Republished  with  Annotations.     By  Jacob 

E.  Schadle,  St.  Paul,   Minn.     1905. The  Value  of  the  Physiological  Principle  in  the  Study  of 

Neurology.  By  J.  J.  Putnam,  Boston,  Mass.  1904. Notes  on  Some  Unusual  Forms  of  Infec- 
tious Disease  of  the  Central  Nervous  System.  By  J.  J.  Putnam  and  G.  A.  Waterman,  Boston. 
Mass.  1904. A  Helpful  Agent  in  the  Treatment  of  Surgical  Debility.  By  J.  S.  Purely,  Lon- 
don, Eng.   -1904. The  Training  of  the  Surgeon.     The  Annual  Address  in  Medicine,  delivered 

at  Yale  University,  June  27,  1904.     By  William  Stewart  Halsted,  Baltimore.    1904. American 

Varieties  of  Lettuce.  By  W.  W.  Tracy,  Jr.,  United  States  Department  of  Agriculture,  Washing- 
ton,  D.   C.     1904. Soil    Inoculation   for  Legumes;    with  Reports  upon  the  Successful  Use  of 

Artificial  Cultures  by  Practical  Farmers.  By  George  T.  Moore,  United  States  Department  of 
Agriculture,  Washington,  D.  C.     1905. 


EDITORIAL  STAFF. 
Sajous's  Analytical  Cyclopaedia  of    Practical  Medicine. 


ASSOCIATE,  EDITORS. 


J    OEOROE  ADAMI,  M.D., 

lONTKIUL,  P.  <J. 


LEWIS  H.  ADLER.  M.D., 

PHILADELPHIA. 


JAMES  M.  ANDERS,  M.D.,  LL.D., 

PHILADELPHIA. 


THOMAS  G.  ASHTON,  M.D., 

PHILADELPHIA. 


A.  D.  BLACKADER,  M.D., 

MONTREAL,  P.  Q. 


E.  D.  BONDURANT.  M.D., 

lllilill.1..   ALA. 


DAVID  BOVAIRD,  M.D., 

NEW  YORK  CITY. 


WILLIAM  BROWNING,  M.D., 

BROOKLYN,  N.  Y. 


WILLIAM  T.  BULL.  M.D., 

NEW  YORK  CITY. 


CHARLES  W.  BURR,  M.D., 

PHILADELPHIA. 


HENRY  T.  BYFORD,  M.D., 

CHICAGO,  ILL. 


HENRY  W.  CATTELL,  M.D., 

PHILADELPHIA. 


WILLIAM  B   COLEY,  M.D., 

NEW  YORK  CITY. 


fLOYD  M.  CRANDALL,  M.D., 

NEW  YORK  CITY. 


ANDREW  F.  CURRIER,  M.D.. 

NEW  YORK  CITY. 


ERNEST  W.  CUSIIING,  M.D.. 

BOSTON,  MASS. 


GWILYM  G.  DAVIS,  M.D., 

PHILADELPHIA. 


N.  S.  DAVIS,  M.D., 

CHICAGO,  ILL. 


AUGUSTUS  A    ESHNER,  M.D., 

PHILADELPHIA. 


SIMON  FLEXNER.  M.D., 

PHILADELPHIA. 


LEONARD  FREEMAN,  M.D., 

DENVER.  COL. 


B.  O.  GANT.  M.D. 

NEW  YORK  CITY. 


J.  MoFADDEN  GASTON,  Sr..  M.D.. 

ATLANTA,  GA. 


4    MoFADDEN  GASTON,  JR..  M.D.. 

ATLANTA,  GA. 


B.  OLEASON.  M.D.. 

PHILADELPHIA. 


BitBEHT  H.  ORANDIN.  M.D.. 

<IW  TOEB  CITY 


J.  P.  CROZER  GRIFFITH,  M.D., 

PHILADELPHIA. 


C.  M.  HAY.  M.D., 

PHILADELPHIA. 


FREDERICK  P.  HENRY,  M.D., 

PHILADELPHIA. 


L.  EMMETT  HOLT   M.D., 

NEW  YORK  CITY. 


EDWARD  JACKSON,  M.D., 

DENVER,  COL. 


W.  W.  KEEN,  M.D., 

PHILADELPHIA. 


EDWARD  L.  KEYES,  Jr.,  M.D., 

NEW  YORK  CITY. 


ELWOOD  R.  KIRBY,  M.D., 

PHILADELPHIA. 


L.  E.  La  FETRA,  M.D., 

NEW  YORK  CITY. 


ERNEST  LAPLACE,  M.D.,  LL.D., 

PHILADELPHIA. 


R.  LEPINE.  M.D., 

LYONS.  FRANCE. 


F.  LEVISON.  M.D., 

COPENHAGEN,  DENMAR8 


A.  LUTAUD.  M.D., 

PARIS,  PRANCE. 


G.  FRANK  LYDSTON,  M.D., 

CHICAGO,  ILL. 


F.  W.  MARLOW,  M.D., 

SYRACUSE,  N.  Y. 


SIMON  MARX.  M.D., 

NEW  YORK  CITY. 


ALEXANDER  MoPHEDRAN,  M.D., 

TORONTO,  ONT. 


E.  E.  MONTGOMERY,  M.D.. 

PHILADELPHIA. 


HOLGER  MYGIND,  M.D., 

COPENHAGEN.  DENMARK. 


W.  P.  NORTH RUP.  M.D., 

NEW  YORK  CITY. 


RUPERT  NORTON,  M.D., 

WASHINGTON,  D.  0. 


H.  OBERSTEIXER.  M.D.. 

VIENNA,  AUSTRIA. 


CHARLES  A.  OLIVER,  M.D., 

PHILADELPHIA. 


WILLIAM  OSLER.  M.D.. 

BALTIMORE,  MD. 


LEWIS  S.  PILCHER,  M.D., 

BROOKLYN,  H.  T 


WI1,L1AM  CAMPBELL  POSEY    M.D.. 
PHILADELPHIA 


W    B.  PRITCHARD    M.D., 

NEW  YORK  CITY. 


JAMES  J.  PUTNAM,  M.D., 

BOSTON. 


B.  ALEXANDER  RANDALL,  M.D.. 

PHILADELPHIA. 


CLARENCE  C.  RICE,  M.D., 

NEW   YORK  CITY. 


ALFRED  RUBINO,  M.D., 

NAPLES.   ITALY. 


REGINALD  H.  SAYRE,  M.D.. 

NEW  YORK  CITY. 


JACOB  E.  SCIIADLE,  M.D., 

ST.  PAUL,  MINN. 


JOHN  B.  SHOBER.  M.D., 

PHILADELPHIA. 


J.  SOLIS-COIIEN,  M.D., 

PHILADELPHIA. 


SOLOMON  SOLIS-COIIEN,  M  D., 

PHILADELPHIA. 


II.  W.  STELWAGON,  M.D., 

PHILADELPHIA. 


D.  D.  STEWART,  M.D., 

PHILADELPHIA. 


LEWIS  A.  STIMSON,  M.D., 

NEW  YORK  CITY. 


J.  EDWARD  STUBBERT,  Ml), 

LIBERTY,  N.  Y. 


A.  E.  TAYLOR.  M.D., 

SAN  FRANCISCO,  CAL. 


J.  MADISON  TAYLOR.  M.D.. 

PHILADELPHIA. 


M.  B.  TINKER.  M.D., 

PHILADELPHIA. 


CHARLES  S.  TURNBULL,  M  D.„ 

PHILADELPHIA. 


HERMAN  F.  VICKERY,  M.D.. 

BOSTON,   MASS. 


F.  E.  WAXHAM.  M.D., 

DENVER,    COL. 


J.  WILLIAM  WHITE.  M.D., 

PHILADELPHIA. 


JAMES  C.  WILSON.,  M.D., 

PHILADELPHIA. 


C.  SUMNER  WITHERSTINE,  M  !>., 

PHILADELPHIA. 


ALFRED  C.  WOOD,  M.D., 

PHILADELPHIA. 


[End  of  the  Editorial  Department  of  the  Monthly  Cyclopaedia  for    Teh.,  1905.] 


THE    MONTHLY   CYCLOPEDIA 

OF 

PRACTICAL   MEDICINE 


(Published  the  Last  of  Each  Month) 


Vol.  XVIII. 
Old  Series. 


PHILADELPHIA,  MARCH,  1905. 


Vol.  VIII,  No.  3. 
New  Series. 


TABLE  OF  CONTENTS. 


PAGE 

EDITORIALS 

THE  NATURE  AND  TREAT- 
MENT OF  "INBANITT."  Theo- 
dore Diller 97 

ROENTGEN  THERAPY :  ITS  SPHERE 
OF  APPLICABILITY.  Charles 
Lester  Leonard 1*9 

ELEMENTS  OF  8UCCEI8  IN  TREAT- 
MENT OF  LARYNGEAL  TUBER- 
CULOSIS.    E.  S.  Bullock 1  3 

NEURASTHENIA  PLUS  CHB0N1C 
INTOXICATIONS.  J.  Madison 
Taylor 106 

CYCLOPAEDIA    OF   CURRENT 
LITERATURE 

ACID  INTOXICATIONS.    J.A.Kelly.  Ill 

ADRENALIN,  ACTION  OF.     Neujean.  Ill 

ADRENALIN  IN    SURGERY.     Hilde- 

brandt 112 

APPENDICITIS,  PERILOUS    CALMS 

OF.     R.  W.  Hardon 113 

CEREBRAL  HEMORRHAGE.     J.   W. 

Russell 113 

CHLOROFORM,    ELIMINATION    OF, 

BY  VOMITING.    Gelpke 113 

CONVULSIONS     IN      NEPHRECTOM- 

IZED  RABBITS.    Blumreich 113 

DEFEN8IVE  POWBBS  OF  THE  BODY 

IN  DI8EA8E.     Muir 1U 

DIABETES,    CONTAGIOUSNESS    OF 

Hutinet 114 

DIABETE8  INSIPIDUS,  TREAT- 
MENT OF.     B.  Stein 115 

DIABETES  MELLITU8,  MA8TOID 
DI8EABE  COMPLICATING.  S. 
MacCuen  Smith 115 

DIPHTHERIA  TOXIN,  ACTION  OF 
LIVER  OH.  Lauder  Bninton 
and  Bokenham 115 

FEEDING      IN      INFANCY.       W.     P. 

Northrup 116 

FIBROID  TUMORS  AND  PREG- 
NANCY.     S.Marx 116 

GONORRHOEA, ACTIVE  TREATMENT 
OF,  IN  EARLY  STAGE8  F.J. 
Cotton 117 

GRAVES'S  DISEASE,  PIGMENTA- 
TION OF  EYELIDS  IN.  Jel- 
linck 117 

HEMOPTYSIS,  TREATMENT  OF.    C. 

II.  Cattle 118 

HEMORRHOIDS,    TRIATMENT    OF. 

T.  C.  Hill 118 

HEADACHE,     NA8AL     DISEASE    AS 

A  CAUSE  OF.    A.  L.  Whitehead.    119 


LABOR,    PROPHYLACTIC     USE     OF 

ERGOT  DURING.     Priissmann...  1111 
LE ID-POISONING,  BABOPHILIS 

GRANULATIONS    OF   THE 

ERYTHROCYTE  IN.    W.  B.  Cad 

walader 119 

LITTEN'S     "DIAPHRAGM     IHINO- 

MENON    "  IN  DIAGN08IS.     W. 

N.  Berkeley 119 

MEASLES,     PRODROMAL      RASHES 

OF.     J.  D.  Rolleston 120 

MELANOMA.      J.  C.  Johnson 120 

METABOLISM,  INFLUENCE  OF  DIET 

POOR  IN    CHL0RIDE8    ON. 

Calahrese 121 

MOVABLE  KIDNEY.  NEW  OPERA- 
TION FOR.     A.  FnllertOB 121 

NARCOSIS,   PHYSICAL    BASIS    OF. 

J.Trauhe 121 

PANCREAS,  ROLE   OF  THE  NERVES 

OF.     G.  Zamboni 123 

PNEUMONIA.      W.  J.  Ualbraith 124 

PNEUMONIA,  LOBAR,  SOME  IR- 
REGULAR   FEATURES    OF.     C. 

K.  Law 124 

PNEUMONIA,    TREATMENT    OF. 

William   Ewart 125 

PROSTATIC        ENLARGEMENT, 

PATHOLOGICAL     CHANGES 

RE8ULTING  FROM.     C.  E.  Bar- 

nett 126 

PROSTATIC   HYPERTROPHY, 

SURGICAL     TREATMENT     OF. 

E.  G.  Bal  enger 126 

PRURIGINOUB      DERMATOSES,     X- 

RAY8      IN     TREATMENT     OF. 

Belot 127 

PRURITU8    ANI,   INVETERATE, 

TREATMENT  OF.     Charles  Ball.  127 
PURGATION    BEFORE    AND    AFTER 

OPERATION,  ABUSE  OF.    I.  S. 

Stone 127 

RENAL  AND    URETERAL  CALCULI, 

DIAGNOSIS  OF.     H.  A.  Fowler.  128 
REKAL  CALCULUS,  DIAGNOBIB  OF, 

BY    MEANS    OF     X-RAYS.     A. 

B.  Johnson 128 

RENAL    CAPSULE,    FUNCTION    OF. 

I.  Levin 129 

RHEUMATISM,  RARER  FORMS  OF. 

J.  Schreiber 129 

RUPTURE    OF    INTEBTINEB.      C.    P. 

Flint 130 

SCARLET  FEVER,  INFEOTIVITY 
AND  MANAGEMENT  OF.  W. 
T.  G.  Pugh 130 


PAGE 

SCIATICA,  TREATMENT  OF. 

Lange 131 

8ERUM    INJECTIONS,   EFFECT    OF, 

ON  THE  BLOOD.  Kucharzewski.  131 

SLEEP,    BIOLOGICAL    THEORY    OF. 

Claparede 132 

STOMACH,  PASSAGE  OF  FOOD- 
STUFFS FROM.  W.  B.  Cannon,    1S2 

SUBCUTANEOUS     ALIMENTATION. 

A.  E.  Barker 1  3 

SUPPURATION,  TEMPERATURE  AS 
A  GUIDE  TO  EXISTENCE  OF. 
Lyman  Allen 133 

SUPRARENAL  PREPARATIONS, 
EFFECT  OF,  ON  LIVING  PRO- 
TOPLASM.    Beaman  Douglass....  133 

SYPHILITIC  RECRUDESCENCES, 
PATHOGENESIS  OF.  "Medical 
Record  " 133 

TENDON  REFLEXES,  INCREASED, 
IN  INFECTIONS.  R.  Massa- 
longo 135 

THYROIDIBM,    ACUTE    POST- 
OPERATIVE.    S.  E.  Sanderson...  135 

TONSIL,  GROWTH  OF  BONE  IN.   W. 

W.  Carter 136 

TUBERCULOSIS  OF  LARYNX, 
TREATMENT  OF,  WITH  BUN- 
LIGHT.      Kunwald 136 

TUBERCULOSIS,    8UGAR     IN.      R. 

Massalongo  and  G.  Danio 137 

TYPHOID  AND  COLON  BACILLI  IN 
WATER,  EFFICIENCY  OF 
COPPER  FOIL  IN  DESTROY- 
ING.    Henry  Kraemer 137 

TYPHOID  FEVER,  TREATMENT  OF. 

"Medical    Record" 137 

TYPHOID  FEVER,  WATER-DRINK- 
ING IN.  E.  F.  Cushing  and  T. 
W.  Clarke 140 

BRETER8,  OPERATIONS  ON  LOWER 

ENDS  OF.     John  A.  Sampson 140 

URETHRAL  STRICTURE,  TREAT- 
MENT OF.     F.  S.  Watson 141 

SUPRARENAL  EXTRACT  IN 
CARDIO-VASCULAR  DISEASE. 
CORRECTION.     James  Tyson 141 

C0UR8E  OF  PUBLIC  HEALTH  AT 
THE  UNIVERSITY  OF  PENN- 
SYLVANIA   142 

BOOK  REVIEWS 142 

BOOKS  AND  MONOORAPHB  RE- 
CEIVED   U3 

8TAFF  LIST Ui 


Editorials. 


DEPARTMENT   IN   CHARGE   OF 

J.  MADISON   TAYLOR,  A.M.,  M.D. 


THE  NATURE  AND  TREATMENT   OF  "INSANITY." 

There  has  been  enough  discussion  of  "insanity"  to  lead  me  to  adopt  the 
conclusion,  reached  by  a  few  writers,  that  it  is  absolutely  indefinable.  What  it  is, 
and  what  is  necessary  to  constitute  it,  is  a  matter  of  individual  opinion.     Even 


98  THE  NATURE  AND  TREATMENT  OF  "INSANITY." 

with  practical  agreement  as  to  the  observation  of  the  facts,  honest  alienists  differ 
as  to  what  shall  be  called  "insanity."  Should  we  then  be  surprised  that  in  the 
concepts  of  the  law,  and  among  the  laity,  the  utmost  confusion  and  haziness  should 
prevail  on  all  sides? 

Dr.  Bichard  Dewey's  proposition  to  discard  the  name  "insanity"  with  all  the 
opprobrium  which  attaches  to  it  and  to  substitute  that  of  "psychosis;"  to  include 
not  only  what  is  commonly  known  as  "insanity,"  but  also  the  so-called  "border- 
land" conditions  and  many  conditions  presenting  mental  symptoms  not  commonly 
denominated  as  "insanity,"  has  much  to  commend  it.  The  term  "psychosis"  is 
more  inclusive  and  less  definite  than  that  of  "insanity,"  facts  which,  in  the  present 
state  of  our  knowledge  and  ignorance,  argue  for  its  use. 

That  certain  morbid  mental  phenomena  should  be  held  to  constitute  "insanity," 
while  others  perhaps  differing  only  in  degree,  should  not  (although  both  groups 
depend  upon  the  same  underlying  mechanism)  ;  that  certain  morbid  mental  phe- 
nomena should  be  called  "insanity"  if  prolonged  and  something  else  is  of  short 
duration,  constitute  artificial  distinctions  which  are  unscientific.  Moreover,  the 
distinction  or  differentiation  is  impossible,  since  the  facts  are  differently  observed, 
measured,  and  interpreted.  The  whole  study  of  abnormal  mental  manifestations 
has  been  greatly  hindered  by  the  attempt;  and  indeed,  by  the  supposed  necessity 
of  stating  specifically  which,  and  how  many  of  them,  shall  constitute  "insanity," 
and  which,  and  how  many,  may  exist  without  constituting  "insanity."  Thus  the 
unity,  or  the  essential  sameness,  of  the  underlying  mechanism  in  all  morbid  mental 
phenomena  has  been  obscured  and  often  lost  sight  of  entirely.  "Insanity"  has  for 
countless  ages  been  a  mythical  entity — a  fetish. 

Therefore,  because  it  never  has  been  and  never  can  be  defined  and  isolated; 
because  attempts  to  do  so  hinder  the  study  of  morbid  psychology  from  a  broad  point 
of  view,  the  attempts  to  erect  among  the  sum  total  of  morbid  mental  phenomena 
an  impossible  artificial  entity — "insanity" — should  be  abandoned. 

But  what  about  the  legal  requirements?  Let  the  law  take  care  of  itself.  Let 
the  physician  on  the  witness  stand  state  the  qualities,  degrees,  and  kinds  of  abnor- 
mal mental  phenomena  observed  by  him,  and  if  possible  state  their  significance 
and  let  the  Court  determine  whether  they  constitute  unsoundness  of  mind,  irre- 
sponsibility, or  a  sufficient  excuse  for  crime. 

But  the  term  "insanity"  has  been  used  too  long  to  be  abolished  at  a  suggestion, 
or  a  hundred  suggestions.  Let  it  then  for  the  present  be  written  between  quotation 
marks  to  denote  its  uncertain  definition  and  a  desire  that  it  shall  pass,  and  with 
the  intention  of  conveying  only  the  idea  of  severe  and  prolonged  departures  from 
mental  health,  and  with  the  acknowledgment  that  the  term  is  irretrievably  vague. 

With  the  acceptance  of  these  ideas  one  need  not  debate  as  to  whether  the  morbid 


ROENTGEN  THERAPY.  99 

mental  phenomena  accompanying  neurasthenia,  alcoholism,  hysteria,  etc.,  consti- 
tute "insanity"  or  not.    The  broader  term  psychosis  will  satisfactorily  cover  all. 

How  shall  "insanity"  be  treated?  It  is  one  group  of  many  observable  phe- 
nomena of  physical  disease,  and  it  is  never  the  sole  expression  of  disease.  Physical 
signs  and  symptoms  always  accompany  it.  To  emphasize  the  great  unity  of  disease 
and  to  rightly  estimate  its  expressions,  patients  who  exhibit  "insanity"  among  their 
symptoms  should,  so  far  as  possible,  be  treated  in  general  hospitals;  and  these 
should  be  properly  equipped  to  handle  them.  Thus  much  of  the  opprobrium  and 
mystery  of  "insanity"  would  be  removed.  Thus  practical  expression  would  be  given 
to  the  view  that  "insanity"  was  only  one — even  though  the  dominant  one — expres- 
sion of  physical  disease,  and  not  a  mystery  or  an  entity,  or  a  possession  apart  from 
other  expressions  of  disease,  as  it  has  been  regarded  for  countless  centuries.  Ob- 
viously only  acute  "insanities"  should  be  so  treated.  Chronic  invalids  of  any  kind 
have  no  place  in  the  general  hospital.  Psycopathic  hospitals  conducted  apart  from 
general  hospitals  cannot  accomplish  the  same  good;  for,  to  the  laity,  they  will 
inevitably  be  known  as  "insane  asylums." 

St.  Francis',  a  general  hospital  of  Pittsburg,  with  its  four  well-equipped  wards 
for  patients  who  exhibit  departures  from  normal  mental  health,  has  for  years  exem- 
plified the  ideas  above  advocated.  I  know  of  no  similar  hospital  in  this  country. 
The  new  city  hospital  of  Nuremberg  has  provided  a  small  number  of  beds  for 
"insane"  patients ;   and  in  a  few  other  general  hospitals  in  Europe  similar  provision 

is  made. 

Theodore  Diller,* 

Pittsburg. 

ROENTGEN  THERAPY:    ITS  SPHERE  OF  APPLICABILITY. 

The  Roentgen  rays  have  demonstrated  a  practical  power  to  alter  cells  of  low 
vitality  and  stimulate  regenerative  changes.  They  have  proved  themselves  capable 
of  effecting  the  cure  of  many  chronic  skin  lesions  in  a  remarkably  short  time,  that 
have  baffled  other  therapeutic  measures.  They  have  shown  an  analgesic  power  in 
severe  neuralgias  and  rheumatisms,  which  in  most  cases  is  combined  with  alterative 
effects  that  result  in  permanent  relief  and  restoration  of  function.  They  have 
demonstrated  an  inhibitory  action  over  the  growth  of  malignant  cells  that  has 
amounted  to  a  cure  in  epitheliomas  and  superficial  growths,  while  for  want  of  time 
to  prove  their  permanency,  the  remarkable  effects  seen  in  graver  lesions  can  be 
termed  as  yet  only  an  inhibitory  action.  In  tubercular  manifestations,  especially  in 
lupus  and  tubercular  adenitis,  they  have  been  found  the  most  effective  therapeutic 
agent  known.  Besides  all  these  effects  they  have  proved  equally  efficient  in  their 
action  upon  non-malignant  growths. 

*  Neurologist  to  the  Allegheny  Genera]  Eospital. 


100  ROENTGEN  THERAPY. 

It  is  because  their  action  is  stimulant  and  alterative  that  they  have  found  so 
wide  a  field  of  application.  Whenever  they  can  be  applied  to  stimulate  altered 
metabolism  or  act  upon  pathologic  cells  of  low  vitality,  they  have  proved  effective 
agents  in  restoring  normal  conditions. 

This  demonstrated  power  to  produce  beneficial  effects,  in  conditions  that  have 
previously  been  hopeless  or  have  become  chronic,  makes  it  essential  that  every 
conscientious  practitioner  should  appreciate  the  conditions  in  which  they  may  be 
relied  upon  to  aid  in  treatment,  either  primarily  or  as  supplementary  to  operation 
or  other  methods  of  treatment. 

For  convenience  the  classes  of  cases  may  be  divided  into  non-malignant  skin 
lesions,  including  tubercular  and  glandular  lesions,  neuralgias,  neurites,  and  rheu- 
matic conditions  and  superficial  and  deep  malignant  growths. 

The  varied  and  apparently  antagonistic  effects  which  can  be  produced  by  the 
proper  dosage  of  this  therapeutic  agent  finds  no  better  illustration  than  in  its 
application  to  hursitis  and  alopecia  areata.  Here  the  alterative  action  as  well  as 
the  stimulative  must  be  taken  into  consideration.  The  highly  specialized  hair 
follicle  can  be  destroyed  without  injury  to  the  surrounding  normal  structures  and 
the  hair  removed,  or  the  dose  can  be  regulated  to  produce  only  a  stimulant  action 
and  thus  restore  the  normal  vitality.  According  to  the  dose  given  the  hair  is 
removed  permanently,  or,  if  the  follicle  is  not  totally  destroyed,  the  hair  can  be  made 
to  grow  again.  The  depilatory  action  of  this  agent  is  very  valuable  in  the  treat- 
ment of  other  dermic  lesions,  as  sycosis  in  which  the  disease  has  invaded  the  hair 
follicles  and  all  hair  must  be  removed  before  a  cure  can  be  effected.  These  lesions 
yield  rapidly  to  treatment,  and  the  cure  can  be  permanent  without  the  total  destruc- 
tion of  the  hair.  This  condition  will  serve  to  illustrate  its  application  to  all  lesions 
where  the  hair  follicles  are  involved. 

Severe  acne,  particularly  the  pustular  type,  is  especially  amenable  to  treatment 
by  this  method.  The  pustules  break  and  heal  with  less  scar  formation  than  after 
curetting,  while  chronic  inveterate  cases  yield  rapidly  to  this  stimulant  and  altera- 
tive. 

The  action  of  Roentgen  rays  upon  skin  lesions  is  apparently  more  thorough 
than  that  of  ointments  and  lotions;  it  seems  to  reach  deeper  and  produce  altera- 
tions and  destructions  of  the  deep-lying  pathologic  tissues.  This  is  illustrated 
forcibly  in  its  action  upon  eczema  and  psoriasis.  In  eczema,  whether  of  the  dry 
or  moist  form,  and  in  cases  of  even  five  and  twelve  years'  standing,  the  treatment 
has  proved  remarkably  efficient.  The  same  is  true  of  psoriasis,  of  which  a  severe 
case  yielded  permanent  results,  though  the  treatment  had  to  be  vigorous  and  extended 
over  a  number  of  months.  In  these  cases  of  local  manifestation  of  what  is  appa- 
rently a  disease  due  to  systemic  causes,  there  can  of  course  be  no  guarantee  against 
the  recurrence  of  the  disease  in  other  portions  of  the  body. 


ROENTGEN  THERAPY.  101 

The  remarkable  absence  of  scar  tissue  in  the  results  following  this  treatment, 
even  where  there  has  been  loss  of  substance,  render  it  particularly  valuable  from 
the  cosmetic  standpoint.  This  effect  in  removing  scar  tissue  is  demonstrated  more 
thoroughly  in  its  effect  upon  keloids  which  yield  readily  to  this  agent. 

In  speaking  of  tubercular  manifestations,  lupus  or  tubercular  ulceration  claims 
attention  because  of  the  great  difficulty  in  producing  a  cure  by  other  known  means, 
and  the  almost  specific  action  which' the  Eoentgen  ray  has  shown.  No  tubercular 
skin  lesion  has  failed  to  react  to  appropriate  dosage  in  my  hands,  and  this  is  true 
of  everyone  who  employs  this  agent  judiciously.  Many  other  tubercular  lesions 
have  shown  a  similar  readiness  to  yield  to  this  therapy.  Tubercular  adenitis  and 
simple  adenitis  of  the  cervical  lymphatics,  even  when  due  to,  and  following,  exan- 
themata, yield  rapidly  to  this  agent,  without  the  necessity  for  fixation  dressings  or 
even  simple  incision  if  they  are  taken  early  before  suppuration  has  ensued.  The 
great  advantages  of  early  treatment  in  these  conditions,  where  such  excellent  results 
can  be  obtained  without  disfiguring  the  patient,  are  very  manifest.  The  treatment 
can  be  undertaken  earlier  and  carried  out  much  more  thoroughly  than  when  fixation 
collars  are  to  be  worn  or  operation  consented  to.  Other  tubercular  lesions  as 
synovitis,  tenosynovitis,  orchitis,  and  arthrites  of  small  joints  have  been  very  bene- 
ficially influenced,  but  the  cures  cannot  be  attributed  wholly  to  this  agent,  for  with 
it,  as  in  all  other  conditions,  the  patient  demands  the  continuous  care  of  the  family 
physician  to  keep  the  physical  condition  and  the  recuperative  power  as  high  as 
possible. 

One  of  the  most  remarkable  effects  which  this  agent  has  produced  is  in  the 
relief  of  pain.  It  was  first  noted  in  cases  of  malignant  disease,  where  its  palliative 
action  was  most  valuable.  The  observation  of  this  action  led  the  author  to  employ 
it  in  a  case  of  acute  neuralgia  following  influenza.  Five  short  treatments  gave  relief 
immediately  and  resulted  in  a  permanent  cure.  Encouraged  by  this  result  it  was 
applied  in  chronic  facial  neuralgia  of  six  months'  duration,  in  a  patient  who  had 
been  the  subject  of  neuralgia  for  twelve  years,  with  relief  and  finally  a  cure  that 
has  lasted  two  years.  It  has  also  relieved  a  case  of  migraine  in  which  frequently 
recurring  attacks  had  persisted  for  twelve  years,  so  that  the  patient  has  not  had 
an  attack  for  fourteen  months. 

A  case  of  severe  tic  douloreux,  in  which  an  acute  attack  had  resisted  the  best 
treatment  for  six  weeks,  was  relieved  almost  immediately  of  pain  and  finally  cured, 
and  has  remained  well  for  the  past,  eight  months.  Where,  however,  a  Imr  neuritis, 
with  spots  of  local  anaesthesia,  has  developed,  nothing  can  be  promised  but  tem- 
porary relief  from  pain,  while  the  chances  of  complete  restoration  and  recovery 
depend  largely  on  the  chronicity  and  severity  of  the  lesion. 

As  might  he  expected  the  pain  of  rheumatism  yields  t<»  the  analgesic  influence 

3 


102  ROENTGEN  THERAPY. 

of  this  agent,  while  the  pathologic  inflammatory  process  is  beneficially  influenced 
in  most  cases  by  its  alterative  action.  The  results  in  chronic  rheumatoid  arthritis 
are  surprising,  but  are  comparable  to  those  it  produces  in  other  chronic  conditions. 
The  results  in  some  cases  of  arthritis  deformans  are  truly  remarkable. 

This  brief  review  of  the  non-malignant  conditions  does  not  include  the  purely 
medicinal  cases  in  which  very  valuable  results  have  been  produced,  as  in  Addison's 
disease,  tubercular  peritonitis,  and  the  various  forms  of  goiter,  as  too  few  cases 
have  been  reported  upon  which  to  base  any  valuable  conclusions. 

In  dealing  with  the  application  of  this  remedy  to  malignant  disease,  other 
factors  than  its  demonstrable  effects  must  be  taken  into  consideration,  because  of 
the  known  tendency  of  malignant  disease  to  recur,  and  the  difficulties  that  lie  in 
the  way  of  establishing  the  permanency  of  a  cure. 

Up  to  the  present  time  we  can  only  say  that  an  inhibitory  action  upon  the 
growth  and  development  of  malignant  disease  has  been  demonstrated,  as  it  is  too 
early  to  prove  that  any  case  has  been  cured.  Under  these  conditions  it  is  absolutely 
essential  to  scientific  judgment  that  in  all  cases,  where  the  patient's  life  would 
otherwise  be  jeopardized,  and  where  operation  is  permissible,  operation  must  pre- 
cede Eoentgen  treatment.  The  patient  must  be  given  all  the  possible  chances  of 
the  best  known  methods.  It  is,  however,  equally  certain  that  the  demonstrated 
power  of  the  Eoentgen  rays  over  the  growth  of  malignant  cells  makes  it  equally 
essential  that  every  patient  be  given  Eoentgen  treatment  as  well,  or  his  chances 
for  recovery  will  be  lessened. 

Superficial  lesions,  such  as  epitheliomas  and  rodent  ulcers,  that  do  not  neces- 
sarily threaten  the  life  of  the  patient  can  be  treated  with  advantage  primarily  by 
Ihe  Eoentgen  method,  because  they  can  be  effectively  destroyed,  and  with  a  resulting 
scar  that  is  not  appreciable  or  disfiguring.  Scirrhus  of  the  breast  is  a  condition 
in  which  surgical  teaching,  the  result  of  pathologic  findings,  seems  to  contraindicate 
operative  intervention.     This  condition  yields  rapidly  to  Eoentgen  treatment. 

The  rapid  recurrences  which  generally  follow  operations  upon  sarcomata  and 
their  distribution  into  regions  remote  from  the  original  lesion  are  facts  which, 
combined  with  the  efficiency  noted  in  the  Eoentgen  treatment,  especially  where 
there  has  been  no  operative  interference,  would  seem  to  indicate  a  tentative  course 
of  Eoentgen  treatment  in  these  cases,  to  be  followed  by  operation  if  acute  conditions 
demand  it. 

The  only  other  exception  to  early  radical  surgical  removal  of  the  malignant 
disease  is  in  recurrences  or  massive  growths  that  arise  too  late  for  any  treatment. 
Here  the  removal  of  the  larger  masses  facilitates  the  effective  Eoentgen  treatment, 
and  renders,  even  in  hopeless  cases,  its  palliative  action  of  the  greatest  benefit. 

The  demonstrated  effective  inhibitory  and  destructive  influence  of  this  agent 


TREATMENT  OF  LARYNGEAL  TUBERCULOSIS.  103 

over  malignant  disease  makes  it  essential  as  a  supplement  to  every  operation  for  the 
radical  relief  from  malignant  disease.  It  then  can  attack  any  remaining  foci  of 
malignant  disease  that  have  escaped  the  operator,  while  they  are  devitalized  as  the 
result  of  the  operative  trauma  and  before  they  have  had  time  to  engraft  themselves 
upon  the  tissue  of  the  patient.  While  the  mortality  of  malignant  disease  remains 
so  high  after  operation,  it  is  essential  that  every  means  at  command  be  employed 
in  combating  it.  An  agent  which  has  demonstrated  such  power  over  malignant 
cellular  activity  cannot  be  neglected  without  seriously  impairing  the  patient's 
chances.  The  post-operative  treatment  in  no  way  interferes  with  the  patient's 
recovery;  in  fact,  hastens  it.  Treatment  can  be  given  effectively  through  the  dress- 
ings, and  if  no  irritating  antiseptic  has  been  employed  it  facilitates  and  hastens  the 
healing.  As  a  palliative  in  hopelessly  inoperable  cases  there  is  nothing  which  is 
more  efficient  than  the  Roentgen  rays  in  relieving  the  patient's  suffering  and  ren- 
dering life  tolerable;  while  many  remarkable  cases  have  demonstrated  that  it  is 
impossible  to  say  how  much  such  treatment  may  lengthen  life. 

It  must  be  clearly  understood  that  these  results  are  attainable,  even  in  super- 
ficial benign  lesions,  only  when  the  proper  dose  is  given  in  proper  time,  quality 
and  quantity  to  effect  a  lesion  to  which  its  quality  is  particularly  adapted.  Quinine 
might  as  well  be  given  to  cure  syphilis,  or  mercury  to  cure  malaria,  as  to  use  the 
wrong  quality  of  Roentgen  discharge  in  treating  any  lesion.  The  quality  and 
quantity  can  only  be  produced  with  the  development  of  special  technique,  and  the 
acquirement  of  clinical  experience,  in  adapting  them  to  the  lesion  in  hand. 

This  agent  is,  like  all  others,  incapable  of  producing  results  unless  properly 
employed,  and  efficiency  is  due  as  much  to  the  way  in  which  it  is  employed  as  to 
the  agent. 

Charles  Lester  Leonard,* 

Philadelphia. 

[Note  by  the  Associate  Editor. — It  is  idle  to  expect  legitimate  results  with  this  highly 
complex  and  as  yet  seemingly  mysterious  agent,  unless  carefully  administered  by  an  expert,  fully 
equipped  in  medicine,  pathology,  physics,  and  the  special  technique  of  the  rays.  No  blame  can  be 
fairly  placed  for  negative  or  calamitous  findings  upon  the  Roentgen  rays  when  applied  by  other 
than  a  master.  The  practice  cannot  be  too  strongly  condemned  of  delegating  its  employment  to 
electricians,  nurses,  orderlies,  or  resident  physicians,  or  any  one  without  adequate  experience. — 
J.  M.  T.] 

ELEMENTS  OF  SUCCESS  IN"  THE  TREATMENT  OF 
LARYNGEAL  TUBERCULOSIS. 

Years  of  daily  work  with  the  laryngeal  type  of  tuberculosis  has  impressed 
upon  me  the  importance  of  several  facts  which  seem  clear  enough  and  suffi- 
ciently well  substantiated  to  permit  of  their  enunciation  as  general  principles  in 


President  of  the  Roentgen  Ray  Society. 


104  TREATMENT  OF  LARYNGEAL  TUBERCULOSIS. 

the  treatment  of  this  serious  and  distressing  complication  of  pulmonary  tubercu- 
losis, for  as  such  it  is  usually  presented  to  the  practitioner  and  specialist.  In  the 
beginning  I  approached  its  treatment  with  the  customary  scepticism  as  to  results, 
and  it  required  a  number  of  successes  to  disabuse  my  mind  of  faithlessness  and 
convince  me  that  there  is  hope  for  at  least  a  fair  proportion  of  these  sadly  afflicted 
persons.  It  is  only  proper  to  say,  however,  that  in  my  work  I  have  always  had 
the  assistance  of  excellent  climatic  conditions,  a  factor,  the  relative  importance  of 
which  is  difficult  of  correct  estimation,  though  I  am  personally  inclined  to  give  it 
rather  a  high  place.  At  the  outset  it  must  be  remembered  that  in  a  failing  patient 
nothing  but  more  or  less  complete  relief  of  symptoms  can  be  expected  from  laryn- 
geal treatment.  I  have  yet  to  see  a  progressive  pulmonary  and  genera]  failure 
accompanied  by  improvement  in  the  local  lesion,  though  it  is  quite  possible  to  hold 
the  disease  in  check  by  means  of  careful  and  persistent  treatment,  a  course  that  is 
always  justifiable  on  account  of  the  suffering  which  attends  laryngeal  tuberculosis, 
especially  in  advanced  stages,  and  the  relief  which  follows  tborough  cleansing  of 
the  diseased  areas. 

The  factors,  the  careful  utilization  of  which  will,  in  my  opinion,  give  the 
highest  success,  are  five  in  number,  viz. :  avoidance  of  continued  irritation,  avoid- 
ance of  operative  procedures,  constancy  in  treatment,  employment  of  a  highly  dif- 
fusible, penetrating,  bactericidal  agent,  and  the  use  of  mopping  instead  of  spraying. 

The  continued  use  of  any  agent  sufficiently  irritative  to  cause  distress,  cough- 
ing, or  local  reaction,  which  is  more  than  transitory  will  be  productive  of  more 
harm  than  good  in  the  long  run.  Nature's  efforts  to  limit  the  spread  of  a  tuber- 
culous lesion  should  not  be  interfered  with  or  destroyed  by  operative  procedures 
which  at  best  cannot  certainly  remove  all  of  the  infectious  material  or  diseased 
area.  The  only  permissible  exception  to  this  rule  is  when  fungous  or  papillomatous 
overgrowths  prevent  free  breathing,  and  when  the  growth  is  of  itself  productive 
of  sufficient  irritation  to  cause  excessive  coughing,  with  consequent  loss  of  rest  and 
sleep.  Under  such  conditions  the  thorough  use  of  the  electro-cauter3r,  or  preferably, 
the  curette,  is,  of  course,  the  choice  of  the  least  of  evils. 

As  for  every  day  treatment  nothing  is  to  be  gained  by  making  a  distinction 
between  ulcerative  and  infiltration  cases.  The  same  general  principles  apply  equally 
to  both,  and  in  both  thorough  cleanliness  is  the  way  that  leads  to  success.  Infiltra- 
tion of  the  larynx  corresponds  to  incipiency  in  pulmonary  tuberculsois,  and  is 
curable  in  about  the  same  proportion  of  cases.  Ulceration  usually  occurs  in  the 
advanced  pulmonary  types,  and  is  also  curable  in  corresponding  proportion.  Under 
correct  treatment  I  am  not  able  to  see  that  a  laryngeal  lesion  alters  materially  the 
general  curability  of  the  type  in  which  it  occurs. 

Constancy  and  perseverance  are  much  neglected  factors  in  treatment  as  com- 


TREATMENT  OF  LARYNGEAL  TUBERCULOSIS.  105 

monly  practiced,  and  yet,  are  absolutely  essential  to  success.  Tuberculosis  of  the 
larynx  is  a  disease  which  is  always  working  overtime,  and  to  defeat  it  the  physician 
must  work  overtime  as  well.  It  was  formerly  my  custom  to  treat  these  cases  once 
daily,  but  improvement  in  results  at  once  followed  the  practice  of  twice  daily  treat- 
ment, and  if  it  were  only  practicable,  I  am  not  sure  I  would  not  treat  them  four 
times  daily.  The  difficulty  of  accomplishing  this  is  practically  insuperable  out- 
side of  institutions  where  a  physician  is  always  at  hand,  and  yet  in  no 
other  way  can  the  highest  success  be  attained.  Further,  by  having  a  patient 
who  is  attempting  to  take  the  "rest  cure"  make  daily  or  twice  daily  visits  to  a 
physician's  office,  which  will  usually  be  some  distance  away,  would  probably  defeat 
the  essentials  of  general  treatment.  But,  however,  I  am  very  sure  that  the  usual 
custom  of  treating  such  cases  twice  or  thrice  weekly  is  almost  worse  than  useless. 
As  for  self-administered  laryngeal  treatment,  there  is  not  one  patient  in  fifty  who 
may  be  taught  to  spray  the  larynx  efficiently,  and  at  best  the  spray  is  a  "weak 
sister"  in  treatment. 

The  use  of  a  proper  agent,  following  mechanical  cleansing  with  simple  alkaline 
solutions,  is,  of  course,  a  matter  of  prime  importance.  The  ideal  agent  for  this 
purpose  must  be  actively  bactericidal  and  non-irritating  in  efficient  concentration. 
It  must  be  very  penetrating,  and  for  this  purpose  we  have  two  substances  which  in 
character  approach  the  ideal,  namely :  formaldehyde  and  trichloride  of  iodine.  For 
routine  work  the  first  is  desirable,  for  in  proper  strength  solutions  it  may  be  used 
almost  indefinitely  without  injury  to  delicate  structures.  Begin  with  two  drops 
of  a  forty  volume  solution  to  one  ounce  of  water,  and  be  guided  in  increasing  its 
strength  by  the  burning  sensation  caused  upon  its  application.  This  should  not  be 
more  than  a  distinctly  warm  feeling  which  is  momentary  in  duration.  It  is  rarely 
practicable  or  desirable  to  exceed  ten  drops  to  the  ounce.  Formaldehyde  used  in 
this  manner  will  not  cause  coughing  or  irritation.  As  an  alternate  the  trichloride 
of  iodine  is  second  only  to  formaldehyde  in  value,  the  proper  strength  being  from 
one-half  to  two  grains  to  the  ounce  of  distilled  water. 

The  only  efficient  method  of  making  applications  to  the  larynx,  and  \n;v  easy 
and  simple  moreover,  is  by  means  of  cotton  and  a  laryngeal  applicator.  The  instru- 
ment should  be  armed  with  teeth  which  will  firmly  grip  the  cotton  and  prevent 
its  becoming  detached  in  the  larynx.  Even  after  protracted  training  of  the  patient 
in  the  use  of  the  long  tipped  laryngeal  atomizer,  spraying  is  an  inefficient  method 
of  applying  medicinal  agents  to  the  larynx,  and  further,  a  forcible  spray,  such  as 
is  required  to  penetrate  the  parts,  may  do  a  vast  deal  of  harm  to  the  mucous  mem- 
brane, causing  abrasions  which  form  "locus  minoris  resistentice"  for  further  infec- 
tion.  Any  physician  can  make  etlicient  applications  to  the  larynx  if  he  only  thinks 
he  can.    The  services  of  a  specialist  or  of  a  highly  developed  technique  are  unneces- 


1()6  NEURASTHENIA  PLUS  CHRONIC  INTOXICATIONS. 

pary,  though,  of  course,  desirable.  The  lesion  should  be  thoroughly  mopped  from 
two  to  five  times  at  a  sitting,  according  to  the  condition  of  the  patient.  The  laryn- 
geal mirror  must,  of  course,  be  employed  during  the  introduction  of  the  cotton- 
armed  applicator.  With  patience  and  admonitions  to  breathe  naturally  the  sub- 
ject may  be  trained  in  a  week  or  so  to  tolerate  the  presence  of  the  applicator  in  the 
larynx,  without  coughing,  breathing  naturally  all  the  time,  sometimes  for  an  entire 
minute.  A  good  contraction  of  the  larynx  upon  the  cotton  is,  however,  not  desir- 
able, as  it  thoroughly  squeezes  the  agent  out  of  the  cotton  and  over  the  lesion,  and 
may  be  induced  by  a  sudden  movement  of  the  applicator.  Some  patients  learn  by 
long  practice  to  use  the  laryngeal  hand  atomizer  sufficiently  well  to  afford  relief 
of  the  annoying  dryness  which  often  accompanies  tuberculosis  in  this  region,  and 
nothing  can  be  lost  by  providing  patients  with  a  hand  atomizer  charged  with  for- 
malin solution.    The  possible  pressure  is  never  sufficient  to  cause  injury. 

By  careful  attention  to  the  principles  laid  down  thus  briefly,  I  feel  sure  that 
a  goodly  proportion  of  these  cases  may  be  cured,  and  others  more  seriously  effected 
efficiently  relieved,  and  in  many  instances  life  indefinitely  prolonged. 

E.  S.  Bullock,* 

St.  Joseph  Sanatorium,  Silver  City,  N.  M. 


NEURASTHENIA  PLUS  CHRONIC  INTOXICATIONS. 

Pew  or  no  problems  confront  the  physician  comparable  in  complexity  to 
instances  of  neurasthenia,  to  which  are  superadded  the  effects  of  pronounced  chronic 
intoxications.  These  occur  more  commonly  among  men  for  obvious  reasons.  Neu- 
rasthenia must  be  regarded  as  a  clinical  entity,  although  our  knowledge  of  the 
precise  underlying  conditions  leaves  much  in  obscurity.  We  recognize  two  palpable 
varieties,  by  no  means  distinctly  separable,  (1)  the  so-called  inherited  form,  depend- 
ing upon  developmental  defects  chiefly  in  the  nervous  system  or  ductless  glands, 
and  (2)  the  acquired  forms,  the  product  of  perversions  of  function  due  to  over- 
strain, hypertensions,  worries,  and  the  like.  The  differentiation  between  these  is 
not  always  possible,  but  usually  to  be  achieved  by  the  man  of -educated  instinct. 
Treatment,  to  be  successful,  should  then  differ  somewhat  widely.  Prognosis  is  even 
more  difficult,  but  is  vitally  important. 

Where  the  fundamental  fault  is  wholly,  or  mainly,  due  to  deviations  in  original 
functional  competence,  the  problem  is  to  measure  possible  progress  by  the  standard 
of  the  weakest  organ ;  to  conserve  the  action  of  this  one  and  supplement  it  by  bring- 
ing the  others  in  line,  and  maintaining  an  even  plane  of  advance  toward  the  normal 
for  that  individual.     When  the  basis  of  disability  is  exhaustion  in  the  central 

*  Late  Pathologist  U.  S.  General  Hospital  for  Tuberculosis,  Fort  Bayard,  N.  M. 


NEURASTHENIA  PLUS  CHRONIC  INTOXICATIONS.  107 

nervous  system,  and  where  this  has  progressed  to  a  point  demanding  rest,  then  this 
rest  must  be  absolute  of  mind  and  body  for  a  time,  otherwise  the  nutritive  forces 
cannot  be  rehabilitated.  The  most  significant  data  in  the  differentiation  are  psy- 
chical. Experience,  a  wide  familiarity  with  analogous  states,  can  alone  fit  one  to 
correctly  estimate  and  control  the  derangements. 

The  subject  under  consideration  is  the  complex  syndrome  presented  by  chronic 
intoxication  superadded  to  the  phenomena  of  exhaustion. 

Modern  competitions  in  industrial  problems  have  produced  an  increasing  group 
of  persons,  chiefly  men,  who,  after  intense  application  to  business,  meet  with  more 
or  less  success.  This  success  provides  them  with  means  for  gratifying  tastes,  per- 
haps over-liberally,  which  too  often  tend  more  toward  food  and  drink  and  late 
hours  and  the  mysteries  of  darkness  rather  than  for  wholesome  outings  and  rational 
sports.  The  man  usually  claims  that  he  has  little  or  no  time  for  outdoor  sports  or 
for  daylight  leisure,  but  admits  that  relaxation  is  essential  for  rest  and  repair; 
hence  he  chooses  to  adopt  for  himself  the  exhilaration  of  stimulating  dishes  and 
drinks,  garish  amusements,  etc.,  trusting  his  originally  vigorous  powers  of  recupera- 
tion to  place  him  where  he  wishes  to  be  by  the  morning  business  hours.  The  exi- 
gencies of  business  to-day  may  be  similar  to  those  of  yesterday,  seldom  less  engross- 
ing; but  often  suddenly  a  crisis  confronts  a  jaded  organism,  of  which  there  is  then 
demanded  the  largest  concentration  of  vital  forces.  No  wonder  catastrophies  are 
frequent,  partly  physical,  partly  mental,  and  often  financial.  The  same  man  would 
scorn  the  athlete  who,  approaching  the  crucial  contest,  would  fail  to  pay  some, 
indeed  much,  deference  to  the  conservation  of  forces  imperatively  needed  in  the 
accomplishment  of  desirable  results.  Yet  he  will  thus  jeopardize  not  only  fortune, 
fame,  health,  character,  but  life,  day  after  day.  Others  do  so,  he  tells  himself; 
some  survive;  hence  this  creature,  claiming  to  be  of  a  high  intelligence,  will  act 
like  a  madman  or  fool  for  so  long  as  his  fund  of  vitality  lasts.  This  picture  is  only 
too  common.    Let  us  enumerate  the  features  in  the  inevitable  breakdown. 

To  the  factors  of  nerve  exhaustion,  including  the  whole  train  of  contributory 
phenomena,  nutritive,  circulatory,  eliminative,  etc.,  the  logical  sequences  of  pro- 
longed hypertension,  loss  of  sleep,  omission  of  economic  relaxation,  enforced  per- 
versions of  function,  muscular,  pulmonary,  etc.,  arc  added  a  series  of  definite 
intoxications. 

Tt  is  an  axiom  that  a  well-balanced  organism  can  endure  much  insult  from 
malhygiene,  poisons  of  various  sorts  and  degrees,  provided  there  shall  be  given 
opportunities  for  repair;  remissions  in  morbid  activities  and  strained  attention, 
wherein  the  vital  forces  may  regain  balance. 

It  is  also  admitted  that  a  healthy  organism  can  become  gradually  inured  to 
increasing  amounts  of  irritant  poisons  with  apparently  small  harm.     It  is  essen- 


108  NEURASTHENIA  PLUS  CHRONIC  INTOXICATIONS. 

tial,  however,  to  the  success  of  this  acquired  immunity  to  assume  an  original  and 
well-sustained  vigor  of  central  nervous  forces  and  also  organic  integrity.  If,  how- 
ever, a  man  of,  it  may  be,  exceptional  inherent  powers  shall  place  himself  for  an 
indefinite  period,  more  or  less  constantly,  under  not  only  (first)  the  strains  of  com- 
petitive work,  and  (second)  irrational  forms  of  so-called  relaxation,  the  concomitant 
of  late  hours,  etc.,  he  must  expect  to  suffer,  and  that  seriously,  ere  long.  But  if 
also  he  adds  to  these  the  destructive  effects  of  (third)  the  overstimulation  of  rich 
tempting  foods,  and  (fourth)  strong  wines,  if  even  only  at  dinner,  as  well  as  pos- 
sible cocktails,  highballs,  "hracers,"  at  odd  times,  and  (fifth)  tobacco  often  in  far 
greater  excess  than  he  realizes,  he  is  carrying  a  heavy  and  dangerous  burden. 

If  also  there  be  (sixth)  a  heritage  of  gout,  which  is  thus  encouraged,  and  is 
often  insidious,  it  may  become  sudden  or  explosive,  menacing  not  only  by  pains, 
but  striking  at  organic  integrity;  also  (seventh)  possibly  a  latent  tuberculosis,  or 
(eighth)  syphilis,  no  matter  how  thoroughly  treated  and  supposedly  cured,  there  is  a 
status  quo  at  which  a  prudent  man  may  well  stand  aghast.  Yet  it  is  by  no  means  rare 
to  have  this  problem  suddenly  offered  us,  either  in  the  incipient  stages  of  some  of 
its  phenomena,  or  late,  after  various  kinds  of  makeshift  solutions  have  been  fruit- 
lessly attempted.  The  purpose  of  this  article  is  merely  suggestive;  to  outline  the 
picture,  not  to  discuss  it  further  than  to  offer  a  few  hints  as  to  its  solution. 

Clearly  the  condition  presented  is  one  of  vital  bankruptcy,  and  must  be  met 
with  the  same  preparedness,  intelligent  candor,  a  willingness  to  adopt  radical  re- 
vision of  methods,  which  this  same  man  would  accept  if  it  were  a  business  propo- 
sition. 

It  is  true  that  often  one  so  circumstanced  may  not  suffer  markedly  from  pain, 
discomforts,  obvious  organic  damage,  or  any  other  obtrusive  subjective  evidences  of 
health  destruction. 

These  masterful,  successful  men  are  usually  well  endowed  with  self-satisfaction 
and  large  confidence  in  their  own  wisdom.  They  usually  relate  unsatisfactory  ex- 
periences with  physicians  who  were  often  far  from  blameless,  and  these  counsellors 
they  over-liberally  denounce.  They  pride  themselves  on  having  become  medical 
nihilists,  stating  emphatically  that  the  profession  has  forfeited  their  confidence,  and 
cite  pretty  cogent  reasons  for  the  negative  belief  that  is  within  them.  In  short, 
not  only  are  they  physical  invalids,  they  are  mentally  in  gravest  peril.  The  worst 
danger  is  from  vitiated  psychic  attitudes,  which  leads  them  to  vent  childish  denun- 
ciation on  all  constituted  or  family  or  medical  authority.'  The  only  ultimate  salva- 
tion is  for  such  men  to  seek  humbly  for,  and  be  guided  by,  consistent  salutary 
advice,  one  item  of  which  is  capable  of  being  fitted  into  and  supplementing  the 
other. 

The  complex  problems  entering  into  chronic  gouty  states  alone  (varying  as  they 


NEURASTHENIA  PLUS  CHRONIC  INTOXICATIONS.  109 

do  with  temperamental  peculiarities),  are  enough  to  puzzle  even  those  who  make 
this  disorder  a  special  study.  The  aggravations  caused  by  the  common  poisons,  also 
frequently  encountered,  of  errors  in  diet,  in  the  use  of  alcohol  and  tobacco,  give 
cause  enough  for  anxiety.  These  sketched  upon  a  background  of  insufficient  sleep 
and  rest  of  mind  and  body,  especially  when  business  responsibilities  cannot  be  im- 
mediately or  completely  omitted,  make  repair  measures  difficult.  When,  as  some- 
times happens,  there  is  a  history  of  lues,  the  foundations  of  health  are  thus  doubly 
imperiled. 

It  has  often  transpired  in  my  experience  to  meet  the  last  combination  and  to 
find  that  then  antiluetic  remedies  cannot  be  borne;  iodides  and  mercurials  irritate 
violently. 

The  fundamental  factor  in  the  whole  process,  however,  is  plainly  inhibition 
of  the  vital  process  in  the  great  elaborating  glands,  the  liver,  the  pancreas,  etc., 
through  debility  of  the  adrenal  system,  which,  as  unquestionably  demonstrated 
by  Sajous  ("unquestionably"  for  those  who  have  conscientiously  studied  his  works), 
governs  all  oxidation  processes,  i.e.,  general  nutrition. 

The  complexity  of  the  pathologic  problem  is  here  a  matter  of  common  reproach 
from  patient  to  physician,  and  on  the  part  of  the  profession  with  equal  candor  among 
themselves. 

The  essential  pathogeny  of  gout  is  still  a  matter  in  much  dispute,  though  re- 
search on  the  subject  is  monumental.  Our  most  practical  knowledge  is  gained  from 
empirical  findings.  The  chronic  forms  have  certain  points  in  common  with  the 
phenomenon  of  other  destructive  processes,  in  defective  oxygen  distribution  and 
especially   impairment   of   digestive   elaboration. 

The  characteristic  changes  in  syphilis  are  chiefly  displayed  in  the  blood  vessels. 
In  both  there  is  marked  impairment  of  the  central  control  mechanism,  especially  in 
nutrition  of  the  vasomotor  centers  and  peripheral  vessels.  The  liver,  the  largest 
poison  filter,  grows  habitually  inefficient.  The  blood  vessels  of  this  organ  become 
chronically  dilated.  Where  alcohol  has  been  used  to  excess,  paralytic  vasodilation 
in  this  territory  has  been  induced  along  with  connective  tissue  hyperplasia;  in 
short,  although  there  may  be  fair  motor  capabilities,  it  is  plainly  important  to 
conserve  all  the  forces  for  a  time  with  the  same  insistency  required  in  a  febrile 
process,  like  typhoid  fever.  Best  results  follow  absolute  rest  in  bed  with  the  sim- 
plest feeding,  attention  to  the  vasomotor  tone,  and  adrenal  efficiency  until  enough 
force  is  husbanded  to  follow  specific  indications. 

It  has  been  my  experience  to  find  many  sufferers  from  this  combination  who 
have  spent  months,  even  years,  undergoing  spa  treatment  or  various  forms  of  partial 
rest  along  with  rational  measures,  who  yet  continued  to  lose  strength  steadily.  After 
a  period  of  some  weeks  or  months  of  absolute  rest  in  bed,  with  the  full  rest  measures 


HO  NEURASTHENIA  PLUS  CHRONIC  INTOXICATIONS. 

enjoined  by  Weir  Mitchell,  finally  it  becomes  possible  to  specialize  further  treat- 
ment according  to  constitutional  or  specific  indications. 

It  is  no  small  thing  to  interpret  our  duty  when  a  man  compassed  by  these 
perils  appeals  to  us  to  put  him  in  condition  to  do  his  uttermost  in  the  next  two  or 
three  months,  wherein  he  must  fight  a  great  fight  involving  large  moneys,  or  reputa- 
tion, or  maybe  character.  If  we  push  his  hard-beset  machinery  by  tonics  and  forc- 
ing measures,  howsoever  wisely,  and  the  little  rift  in  the  lute  suddenly  widens  and 
gives  way,  we  become,  without  a  doubt,  particeps  criminis.  If  we  decline  to  thus 
aid  and  abet  a  possible  felony,  our  client  will  naturally  rate  us  as  unreliable,  from 
his  point  of  view.  If  we  reason  with  him,  his  mental  vision  is  so  obscured  by  the 
obsession  of  greed,  aggravated  by  toxasmias,  impaired  cerebral  circulation  and  nutri- 
tion, that  he  cannot,  or  will  not,  appreciate  our  ethical  position — our  disinterested 
conservatism. 

Though  it  is  plain  that  mental  alienation  of  this  sort  is  ethically  just  as  much 
subject  to  the  jurisdiction  of  the  law,  nevertheless  statutory  law  does  not  give  us 
control  of  the  individual  till  he  has  committed  some  overt  act. 

The  temptation  is  "to  do  the  best  we  can,"  but  the  best  for  keeping  the  peace 
and  parallelizing  the  lines  of  least  resistance,  is  not  the  best  for  the  erring  patient. 
All  we  can  do  is  to  acquit  ourselves  honestly  within  our  sphere  of  permitted  action, 
and  to  hope  the  law  will  grant  us  larger  powers  to  control  sick  minds,  as  lawmakers 
grow  in  wisdom  and  statutes  enlarge. 

In  the  treatment  for  these  cases  certain  principles  obtain  in  all.  The  man's 
affairs  must  be  set  in  order  as  swiftly  as  possible,  taking  from  him  the  burden  of 
responsibility  with  all  reasonable  despatch.  The  killing  factor  is  continuance  of 
fixed  attention,  of  latent  stimulation.  Simplicity  of  living  is  imperative.  After 
a  period  of  absolute  rest  of  mind  and  body  (and  isolation  is  essential,  entire  or  in 
part),  a  return  to  the  primitive  forms  of  living  must  be  enforced.  When  organic 
activities  are  fairly  restored,  the  ideal  life  is  in  the  deep  woods ;  struggles  with  the 
forces  of  primeval  nature  in  securing  and  maintaining  the  elemental  needs  of  food, 
bed,  shelter,  and  sane  and  simple  amusements.  This  can  best  be  secured  in  a  remote 
camp,  tenting  rather  than  under  roof.  Later,  most  satisfactory  results  come  from 
"the  long  trail"  afoot,  in  canoe  or  pony  back,  and  continued  for  weeks  or  months. 
Thus  in  perfection  is  to  be  had  the  training  whereby  manliness,  self-restraint, 
sobriety,  and  wisdom  grow  insensibly.  Instinctive  powers,  long  dormant,  slowly  but 
steadily  come  to  full  fruition  by  deliberate  reflection  when  alone.  Thus  character, 
mental  clarity,  moral  wholesomeness,  and  physical" efficiency  are  again  achieved;  or 
if  never  fully  learned  or  earned,  through  the  exercise  of  self-obligation  from  neces- 
sity, if  not  from  choice,  they  will  as  surely  grow  as  there  are  seeds  in  the  organism. 
If  no  seeds  are  there,  then  no  crops;  given  seeds  of  character,  of  strength,  the  soil 


ACID  INTOXICATION. 


ADRENALIN,  ACTION  OF. 


Ill 


needs  careful  tending,  adequate  time,  suitable  pruning,  and  a  citizen  can  then  be 
new  made  or  constructed  ab  initio  in  proportion  to  the  inherent  possibilities.  Of 
course,  we  may  be  forced  to  use  substitutes,  by  adopting  a  second,  third,  or  tenth 
choice.  Other  plans  of  isolation  and  primitive  activities  may  suffice.  We  usually 
are  hampered  by  this  necessity,  but  if  unsuccesful  the  fault  is  then  not  ours;  the 
defeat  comes  from  enemies  within  the  walls. 

J.  Madison  Taylor, 

Philadelphia. 

Cyclopaedia  of  Current  literature. 


ACID   INTOXICATION. 

At  present  the  knowledge  of  the  con- 
ditions accountable  for  the  symptoms 
present,  and  for  the  occurrence  of  ace- 
tone and  diacetic  in  the  urine,  is  yet  in 
its  infancy.  It  has  been  proved  experi- 
mentally that  it  is  not  due  to  acetone 
circulating  in  the  blood,  as  the  same 
condition  has  been  produced  experi- 
mentally by  other  substances.  The 
amount  of  acetone  found  in  the  urine  is 
no  index  as  to  the  severity  of  the  affec- 
tion. Whether  the  occurrence  of  the 
symptoms  is  due  to  a  toxic  substance 
acting  on  psychomotor  centers,  or  due 
to  pressure  on  these  centers,  has  not 
been  proven.  This  is  only  offered  as  a 
suggestion  as  to  the  causation.  That 
there  is  some  toxaemia  occurring  is  doubt- 
less true;  whether  it  is  due  to  the  pres- 
ence of  volatile  fatty  acids,  to  the  rapid 
destruction  of  proteid  matter,  or  to  the 
rapid  elimination  of  the  alkalies,  is  im- 
possible to  say  at  the  present  time. 
James  A.  Kelly  (Annals  of  Surgery, 
February,  1905). 

ADRENALIN,   ACTION  OF. 

The  writer,  working  in  the  Therapeu- 
tic Institute  of  the  University  of  Liege, 
has    made    an    elaborate    experimental 


study  of  the  action  of  adrenalin,  of 
which  the  following  are  the  conclusions : 
The  acceleration  of  the  pulse  which  suc- 
ceeds the  initial  retardation  after  injec- 
tion of  adrenalin  in  an  animal  is  due  to 
excitation  of  all  the  accelerator  apparatus 
of  the  heart,  as  much  central  as  periph- 
eral. The  participation  of  the  central 
apparatus  is  not  indispensable  for  this 
acceleration.  The  cerebral  vessels,  like 
all  other  vessels  of  the  body,  contract 
under  the  influence  of  adrenalin,  and  this 
lasts  as  long  as  the  adrenalin  is  in  action. 
The  increase  in  the  volume  of  the  brain 
following  an  injection  of  adrenalin  is 
probably  due  to  a  venous  stasis  depend- 
ing on  slowing  of  the  pulse  and  a  mo- 
mentary arrest  of  respiration.  The  vaso- 
motor center  takes  part  in  the  produc- 
tion of  high  blood  pressure  by  adrenalin 
only  secondarily,  and  this  from  the  cere- 
bral anosmia  provoked  by  the  constriction 
of  the  cerebral  vessels.  The  slowing  of 
the  pulse  observed  to  follow  the  injection 
of  adrenalin  in  an  animal  whose  vagi  arc 
intact  appears  to  be  due  to  two  factors — 
a  direct  action  of  the  cardio-inhibitory 
center,  and  a  secondary  action  produced 
by  the  irritation  of  this  center  by  the 
cerebral  anaemia  set  up  by  the  constric- 
tion of  the  cerebral  vessels.     Adrenalin, 


112 


ADRENALIN  IN  SURGERY. 


without  doubt,  acts  on  the  intracardiac 
terminations  of  the  vagus,  producing 
their  excitation,  which  is  demonstrated 
by  the  slowing  of  the  heart  which  follows 
its  injection  into  an  animal  whose  vagi 
are  divided.  Adrenalin  acts  directly  on 
the  respiratory  center,  producing  its  in- 
hibition. The  dyspnoea  which  follows 
the  apncea  produced  by  the  injection  of 
large  doses  appears  to  be  rather  due  to 
the  secondary  excitation  of  the  respira- 
tory center  by  the  cerebral  anaemia.  The 
fact  that  adrenalin  may  be  destroyed  in 
the  organism  by  oxidation  is  far  from 
being  demonstrated.  Neujean  (Arch. 
Internat.  de  Pharmacodynamic  et  do 
Therapie,  vol.  xiii,  fascic.  1  and  2,  p. 
45,  1904;  from  British  Medical  Jour- 
nal, January  28,  1905). 

ADRENALIN  IN   SURGERY. 

The  author  reviews  the  history  of  ad- 
renalin and  extols  its  advantages  for  the 
surgeon.  Combined  with  cocaine  it  in- 
sures anaesthesia  with  very  much  smaller 
doses,  while  it  prolongs  the  action  of 
the  anaesthetic  and  reduces  its  toxicity. 
Subdural  injection  of  cocaine  is  fatal  for 
the  rat  in  a  dose  of  .018  gram,  while 
addition  of  adrenalin  raises  the  lethal 
limit  to  .11  gram.  Bier  has  announced 
that  the  addition  of  adrenalin  robs  spinal 
cocainization  of  all  danger,  but  some 
fatalities  have  been  reported  from  this 
technique.  In  one  obstetric  case  Bier's 
directions  were  closely  followed,  but  the 
patient  succumbed.  Konig  has  fre- 
quently found  adrenalin  a  great  help  in 
plastic  operations  on  the  urethra,  to  pre- 
vent the  annoying  bleeding  from  the 
l)ii lb.  Analgesia  of  the  mucous  mem- 
branes is  readily  attained  in  five  minutes 
by  dabbing  the  part  with  a  5  per  cent, 
solution  of  cocaine  or,  better,  eucaine, 
to  which  a  few  drops  of  a  1  to  1000 
adrenalin  have  been  added.    To  anaesthe- 


tize the  bladder  1  cubic  centimeter  of 
suprarenin  is  added  to  a  1  or  2  per  cent, 
solution  of  cocaine,  analgesia  being  com- 
plete in  about  fifteen  minutes.  The  fluid 
must  be  withdrawn  afterward.  In  oper- 
ating on  the  skin  or  subjacent  tissue, 
Schleich's  infiltration  method  can  be 
used,  adding  10  drops  of  adrenalin  to 
50  cubic  centimeters  of  the  fluid.  A  still 
better  technique  is  to  make  a  circle  of 
injections  of  the  fluid  around  the  field 
of  operation.  This  requires  a  little 
stronger  concentration,  about  .05  to  .1 
per  cent,  solution  of  cocaine  or  eucaine, 
with  from  5  to  10  drops  of  adrenalin  to 
the  50  cubic  centimeters.  A  circle  of 
blisters  is  made  around  the  field,  at  some 
little  distance  from  it,  and  the  canula  is 
then  inserted  in  the  subcutis  and  the 
surrounding  tissue  infiltrated,  thus  en- 
closing the  field  in  a  complete  ring.  By 
this  technique  it  is  possible  to  resect  the 
ribs  without  pain,  infiltrating  the  sub- 
cutaneous cellular  tissue  and  the  mus- 
culature down  to  the  pleura,  in  the  inter- 
space just  above  and  below.  A  longer 
interval  is  required,  however,  when  such 
extensive  excision  is  contemplated.  The 
larger,  superficial  nerves  can  be  deadened 
in  ten  minutes  by  injecting  across  their 
course  a  few  cubic  centimeters  of  a 
2  per  cent,  cocaine-adrenalin  solution. 
There  is  danger  of  later  necrosis  of  the 
tissues  if  strong  concentrations  of  ad- 
renalin are  used.  Gangrenous  phlegmons 
have  been  known  to  occur  after  injection 
of  a  few  drops  of  a  1  to  5000  solution. 
After-haemorrhage  is  also  possible,  as  its 
effect  subsides,  if  in  such  strength  that 
the  lumen  of  large-vessels  is  closed.  Both 
of  these  evils  are  avoided  when  the  cir- 
culation in  the  capillaries  alone  is  inter- 
rupted. For  this  a  dilution  under  1  to 
10,000  is  sufficient.  ITiklebrandt  (Ber- 
liner klinische  Wochenschrift,  January 
2,  1905). 


APPENDICITIS,  PERILOUS  CALMS  OF. 


CONVULSIONS  IN  RABBITS.       113 


APPENDICITIS,   PERILOUS   CALMS   OF. 

Defervescence  of  symptoms  and  ap- 
parent better  condition  of  a  patient  do 
not  always  mean  recovery,  but  may  be 
the  forerunner  of  a  more  dangerous  con~ 
dition.  There  being  no  specific  for  the 
disease,  no  matter  what  treatment  is 
used,  the  one  who  procrastinates  should 
shoulder  the  responsibility  for  the  death. 
When  a  clear  diagnosis  is  made,  but  one 
treatment  should  be  advised,  that  of  op- 
eration as  soon  as  possible  under  the  con- 
ditions, or  the  golden  opportunity  may 
be  forever  gone.  The  physician  who  does 
not  explain  the  great  dangers  of  delay 
and  the  small  comparative  danger  of  op- 
eration is  doing  his  patient  a  serious 
injustice,  which  often  leads  to  fatal  re- 
sults. Operation  at  the  proper  time 
usually  greatly  shortens  convalescence, 
and  eliminates  all  danger  from  this  cause 
hereafter.  Procrastination  is  the  great- 
est cause  of  surgical  deaths,  operation 
often  being  performed  as  a  last  resort, 
when  but  little  hope  of  recovery  exists. 
E.  W.  Hardon  (Boston  Medical  and 
Surgical  Journal,  February  16,  1905). 

CEREBRAL  HEMORRHAGE. 

The  relation  between  various  atmos- 
pheric conditions  and  the  occurrence  of 
cerebral  haemorrhage  has  been  studied  by 
the  author.  He  concludes  that  there 
seems  to  be  a  slight  tendency  toward  the 
occurrence  of  cerebral  haemorrhage  on 
days  of  high  atmospheric  pressure  and 
also  on  days  of  rising  pressure,  the 
former  being  probably  the  important 
factor.  There  is  a  very  marked  tendency 
on  days  of  low  wind  pressure,  and  the 
combination  of  a  low  wind  pressure  with 
a  high  barometric  pressure  is  the  con- 
dition under  which  the  largest  number 
of  cases  took  place.  Apart  from  season, 
temperature  in  itself  has  not  been  shown 
to  exert  any  influence,  though  a  small 


excess  of  cases  has  been  noted  on  days 
with  a  rising  thermometer,  and  also  with 
a  combined  rise  of  atmospheric  pressure 
and  temperature.  J.  W.  Kussell  (Lancet, 
January  28,  1905). 

CHLOROFORM,      ELIMINATION      OF,      BY 
VOMITING. 

It  is  the  author's  practice  to  promote 
vomiting  after  most  operations  requiring 
chloroform  narcosis.  He  is  convinced 
that  this  is  an  important  means  of  elimi- 
nation of  the  chloroform.  He  has  the 
subjects  drink  copiously  of  chamomile 
tea,  and  observes  that  the  discomfort  fol- 
lowing the  narcosis  is  much  more  fleeting 
when  the  vomiting  is  free  and  unchecked. 
In  22  cases  in  which  the  chloroform  nar- 
cosis lasted  from  twenty  to  sixty  minutes, 
the  test  for  chloroform  was  always  posi- 
tive. He  filters  the  vomitus  and  adds  a 
drop  of  aniline  and  a  little  caustic  soda, 
then  heats  to  the  boiling  point.  In  the 
presence  of  chloroform  there  is  an  un- 
mistakable, pungent  odor  of  isonitrit. 
This  test  was  derived  by  Bunge  of  Basle, 
and  is  very  sensitive  and  accurate.  The 
vomitus  must  be  kept  in  an  air-tight 
receptacle  until  the  test  is  applied  to 
prevent  evaporation  of  the  chloroform. 
Gelpke  (Correspondenz-Blatt.  f.  Schwei- 
zer  Aerzte,  vol.  xxxiv,  No.  13,  1904). 

CONVULSIONS    IN    NEPHRECTOMIZED 
RABBITS. 

The  animals  at  first  become  more  ex- 
citable, then  timid  and  fretful;  these 
phenomena  are  soon  followed  by  convul- 
sions which  are  regular,  but  not  general ; 
they  begin  in  the  muscles  of  the  nock. 
In  the  course  of  a  few  minutes  the  head 
is  drawn  forward.  In  a  few  cases  the 
attacks  began  with  clonic  twitchings  of 
the  muscles.  The  convulsions  finally 
spread  to  other  muscle  groups.  So  soon 
as  the  extromities  became  involved,  paral- 


114       DEFENSIVE  POWERS  OF  BODY. 


DIABETES,  CONTAGIOUSNESS  OF. 


ysis  appeared  in  the  intervals  of  the 
convulsions.  The  injection  of  kreatin 
into  the  carotid  produced  paroxysms 
similar  to  those  described.  Since  the 
author  obtained  results  similar  to  those 
attained  by  Zuntz,  that  is,  that  it  takes 
less  kreatin  to  produce  convulsions  in 
pregnant  animals  than  in  non-pregnant 
ones,  he  set  up  a  hypothesis  that  the 
nervous  symptom  possesses  a  specific  sen- 
sitiveness to  certain  agents.  Blumreich 
(Centralblatt  fur  Gynakologie,  No.  49, 
1904;  from  American  Medicine,  Feb- 
ruary 4,  1905). 

DEFENSIVE    POWERS    OF    THE    BODY    IN 
DISEASE. 

This  subject  may  be  considered  in  two 
parts,  the  first  dealing  with  the  histo- 
logical changes  visible  with  the  micro- 
scope, the  second  with  the  subtle  chem- 
ical substances  in  the  cells  and  fluids  of 
the  body  which  aid  in  protecting  the 
body  and  in  curing  disease.  The  chief 
cellular  activities  are  included  in  the 
term  phagocytosis.  This  includes  the  in- 
gestion and  digestion  of  bacteria  within 
the  cells.  Not  all  bacteria  which  are 
ingested  by  the  leucocytes  are  digested ; 
they  may  even  flourish  and  multiply 
within  the  cells.  Bacteria  which  produce 
a  local  emigration  of  the  neutrophile  leu- 
cocytes will  cause  a  neutrophile  leuco- 
cytosis  if  the  infection  be  sufficiently  ex- 
tensive; the  converse  of  this  statement 
is  also  true.  With  normally  reacting 
tissues  the  leucocytosis  increases  with  the 
extent  of  the  infection.  In  infections  in 
which  leucocytosis  is  the  rule  the  absence 
or  diminution  of  such  without  improve- 
ment of  the  symptoms  indicates  severe 
toxaemia  with  interference  with  the  sup- 
ply of  the  defensive  cells,  or  an  inherent 
want  of  reactive  power.  With  regard  to 
the  eosinophiles,  whether  the  cells  pro- 
duced in  excess  act  as  direct  phagocytes 


or  indirectly  produce  some  of  the  de- 
fensive substances,  they  evidently  play 
an  important  part  in  the  defense  of  the 
body.  An  abundant  supply  of  leucocytes, 
free  movement  of  the  same,  and  a  free 
flow  of  lymph  favor  local  defense.  The 
most  important  means  of  increasing 
phagocytic  activity  is  supplied  by  active 
immunization  or  vaccination  in  the  gen- 
eral sense.  The  defensive  powers  of  the 
body,  so  far  as  the  production  of  phago- 
cytic cells  is  concerned,  are  sufficiently 
striking,  but  the  antitoxic  and  bacteri- 
cidal substances,  as  ultimate  weapons  of 
defense,  are  more  remarkable  still. 
These  and  other  antisubstances  have  this 
common  property,  that  they  enter  into 
chemical  union  with  the  substances  on 
which  they  act,  and  show  specific  affinity 
in  such  combination.  Muir  (Glasgow 
Medical  Journal,  January,  1905). 

DIABETES,  CONTAGIOUSNESS  OF. 

Cases  have  been  recorded  from  time 
to  time  of  the  coexistence  of  diabetes  in 
husband  and  wife.  Bebove,  in  1889, 
drew  the  attention  of  the  profession  seri- 
ously to  the  subject,  basing  his  opinion 
and  remarks  upon  five  personal  observa- 
tions of  what  he  characterized  as  con- 
jugal diabetes.  Since  then  the  subject 
has  rarely  been  mentioned.  Hutinet 
(These  de  Paris,  1904)  has  recently 
opened  up  the  question  with  several 
personal  observations  and  collected  cases 
to  the  number  of  161.  Such  well-known 
observers  as  Tessier,  Marie,  and  Talamon 
are  inclined  to  accept  the  possibility  of 
contagion  in  diabetes.  Hutinet  suggests 
that  the  contagion,  whatever  its  nature 
may  be,  is. contained  in  the  mouth,  the 
saliva  being  a  vehicle  which  serves  to 
propagate  the  disease.  It  is  noteworthy 
that  transmitted  diabetes  differs  in  some 
of  its  characteristics  from  ordinary 
forms.     It  is   less   severe,   more   easily 


DIABETES  INSIPIDUS, 


DIPHTHERIA  TOXIN,  ACTION  OF  LIVER. 


115 


treated,  and  certainly  more  curable. 
Symptomatologically  it  differs  ;in  the 
absence  of  thirst  and  polyuria,  and  the 
glycosuria  sometimes  disappears  sponta- 
neously when  the  patient  is  relieved  from 
the  possible  source  of  infection.  Thus, 
it  has  been  noted  in  conjugal  diabetes 
that  when  one  of  the  partners  dies  the 
other  rapidly  recovers.  If  the  contagi- 
ousness of  diabetes  should  become  an 
established  fact,  prophylactic  measures 
are  important.  The  greatest  care  should 
be  taken  to  prevent  spitting,  and  all  arti- 
cles of  clothing  likely  to  have  been  con- 
taminated by  saliva  should  be  disin- 
fected. Should  gingivitis  appear  in 
diabetic  subjects  it  should  be  energetic- 
ally treated.  (British  Medical  Journal, 
February,  1905.) 

DIABETES  INSIPIDUS,  TREATMENT  OF. 

After  trying  various  drugs  recom- 
mended for  this  malady — valerian,  anti- 
pyrine,  arsenic,  opium,  atropine,  etc. — 
with  very  little  effect,  the  writer  has 
treated  a  very  resistant  case  with  sub- 
cutaneous injections  of  strychnine.  After 
twelve  injections  the  quantity  of  urine 
was  diminished  from  15  to  12  quarts 
daily;  during  the  four  following  weeks 
it  was  progressively  diminished  to  3  1/2 
to  4  quarts;  its  specific  gravity  was 
about  1005.  The  polydipsia  became  less 
marked,  and  the  body  weight  increased, 
and  the  patient,  who  had  been  able  to 
walk  only  for  a  short  time,  could  do  so 
for  from  three  to  five  hours.  Healthy 
slumber  also  returned.  The  author  com- 
menced the  treatment  by  injecting  0.015 
grain  of  strychnine  nitrate  daily  for  five 
days;  then,  after  a  remission  of  three 
days,  0.045  grain  was  administered  for 
a  week;  then  another  three-day  remis- 
sion followed  by  a  week  of  injections  of 
0.075-grain  doses.  During  the  fourth 
week   0.15   grain  was   injected.     There 


were  no  ill-effects  from  the  treatment 
other  than  pain  at  the  site  of  the  needle 
punctures.  It  is  important  to  commence 
with  small  doses  and  to  gradually  in- 
crease them.  The  strychnine  seems  to 
act  directly  upon  the  disease,  not  alone 
upon  the  polyuria,  but  the  reason  for  its 
action  is  difficult  to  explain.  B.  Stein 
(Miinchener  medicinischo  Wochenschrift, 
No.  36,  p.  1606,  1904). 

DIABETES  MELLITUS,   MASTOID  DISEASE 
COMPLICATING. 

Aural  complications  of  diabetes  mel- 
litus  may  originate  primarily  in  the  mas- 
toid cells.  The  process  may  be  mani- 
fested by  the  classic  mastoid  symptoms 
without  involving  the  tympanic  cavity. 
This  condition  is  peculiar  to  diabetes 
mellitus.  The  term  "diabetic  ear" 
should  be  limited  to  those  cases  in  which 
the  disease  begins  as  a  primary  osteitis 
of  the  mastoid,  or  in  which  primary 
tympanic  involvement  and  rapid  mas- 
toid complications  seem  simultaneous, 
While  the  writer  believes  it  advisable  to 
reduce  the  amount  of  sugar,  when  pos- 
sible, in  those  cases  showing  an  excessive 
glycosuria,  unless  the  urgency  of  the 
local  symptoms  would  demand  imme- 
diate operation;  however,  the  writer  has 
not  met  any  cases  that  terminated  in 
what  could  be  called  post-operative  coma. 
S.  MacCuen  Smith  (American  Medicine, 
February  11,  1905). 

DIPHTHERIA    TOXIN,     ACTION     OF     THE 
LIVER  ON. 

The  authors  have  circulated  diphtheria 
toxin  through  the  freshly  isolated  livers 
of  rabbits  and  cats,  and  investigated  the 
effects  produced  by  innoculating  into 
guinea-pigs  material  recovered  from  the 
livers.  They  find  that  during  the  cir- 
culation of  diphtheria  toxin  through  the 
liver  its  lethal  action  is  greatly  dimin- 


116 


FEEDING  IN  INFANCY. 


FIBROID  TUMORS  AND  PREGNANCY. 


ished.  This  diminution  occurs  whether 
the  toxin  be  mixed  with  an  indifferent 
fluid  or  with  blood.  The  bile  and  the 
juice  from  such  a  liver  have  a  slight 
antitoxic  action,  and  nucleo-proteids 
separated  from  the  liver  juice  possess 
this  action  in  a  marked  degree.  The 
behavior  of  the  liver  in  lessening  the 
toxic  power  of  diphtheria  toxin  is  re- 
garded as  similar  to  that  which  it  exerts 
in  ordinary  digestion  in  lessening  the 
toxic  action  of  peptones.  These  experi- 
ments are  held  to  support  the  view  that 
"immunity,  natural  or  acquired,  is  noth- 
ing more  than  an  extension  to  the  cells 
of  the  tissue  generally  of  a  power  which 
is  constantly  exercised  during  digestion 
by  those  of  the  intestine  and  liver/' 
Lauder  Brunton  and  Bokenham  (Jour- 
nal of  Pathology  and  Bacteriology,  No- 
vember, 1904). 

FEEDING  IN  INFANCY. 

The  writer  discusses  the  methods  of 
feeding  a  baby  deprived  of  breast  milk. 
The  best  substitute  food  is  prepared  from 
cows'  milk  from  healthy  herds,  the  milk 
collected  clean,  modified  in  clean  sur- 
roundings, and  used  fresh.  The  labora- 
tory method  of  exact  modification  of 
milk  has  been  called  the  American 
method.  Modified  milk  is  not  a  patent 
food,  but  nourishment  as  near  as  pos- 
sible, such  as  the  human  breast  furnishes, 
and  capable  of  being  modified,  or  changed 
to  fit  the  changing  needs  of  the  infant. 
The  proper  modification  can  be  made 
only  by  skilled  persons  in  a  proper  lab- 
oratory. The  cost  of  laboratory  milk  is 
within  the  reach  of  all  who  are  willing 
to  do  part  of  the  work  of  dividing  the 
quart  bottles  of  milk  into  separate  feed- 
ing bottles.  The  prescriber  has  respon- 
sibilities in  feeding  a  baby.  The  feeding 
of  infants  is  an  expert's  work. 

Three    prescriptions    may    serve    as 


points  of  departure:  1.  For  the  new- 
born— to  begin  after  the  fifth  or  seventh 
day:  fats,  2  per  cent.;  sugar,  5  per 
cent.;  proteids,  0.5  per  cont. ;  feeding, 
10;  amount  in  each  feeding,  1  ounce; 
alkalinty,  5  per  cent.  Heated  to  155°  F. 
for  twenty  minutes  or  raw  if  preferred. 
Feed  every  two  hours,  twice  at  night.  2. 
"Low  average"  breast  milk:  Fats,  3  per 
cent. ;  sugar,  6  per  cent. ;  proteids,  1  per 
cent.  3.  "High  average"  breast  milk: 
Fats,  4  per  cent.;  sugar,  7  per  cent.; 
proteids,  2  per  cent.  W.  P.  Korthrup 
(American  Medicine,  January  28,  1905). 

FIBROID  TUMORS  AND  PREGNANCY. 

Prophylaxis.  —  Every  fibroid  during 
the  child-bearing  period,  with  few  ex- 
ceptions, should  be  attacked  by  surgical 
means. 

During  Pregnancy. — Safe  fibroids,  i.e., 
those  beyond  the  dilating  zone  of  the 
uterus,  should  be  carefully  watched. 
Every  complication  during  pregnancy 
depending  upon  the  fibroid  should  war- 
rant the  attacking  of  the  condition  sur- 
gically, or,  at  least,  to  provoke  us  to  the 
indication  for  emptying  the  uterus. 

During  Labor.  —  Again  safe  tumors 
need  watching.  The  resultant  complica- 
tions must  be  met  energetically,  but 
gently,  as  they  arise,  i.e.,  haemorrhage, 
tardy  labor.  Tumors  which  cannot  be 
displaced,  blocking  the  bony  passage, 
warrant  vaginal  enucleation  (seldom  pos- 
sible), or  Ca?sarean  section,  followed  by 
hysterectomy. 

Sloughing  and  necrosis  of  a  puerperal 
fibroid  must  not  be  mistaken  for  retained 
sccundines.  This  doubt  must  be  elimi- 
nated by  the  exploration  with  the  clean 
aseptic  hand.  Eetained  secundines  are 
always  to  be  removed  manually,  and  un- 
der no  condition  musf  the  curette  be 
employed,  because  of  the  great  danger 


GONORRHOEA,  ACTIVE  TREATMENT. 


GRAVES'S  DISEASE. 


117 


of  laceration  of  the  capsule,  and  conse- 
quent sepsis. 

Sloughing  and  necrotic  fibroids  are 
always  to  be  attacked  surgically,  eitheT 
by  enucleation  or  by  a  hysterectomy.  S. 
Marx  (American  Journal  of  Obstetrics, 
February,  1905). 

GONORRHOEA,    ACTIVE    TREATMENT    OF, 
IN  THE  EARLY  STAGES. 

The  author  employs  a  combination  of 
the  modern  irrigation  methods  with  the 
still  more  modern  germicidal  treatment, 
believing  the  combination  has  definite 
advantages  over  either  used  alone.  The 
practical  detail  of  this  method  is  about 
as  follows :  In  cases  in  which  treatment 
is  begun  at  the  first  appearance  of  dis- 
charge immediate  gravity  irrigation  with 
permanganate  of  potash,  1  to  6,000,  as 
hot  as  can  be  borne  comfortably,  in  large 
quantity,  followed  by  syringe  injection  of 
5  per  cent,  solution  of  protargol  or 
argyrol  held  in  for  five  or  ten  minutes. 
This  procedure  is  repeated  twice  a  day 
in  the  same  way,  save  that  at  the  third 
injection  the  silver  solution  is  pushed  up 
to  10  per  cent,  and  held  in  fifteen  or 
twenty  minutes.  After  three  days  the 
interval  is  lengthened,  the  routine  is 
carried  out  but  once  a  day.  At  ten  days 
to  two  weeks  the  process  is  usually  ap- 
parently gone,  save  for  some  shreds,  and 
treatment  is  interrupted  to  test  results. 

In  case  there  is  already  a  discharge, 
ardor,  and  a  stiff  urethra,  permanganate 
alone  is  usually  used  until  conditions 
improve  enough  to  give  the  protargol 
proper  access  to  the  urethra  wall,  lie- 
fore  this  i(  is  nearly  useless  and  may  be 
irritant.  Usually  the  protargol  can  be 
profitably  added  to  the  treatment  at  the 
second  or  third  treatment.  These  eases 
are  not,  as  a  rule,  fit  to  tesl  as  to  cure 
before  two  or  three  weeks. 

In  case  there  is  already  a   posterior 


infection,  the  treatment  is  the  same,  ex- 
cept that  about  every  fourth  treatment  a 
posterior  irrigation  with  permanganate 
is  added.  This  is  usually  sufficient,  and 
the  writer  has  never  become  convinced  of 
the  utility  of  using  silver  proteids  in  the 
posterior  urethra.  These  posterior  cases 
last  longer,  and  unless  the  outlook  is 
encouraging,  it  has  often  seemed  unwise 
to  attempt  treatment,  even  of  the  ante- 
rior process,  more  than  once  a  day.  In 
any  of  the  cases,  if  a  discharge  recurs 
after  ceasing  treatment  to  test  results, 
or  in  any  case  in  which  the  disease  is  not 
apparently  about  well  within  three  weeks, 
it  is  advantageous  to  substitute  irriga- 
tions of  silver  nitrate,  1  to  8,000,  run- 
ning up  to  1  to  2,000  or  1  to  1.500,  or 
occasionally  corrosive  sublimate,  1  to 
15,000  or  1  to  10,000.  F.  J.  Cotton 
(Boston  Medical  and  Surgical  Journal, 
February  11,  1905). 

GRAVES'S  DISEASE,  PIGMENTATION  0E 
THE  EYELIDS  IN. 
In  Graves's  disease  there  is  a  uniform, 
diffuse,  brownish  pigmentation  of  the 
eyelids,  which  is  most  marked  in  the 
upper  lid.  The  pigmentation  is  bounded 
by  the  eyebrows  superiorly,  and  the  lower 
margin  of  the  orbit  interiorly.  The  con- 
junctiva is  not  affected.  This  is  an  early 
symptom,  and  frequently  becomes  less 
distinct  as  the  disease  advance-;  in  rare 
cases  it  may  be  entirely  absent.  A  tend- 
ency to  pigmentation  of  the  skin  has 
been  observed  by  others,  both  in  Graves's 
disease  and  myxedema.  !ml  the  localiza- 
tion on  the  eyelids  has  not  previously 
been  described.  Possibly  the  occurrence 
of  pigmentation  is  related  to  the  peculiar 
condition  of  Hie  blood  in  Graves's  dis- 
ease described  by  the  writer  and  Rosin, 
who  found  that,  though  the  percentage 
of  red  corpuscles  was  normal,  and  the 
percentage  of  iron  was  more  or  less  re- 


118 


HAEMOPTYSIS,  TREATMENT. 


HEMORRHOIDS,  TREATMENT. 


duced,  the  results  of  the  estimation  of 
haemoglobin  were  invariably  higher  than 
normal.  Jellinck  (Wiener  klinische 
Wochenschrift,  October  27,  1904). 

HEMOPTYSIS,   TREATMENT   OF. 

In  this  condition,  as  in  the  case  of 
other  symptoms,  the  golden  rule  is,  if 
possible,  to  remove  the  cause.  Although 
tuberculosis  is  the  most  common  cause 
of  haemoptysis,  there  are  other  causes 
which  should  be  constantly  borne  in 
mind.  The  accessible  cavities  should  al- 
ways be  examined  in  all  cases  of  doubt- 
ful origin — the  nose,  pharynx,  larynx, 
and  mouth.  Bleeding  gums  should  also 
be  thought  of.  Many  patients  with 
bronchitis  or  bronchiectasis  occasionally 
bring  up  a  little  blood-stained  sputum. 
One  form  of  haemoptysis  depends  upon 
degeneration  of  arterioles  and  capillaries, 
in  gouty,  rheumatic,  and  often  emphy- 
sematous patients  of  middle  or  advanced 
age.  The  haemoptysis  of  heart  disease 
can  generally  be  distinguished  by  appro- 
priate physical  signs.  Haemoptysis  may 
be  due  to  thoracic  aneurism  communi- 
cating with  a  bronchus.  When  there  is 
a  brassy  cough  and  persistent  pain  in  the 
chest,  this  disease  should  always  be  sus- 
pected. 

The  treatment  of  all  these  forms  of 
haemoptysis  is  the  same  as  for  the  symp- 
tom in  general,  with  modifications  ap- 
propriate to  the  disease  in  the  course  of 
which  they  occur.  In  the  form  con- 
nected with  pulmonary  tuberculosis,  the 
patient  should  be  placed  at  rest  in  bed. 
When  the  bleeding  is  moderate  in  amount 
it  is  a  good  plan  to  give  hypodermically 
V4  grain  of  morphine.  When,  however, 
the  bleeding  is  so  profuse  as  to  flood  the 
air  passages  and  suffocate  the  patient, 
the  morphine  should  not  be  given.  Free 
purgation  is  a  useful  measure.  Calcium 
chloride  may  be  given  in  20-grain  doses 


every  four  hours.  Turpentine  sometimes 
checks  internal  bleeding.  An  icebag  to 
the  chest  may  do  good  by  quieting  the 
heart.  Inhalation  of  the  nitrite  of  amyl 
may  be  tried.  The  systemic  vessels  are 
of  much  greater  extent  than  the  pulmo- 
nary, and  thus  a  general  dilatation  of 
arterioles  will  be  accompanied  by  diver- 
sion of  blood  from  the  pulmonary  cir- 
culation and  consequent  reduction  of 
pressure.  C.  H.  Cattle  (British  Medical 
Journal,  January  14,  1905). 

HEMORRHOIDS,  TREATMENT  OP. 

The  great  majority  of  cases  of  haemor- 
rhoids of  whatever  form  can  be  treated 
radically,  satisfactorily,  and  with  little 
discomfort  to  the  patient  at  the  physi- 
cian's office.  It  should  also  be  empha- 
sized that  the  after-treatment  of  these 
cases  requires  careful  attention.  The 
bowels,  as  a  rule,  should  be  confined  for 
forty-eight  hours.  On  the  second  night 
V2  drachm  extract  cascarae  sagradae  fl. 
should  be  given,  and  sufficient  thereafter 
to  secure  daily  evacuations.  The  anal 
region  should  be  kept  scrupulously  clean, 
and  a  pad  of  cotton  wool,  wrung  out  of 
bichloride  solution,  x/iooo>  placed  over 
the  anal  orifice  is  more  acceptable  to 
most  persons  than  a  dry  dressing.  Good 
drainage  must  be  secured  and  the  neces- 
sary topical  applications  made  to  induce 
rapid  healing.  Should  there  be  much 
pain  or  soreness  (which  is  rarely  the 
case),  it  can  be  relieved  by  anodyne  sup- 
positories of  morphia,  cocaine,  or  com- 
binations of  both. 

An  irritable  or  hypertropbied  external 
sphincter  is  occasionally  the  cause  of 
pain  after  these  operations.  This  com- 
plication can  be  avoided  by  a  complete 
division  of  both  layers  of  the  muscle,  a 
painless  operation,  under  eucaine.  On 
no  account  should  the'internal  sphincter 
be  damaged,  as  incontinence  might  fol- 


HEADACHE,  NASAL  DISEASE. 


LITTEN'S  "DIAPHRAGM  PHENOMENON."      119 


low.     T.  C.  Hill   (Boston  Medical  and 
Surgical  Journal,  February  2,  1905). 

HEADACHE,  NASAL  DISEASE  AS  A  CAUSE 
OF. 

Nasal  disease  is  undoubtedly  the  cause 
of  headaches  in  a  certain  number  of 
cases;  but  only  where  there  is  discharge 
or  abnormal  nasal  respiration.  In  all 
cases  of  persistent  headache  examination 
of  the  nose  should  be  a  routine  practice. 
Suppuration  in  the  accessory  sinuses  and 
marked  nasal  obstruction  should  be  thor- 
oughly treated.  Small  spurs  and  devia- 
tions should  be  left  alone.  If  the  middle 
turbinates  are  enlarged  and  pressing 
upon  the  septum,  especially  upon  the 
tubercle,  and  if  all  other  possible  causes 
of  headache  have  been  eliminated,  par- 
tial removal  of  the  hypertrophied  bone 
should  be  advised,  since  in  many  such 
cases  complete  relief  is  given.  A.  L. 
Whitehead  (British  Medical  Journal, 
January  28,  1905). 

LABOR,    PROPHYLACTIC    USE    OF    ERGOT 
DURING. 

The  author  believes  that  postpartum 
atony  of  the  uterus  can  be  effectively 
guarded  against  by  the  prophylactic  use 
of  ergot,  in  spite  of  the  views  of  those 
who  hold  that  the  drug  should  be  given 
only  after  the  expulsion  of  the  placenta. 
He  has  found  that  hypodermic  injection 
of  ergotin  the  most  advantageous  method 
of  administration,  and  considers  that  the 
best  time  to  give  it  is  ten  to  fifteen  min- 
utes before  the  birth  of  the  child.  The 
action  of  the  drug  is  less  prompt  in 
primipara  than  in  multipara.  The  au- 
thor recommends  the  prophylactic  use  of 
ergotin  in  this  way  in  all  operative  de- 
liveries, in  multiple  births,  hydramnios, 
in  deformities,  and  fibroid  tumors,  in 
cases  of  deficient  pains  during  the  first 
or  second  stages,  in  cases  in  which  pre- 


vious labors  have  been  followed  by  haem- 
orrhage, and  in  all  Caesarean  sections. 
The  results  obtained  by  this  plan  are 
very  satisfactory,  for  atonic  haemorrhage 
was  observed  in  only  3  of  293  cases  of 
forceps  delivery,  and  only  once  out  of  102 
twin  labors.  Fifteen  cases  of  hydram- 
nios, tumors,  or  uterine  deformity  were 
delivered  without  atonic  complications. 
Priissmann  (Miinchener  medinische 
Wochenschrift,  January  10,  1905;  from 
Medical  Record,  February  4,  1905). 

LEAD-POISONING,  BASOPHILIC  GRANU- 
LATIONS OF  THE  ERYTHROCYTE 
IN. 

Basophilic  granules  occurring  in  ery- 
throcytes are  normally  present  in  small 
numbers  in  the  blood  of  man,  but  may 
be  increased  in  numbers  under  certain 
pathological  conditions,  and  decrease  as 
convalescence  is  established.  Nucleated 
red  corpuscles  are  common  in  the  blood 
of  those  suffering  from  lead  poisoning, 
and  are  always  accompanied  by  an  in- 
crease in  the  number  of  granular  red 
cells.  The  anaemia  secondary  to  lead- 
poisoning,  as  a  rule,  is  only  of  a  mod- 
erate degree.  The  granular  cells  are 
most  common  in  lead-poisoning,  possibly 
have  their  origin  in  the  blood-forming 
tissues,  and  are  probably  the  results  of 
a  fragmentation  of  the  nucleus  of  the 
red  blood  corpuscles.  W.  B.  Cadwalader 
(American  Journal  of  the  Medical 
Sciences,  February,  1905). 

LITTEN'S  "DIAPHRAGM  PHENOMENON" 
IN  DIAGNOSIS. 
To  students  in  physiology,  the  phrenic 
wave  is  useful  as  a  demonstration  of  the 
respiratory  movements  of  the  diaphragm. 
When  unbroken  and  over  three  inches  in 
extent  on  both  sides,  it  is  a  good  indi- 
cation of  healthy  lungs,  and  should  be 
incorporated  as  such  into  life  insurance 


120 


MEASLES.  PRODROMAL  RASHES  OF. 


MELANOMA. 


examinations.  It  is  an  easy  and  prac- 
tical substitute  in  many  eases  for  the 
expensive  and  laborious  x-ray  examina- 
tion of  the  movements  of  the  midriff, 
when  such  an  examination  is  desired 
(Cabot).  When  diminished  markedly 
on  both  sides,  low  down  in  the  thorax, 
and  more  marked  behind  than  in  front, 
it  is  an  excellent  sign  of  asthma  and  em- 
physema. When  absent  or  nearly  absent 
on  one  side  only,  it  is  a  useful  confirma- 
tory sign  of  a  variety  of  conditions  which 
may  be  suspected  from  other  signs,  par- 
ticularly pleurisy  and  early  tuberculosis. 
When  absent  on  both  sides  no  conclusion 
of  any  kind  is  really  justifiable,  unless 
the  patient  has  been  previously  known  to 
have  had  good  waves.  W.  1ST.  Berkeley 
(New  York  Medical  Journal  and  Phila- 
delphia Medical  Journal,  February  4, 
1905). 

MEASLES,    PRODROMAL   RASHES   OF. 

The  writer  summarizes  the  general 
characteristics  of  the  prodromal  rashes  of 
measles  as  follows:  The  great  majority 
of  them  appear  within  the  first  two  days 
of  the  disease.  Frequently  they  precede 
the  catarrhal  symptoms,  Koplik's  spots, 
and  the  characteristic  stomatitis.  They 
are  usually  very  transient,  which  ac- 
counts for  the  scanty  attention  they  have 
hitherto  received.  The  scarlatiniform 
eruptions,  however,  may  last  for  a  day 
and  a  night,  and  the  isolated  macules 
and  papules  even  longer.  They  have  a 
strong  tendency  to  lie  localized.  Ever 
the  scarlatiniform  rashes,  which  are  the 
most  widely  diffused,  seldom  occupy  the 
same  extent  as  the  fully  developed  rash 
of  scarlei  fever.  Their  distribution  is 
capricious,  no  special  situation  being  af- 
fected. Highly  characteristic  is  thf1 
simultaneous  association  of  several  varie- 
ties of  eruption.  Accidental  eruptions 
also  occur   in    the  oilier  acuie   exanthe- 


mata— e.g.,  scarlet  fever — but  coexisting 
or  following,  instead  of  preceding  the 
specific  efflorescence. 

The  prodromal  eruptions  of  measles 
arc  strikingly  free  from  any  symptoms 
of  cutaneous  irritation.  There  is  no 
pain  or  pruritus,  nor  is  there  any  sub- 
sequent desquamation.  Unlike  in  the 
case  of  small-pox,  initial  rashes  appear 
to  be  of  no  aid  in  prognosis  in  measles. 
The  occurrence  of  such  rashes  as  are  here 
described,  in  an  epidemic  focus,  should 
arouse  suspicion,  and  prompt  examina- 
tion should  be  made  of  the  buccal  mu- 
cosa for  Koplik's  spots  and  the  charac- 
teristic stomatitis.  J.  D.  Uolleston 
(British  Medical  Journal,  February  4, 
1905). 

MELANOMA. 

Aside  from  the  natural  division  into 
choroid  and  skin  tumors,  melanotic  neo- 
plasms, which  from  their  diversity  of 
origin,  are  best  called  melanomata,  show 
several  varieties.  The  commonest,  and 
therefore  most  important,  is  that  derived 
from  soft  naevi,  which  are  endothcliomata 
of  lymph  vessel  origin.  Naevomelanoma 
whose  histogenesis  is  not  possible  to  de- 
termine must  be  referred  to  the  same 
origin.  A  second  variety  exists  with  the 
same  histological  pictures  which  does  not 
spring  from  na?vi.  and  whose  origin  is 
directly  traceable  to  endothelium,  prob- 
ably also  lymphatic.  This  group  includes 
melanotic  whitlow  and  the  malignant 
lentigo  of  the  French.  The  third  divis- 
ion is  truly  epithelial  in  origin,  although 
its  existence  has  been  denied.  These  tu- 
mors are  of  various  types,  and  show  only 
a  very  slight  local  tendency  to  malig- 
nancy, a'  fact  sufficient  in  itself  to  deter- 
mine a  cardinal  difference  from  the  mel- 
ano-endotheliomata  whose  capacity  in 
ibis  connection  can  hardly  be  exag- 
gerated.    A  histological  diagnosis  is  the 


METABOLISM. 


NARCOSIS,  THE  PHYSICAL  HAMS  OF. 


121 


only  proper  method  of  differentiation  be- 
tween the  two.  J.  C.  Johnson  (Journal 
of  Cutaneous  Diseases,  February.  1905). 

METABOLISM,     THE     INFLUENCE     OF     A 
DIET    POOR    IN    CHLORIDES    ON. 

From  a  study  of  the  changes  in  oxida- 
tion in  healthy  persons  on  a  diet  rich  or 
poor  in  chlorides,  the  writer  has  found 
that  as  chloride  of  sodium  is  decreased 
there  is  a  greater  decomposition  of  albu- 
mins; he  has  studied  the  effect  en  the 
blond  and  found  that  it  became  poor  in 
corpuscles  and  in  haemoglobin.  The  au- 
thor concludes  that  chloride  of  sodium 
aids  digestion  not  only  as  a  condiment, 
but  as  aii  indispensable  element  for  main- 
taining the  normal  condition  of  the  or- 
ganism. In  some  cases  of  hepatic  cir- 
rhosis no  fixed  relation  between  the  sub- 
traction of  chlorides  and  the  presence  of 
ascites  is  found.  There  is  partial  reten- 
tion of  the  chlorides  in  this  disease,  but 
the  amount  of  chlorides  retained  in  the 
system  is  not  the  same  as  that  excreted 
in  the  urine,  lie  believes  that  the  re- 
moval of  chlorides  from  the  diet  is  noi 
beneficial  in  hepatic  cirrhosis.  Cala- 
brese  (Rivistadi  Clinica  Medica,  Novem- 
ber 26,  r.xii  ;  from  Medical  Record,  Jan- 
uary 28,  1905). 

MOVABLE      KIDNEY,      NEW      OPERATION 
FOR. 

So  many  methods  have  been  employed 
with  varying  success  in  Hie  effort  at  re- 
placing a  movable  kidney  that  a  tech- 
nique which  promises  to  give  better  re- 
sults than  those  previously  employed  will 
be  welcomed.  The  writer  states  that 
by  this  operation  the  kidney  is  swung 
up  in  its  own  capsule  practically  in  nor- 
mal position.  A  four-inch  incision  is 
made  to  the  vertebral  side  of  the  angle 
between  the  la-t  rib  ;ind  the  rector  spina; 
downward  and  outward  toward  the  ante- 


rior superior  spine.  The  kidney  is  found 
and  is  pushed  up  to,  but  not  out  of,  the 
wound,  and  a  small  puncture  is  made  in 
the  capsule  so  that  a  probe  or  dire 
may  be  insinuated,  and  a  large  blister  be 
gradually  separated  from  the  vertebral 
surface  and  outer  border  of  the  kidney. 
This  is  the  portion  of  the  organ  that 
normally  looks  backward,  and  by  peeling 
the  capsule  oif  here  the  kidney  is  kept 
as  nearly  as  possible  in  its  proper  place. 
A  horseshoe-shaped  ilap  of  capsule  can 
be  separated  so  that  the  base  is  just  about 
the  center  of  the  horizontal  axis  of  the 
kidney.  The  margin  of  the  blister  is  now 
cut  in  a  U  shape,  the  concavity  down- 
ward. To  preserve  the  inner  tilt  of  the 
upper  border  of  the  organ,  the  inner 
limb  of  the  incision  may  be  made  a  little 
longer  than  outward.  The  finger  is  now 
insinuated  under  the  ligamentum  arcu- 
atum  externum,  and  the  tissues  on  its 
deep  surface  peeled  up  so  as  to  get  rid 
of  the  pleura.  The  finger  then  protects 
the  pleura  and  an  incision  is  made  about 
a  third  of  an  inch  or  more  above  the 
lower  margin  of  the  ligament  and  paral- 
lel to  its  (ibei's  to  the  whole  available 
distance.  The  last  forsal  nerve  should 
be  avoided.  Kocher's  artery  forceps  are 
pushed  through  the  slit  and  the  free 
end  o!'  the  separated  capsule  is  drawn 
through,  spread  out.  and  si  itched  dow  n 
to  the  ligament.  The  wound  is  sutured 
in  layers,  catgut  being  used  for  the  deep 
stitches  and  silkworm  gut  for  the  skin. 
Andrew  Fullerlon  (British  Medical 
Journal,  December  24,  1904). 

NARCOSIS,  THE  PHYSICAL  BASIS  OF. 

A  subject  that  touches  the  borderlands 
of  physiology,  biology,  pharmacology, 
and  clinical  medicine,  is  that  which  at- 
tempts to  explain  the  relative  power  of 
the  various  narcotics  from  the  stand- 
point   of    physical    chemistry.      A    new 


122 


NARCOSIS,  THE  PHYSICAL  BASIS  OF. 


theory  that  seeks  to  show  the  mutual 
relationship  of  osmosis  and  narcosis,  and 
to  discover  the  physical  laws  that  under- 
lie both,  has  been  carefully  worked  out 
by  the  writer.  Overton  recently  com- 
pared the  various  speeds  with  which  dif- 
ferent narcotics  diffuse  into  protoplasm. 
He  found  that  monatomic  alcohol,  alde- 
hydes, ketones,  etc.,  penetrate  the  cell 
wall  more  quickly  than  the  diatomic  alco- 
hols and  the  amides  of  the  monatomic 
acids,  and  then  in  decreasing  order,  come 
glycerine,  urea,  etc.,  until  the  salts  of 
the  strong  inorganic  and  organic  bases 
and  acids  are  reached,  for  which  the  cell- 
wall  is  wholly  impermeable.  The  per- 
meability is  increased  in  homologous 
series  by  the  substitution  of  hydrogen  by 
methyl,  and  the  latter  by  ethyl.  He 
found  that  the  narcotics  pass  through 
membranes  the  more  quickly  the  more 
soluble  they  are  in  the  lipoids,  such  as 
fats,  cholesterin,  lecithin,  etc.  Overton 
and  H.  Meyer  also  pointed  out  that  the 
good  narcotics,  anaesthetics,  and  antipy- 
retics collectively  belong  to  the  sub- 
stances that  osmose  quickly,  and  they 
proposed  the  theory  that  the  efficiency 
of  a  good  narcotic  depends  in  the  first 
instance  on  the  degree  of  its  solubility  in 
lipoids.  Overton  assumes  that  the  cell- 
wall,  and  if  Quincke's  theory  be  correct, 
that  the  walls  of  the  foamy  cell-contents 
contain  lipoids,  and  the  ease  with  which 
a  substance  penetrates  these  walls  de- 
pends upon  its  solubility  in  these  lipoids. 
The  author  believes  that  there  are 
grounds  for  denying  that  this  is  always 
the  case.  Instead  of  a  foamy  structure, 
he  conceives  of  a  membrane  as  a  net- 
work of  fine  capillaries,  without  regard 
to  whether  it  contains  lipoids  or  not. 
Osmosis  may  be  explained  upon  the  prin- 
ciple of  capillarity.  Repeated  investiga- 
tions have  shown  that  the  greater  the 
osmotic  power  of  a  water-soluble  sub- 


stance is,  the  more  it  lowers  the  capil- 
lary pressure  of  the  water.  Substances 
that  are  capable  of  traversing  mem- 
branes, increase  the  capillary  pressure  of 
the  water  in  which  they  are  dissolved. 
Diminution  in  capillarity  and  increased 
facility  of  osmosis  run  a  parallel  course. 
If  two  liquids  are  separated  by  a  mem- 
brane, such  that  the  surface  tension  of 
one  is  less  than  that  of  the  other,  the 
former  will  osmose  into  the  latter.  Thus 
the  difference  in  surface  tension  deter- 
mines the  direction  and  rapidity  of  os- 
mosis. The  force  of  osmosis  is  not  os- 
motic pressure,  but  surface  tension.  In 
most,  if  not  all  instances  in  physiology, 
surface  tension  is  to  be  put  in  the  place 
of  osmotic  pressure  in  explaining  dial- 
ysis. Whereas,  the  number  of  molecules 
or  ions  determines  the  degree  of  osmotic 
pressure,  it  has  no  effect  on  surface  ten- 
sion; hence  both  forces  must  be  con- 
sidered distinct.  In  determining  the 
various  solubilities  of  different  sub- 
stances, the  author  found  that  those  are 
the  most  soluble  whose  surface  tension  is 
the  least.  Solubility,  solution  tension, 
and  surface  tension  are  therefore  inti- 
mately related.  The  surface  tension  of 
solutions  is  determined  by  that  of  the 
dissolved  substance.  Solution  tension 
and  capillarity  are  more  intimately  con- 
nected than  solubility  and  capillarity. 
Thus  methyl  and  ethyl  alcohol  are  both 
equally  soluble  in  water,  but  the  solution 
tension  of  the  former  is  much  greater 
than  that  of  the  latter.  The  author  dis- 
covered the  following  law,  namely:  that 
substances  of  equal  capillary  activity  be- 
longing to  homologous  series  (ordinary 
alcohols,  fatty  acids,  esters,  etc.),  lower 
the  rise  of  water  in  the  capillary  tube  in 
the  proportion  of  1  :  3  :  32  :  33.  .  .  . 
The  author  believes  that  the  rapidity 
with  which  the  narcotics  penetrate  the 
walls  of  the  ganglion  cells  of  the  brain, 


PANCREAS,  ROLE  OF  THE  NERVES  OF  THE. 


123 


is  not  due  to  the  fact  that  these  sub- 
stances are  soluble  in  the  lipoids  of  the 
cell-wall,  but  is  to  be  attributed  to  the 
surface  tension.  When  the  narcotics 
have  penetrated  the  interior  of  the  cell, 
they  then  dissolve  in  the  lipoids  and  un- 
fold their  narcotic  power  in  proportion 
to  this  solubility.  As  pure  non-toxic 
narcotics,  those  are  to  be  regarded  that 
dissolve  in  the  lipoids  without  causing 
any  chemical  reaction,  either  union  with 
or  decomposition  of  the  proteids  or  other 
bodies  of  the  cell.  On  the  other  hand, 
there  is  a  series  of  narcotics  which  have 
a  decided  toxic  action;  which  is  easily 
explained  on  the  basis  of  their  constitu- 
tion, since  they  give  rise  to  accessory 
chemical  reactions.  As  examples  of  the 
latter  may  be  mentioned  nicotine,  allyl- 
alcohol,  phenol,  etc.  Even  the  pure  nar- 
cotics are  not  entirely  non-toxic,  since 
while  they  are  soluble  in  the  lipoids,  they 
in  their  turn  dissolve  some  of  the  fatty 
substance.  It  is  doubtful  whether  a 
really  good  narcotic  will  ever  be  found. 
Experiments  show  that  in  the  pure  nar- 
cotics there  is  a  close  relationship  be- 
tween surface  tension  and  narcotic 
power.  According  to  Overton,  in  homol- 
ogous series  the  narcotic  action  in- 
creases with  the  increasing  content  of 
carbon,  with  the  substitution  of  hydro- 
gen by  alcohol  radicals,  as  well  as  from 
tertiary  through  iso — to  normal  com- 
pounds. The  same  holds  true  of  the 
capillary  activity  of  these  substances. 
The  substitution  of  hydrogen  or  amido 
groups  in  place  of  a  hydrogen  atom  low- 
ers capillary  activity  as  well  as  narcotic 
power.  It  is  also  found  that  the  narcotic 
action  of  homologous  substances  (as  alco- 
hols, esters,  etc.),  with  an  increasing 
molecular  weight,  increases  in  the 
proportion  of  1:3:  32.  J.  Traube 
(Pfliiger's  Archiv,  December  1,  1904; 
from  Medical  News,  February  18,  1905). 


PANCREAS,    ROLE    OF    THE    NERVES    OF 
THE. 

According  to  the  writer,  there  is  very 
little  in  the  literature  of  the  functional 
relations  of  the  pancreas  which  concerns 
the  role  of  the  nerves  of  this  organ. 
Since  1888,  when  Martinotti  for  the  first 
time  removed  the  pancreas  in  dogs,  a 
great  deal  of  research  work  has  been  done 
on  the  gland  itself,  on  the  islands  of 
Langerhans,  etc.,  and  on  the  relation  of 
the  pancreas  to  diabetes,  but  little  has 
been  done  to  show  the  exact  functions 
of  the  nervous  mechanism  of  the  gland. 
The  writer  resected  the  pancreatic  nerves 
in  a  series  of  dogs,  and  on  another  series, 
in  addition,  tied  portions  of  the  gland 
itself  at  each  end  thereof,  in  order  to 
compare  the  behavior  of  the  isolated  seg- 
ments with  that  of  the  central  portion. 
The  dogs  bore  the  operations  well  and 
not  only  did  not  show  any  signs  of  ill- 
ness, but  increased  in  weight.  There  was 
never  any  sugar  in  their  urine.  On  au- 
topsy, nothing  unusual  was  noted  in  the 
gland  in  the  way  of  lesions.  The  tied 
portions  were  uniformly  atrophied  and 
did  not  show  the  special  resistance  in 
the  islands  of  Langerhans  which  has 
been  described  by  Schultze.  The  blood- 
vessels of  the  gland  were  very  much  di- 
lated, even  as  long  as  six  months  after 
the  operation,  and  their  walls  showed 
degenerative  changes,  except  in  the  cen- 
tral portion  of  the  pancreas.  The  islands 
of  Langerhans  showed  important  degen- 
erative changes,  and  the  fact  that  these 
changes  occurred  without  producing  any 
glycosuria  points  to  the  supposition  that 
these  structures  are  not  concerned  in 
the  function  of  the  pancreas  to  the  ex- 
tent supposed.  The  writer  thinks  that 
the  islands  of  Langerhans  represent  em- 
bryonal residues  in  the  gland,  or  that 
they  are  structures  which  have  a  more 
important  function  in  the  lower  verte- 


124 


PNEUMONIA. 


PNEUMONIA,  LOBAR,  SOME  IRREGULAR  FEATURES  OF. 


brates.     G.  Zamboni   (Eiforma  Medica, 

January  7,  1905). 

PNEUMONIA. 

The  author  believes  that  lie  has  often 
been  able  to  save  life  in  pneumonia  by 
the  treatment  he  advocates.  Two  illus- 
trative eases,  which  give  the  treatment 
in  detail,  are  recorded.  Quinine  and 
the  tincture  of  the  chloride  of  iron  are 
the-  "specifics."  The  iron  is  given  In 
15-minim  doses  every  three  hours;  the 
quinine  according  to  the  severity  of 
the  case.  In  the  first  ease  reported  the 
patient  received  90  grains  of  the  drug  in 
the  first  twenty-four  hours,  40  grains  in 
the  second,  and  45  grains  in  the  third. 
In  the  second  case  the  patient  received 
115  grains  in  two  unequal  doses  in  the 
first  hour  after  his  arrival  at  the  hos- 
pital, and  a  total  of  155  grains  in  the 
first  twenty-four  hours.  During  reso- 
lution quinine  must  be  used  with  care, 
as  cinchonism  may  be  produced  by  5  to 
10-grain  doses.  W.  J.  Galbraith  (Jour- 
nal of  the  American  Medical  Association, 
January  28,  1905). 

PNEUMONIA,  LOBAR,  SOME  IRREGULAR 
FEATURES  OF. 

The  author  points  out  the  sequel  em- 
pyema as  one  of  the  most  common  ir- 
regularities of  pneumonia  met  with. 
This  is  more  common  in  childhood  and 
early  life  than  in  older  patients.  The 
patient  generally  passes  the  crisis  as 
usual.  The  temperature  may.  or  may 
not,  go  to  normal.  But  the  writer  has 
never  seen  a  case  in  which  the  pain  and 
distress  completely  left  the  affected  side. 
In  from  twenty-four  hours  to  a  week  the 
temperature  begins  to  rise  and  fluctuate, 
the  pulse  becomes  weaker  and  more  rapid, 
chills  or  chilly  sensations  occur,  indicat- 
ing the  presence  of  pus.  If,  in  the  course 
of  pneumonia,  the  resistance  of  the  pul- 
monary   pleura    is    overcome,    and    the 


germs  of  the  disease  find  their  entrance 
to  the  pleural  cavity,  which  is  already 
congested  and  inflamed,  they  change  a 
plastic  or  serofibrinous  pleurisy  to  a 
purulent  one,  and  empyema  results.  The 
physician  should  never  forget  the  possi- 
bility of  the  development  of  this  com- 
plication in  cases  of  lobar  pneumonia,  in 
the  young  especially,  and  whenever  the 
pleura  is  extensively  involved,  and  the 
pain  unusually  severe  and  prolonged. 
Another  irregularity  of  lobar  pneumonia 
is  the  so-called  central  pneumonia,  or 
pneumonia  with  late  localization.  The 
chest  symptoms  develop  so  late  that  in 
some  cases  the  crisis  is  passed  before  a 
slight  pleuritic  friction  sound  is  de- 
tected, which  conclusively  establishes  the 
diagnosis.  The  amount  of  involvement 
of  the  lung  in  any  case  does  not  seem 
to    influence   the   temperature. 

Another  irregularity  is  called  migra- 
tory pneumonia.  It  begins  in  a  certain 
lobe,  and  while  it  runs  its  course  there, 
extends  to  one  or  more  other  lobes. 
There  may  be  a  crisis  for  each  lobe  in- 
volved. 

Tympanitis  is  a  serious  feature  of 
pneumonia.  It  is  due  to  a  partial  paral- 
ysis of  the  stomach  and  bowel,  accom- 
panied by  fermentation  of  their  con- 
tents. This  condition  is  doubtless  often 
aggravated  by  too  much  opiate  and  a  too 
copious  diet  of  milk.  The  effects  are 
mechanical  and  toxic.  The  lungs  and 
overworked  heart  are  pressed  upon,  and 
the  fermented  intestinal  products  are  ab- 
sorbed and  added  to  the  toxaemia  of  the 
disease.  TTnless  the  condition  can  be  re- 
lieved in  time,  the  end  is  without  doubt 
fatal. 

The  reflex  pain  in  the  initial  stages  of 
pneumonia  has  attracted  much  attention 
of  late.  Tt  sometimes  leads  the  physi- 
cian to  suspect  the  existence  of  gall- 
stones, peritonitis,  or  appendicitis.    Usu- 


PNEUMONIA,  TREATMENT  OF. 


125 


ally,  a  thorough  examination  of  the  chest 
will  reveal  the  existing  conditions.  A 
central  pneumonia  rarely  gives  rise  to 
much  pain.  In  every  case  of  abdominal 
pain,  the  lungs  should  be  examined,  and 
then  but  few  mistakes  will  be  made.  C. 
K.  Law  (Medical  News,  January  28, 
1905). 

PNEUMONIA,  TREATMENT  OF. 

The  writer  believes  in  an  early  and 
active  treatment  of  pneumonia  based  on 
the  pathology  of  the  disease  and  having 
in  view  the  warding  off  of  disastrous  con- 
sequences. He  scores  roundly  the  so- 
called  expectant  treatment.  The  object 
should  be  to  arrest  the  morbid  process 
by  other  abortive  measures  than  the 
missing  antitoxin ;  to  restrict  the  invad- 
ing host,  though  it  cannot  be  stopped; 
to  destroy  or  to  neutralize  the  poison 
by  the  vital  energies,  and  to  hasten  its 
elimination.  For  the  shock  of  the  in- 
vasion, immediate  recumbency,  warmth, 
and  a  small  dose  of  ether  or  brandy,  with 
hot  water,  are  indispensable.  A  sooth- 
ing draught  is  desirable,  such  as  am- 
monium bromide  with  aromatic  spirits 
of  ammonia.  A  dose  of  calomel  is  given 
at  once,  to  be  followed  half  an  hour 
later  with  a  senna  draught.  Arrange- 
ments must  be  made  for  the  immediate 
supply  of  oxygen,  which  is  to  be  admin- 
istered continuously  as  an  aid  to  the 
heart.  It  has  the  advantage  over  alcohol 
in  being  harmless  and  in  not  compli- 
cating the  alimentary  situation.  The  au- 
thor makes  leeching  a  routine  of  treat- 
ment quite  apart  from  the  question  of 
pain.  The  stronger  measure  of  venesec- 
tion may  be  required  in  some  cases,  but 
viewed  all  round  it  is  not.  perhaps,  so 
desirable  as  leeching.  Me  doubts  that  it 
should  be  resorted  to  after  consolidation 
has  occurred  except  as  a  desperate  rem- 
edy   when    heart    failure    is   threatened. 


The  abstraction  of  blood,  preferably  by 
leeching,  is  of  great  value  in  proportion 
to  the  early  date  of  its  employment  be- 
fore the  deposition  of  fibrin.  Sweating 
may  be  promoted  by  the  hot-air  bath, 
confined  to  the  lower  extremities,  or  by 
Rochester's  hot  mustard  footbath.  The 
chief  aims  of  medication  are  diaphoresis, 
diuresis,  antifibrinosis,  and  absorption. 
The  author  trusts  to  the  free  use  of  am- 
monium citrate,  to  which  sweet  spirits  of 
niter  may  be  added.  Sweating  is  encour- 
aged by  warm  beverages.  Divided  doses 
of  calomel  are  also  given.  Fluidity  of 
the  blood  is  brought  about  by  the  admin- 
istration of  citric  aeid,  which  precipitates 
the  calcium  which  is  essential  to  clotting, 
or  large  doses  of  iodide  of  potassium. 
The  administration  of  the  iodide  of  po- 
tassium is  continued  throughout  to  the 
end  of  the  attack.  The  author  has  pre- 
scribed it  to  the  extent  of  GO  grains  per 
day  with  good  result.  The  prescription 
which  he  uses  for  the  first  clay,  for  adults, 
is  as  follows: — 

ly   Potassii  iodidi,  gr.  v. 
Liq.  amnion,  eitratis,  3ij. 
Spts.  etheris  nitrosi,  5ss. 
Spts.  amnion,  arom.,  mxx. 
Aquae  chloroformi,  q.  s.  §ss. 

One  tablespoonful  of  this  mixture,  di- 
luted, is  given  every  hour  for  six  doses, 
and  subsequently  every  three  hours;  V6 
of  a  grain  of  calomel  is  taken  every  four 
hours. 

The  author  thinks  alcohol  in  modera- 
tion is  indispensable  from  the  first  as  a 
stimulant  and  as  a  food  substitute.  The 
diet  should  be  made  as  watery  as  possible. 
Whey  is  preferable  to  milk,  as  it  gives  no 
heavy  coagula  to  keep  up  fermentation. 

During  the  second  day  the  same  medi- 
cine may  be  continued.  Three  grains  of 
quinine,  in  pill  or  powder,  will  be  a  use- 
ful addition  to  each  dose.     Four  ounces 


126 


PROSTATIC  ENLARGEMENT. 


PROSTATIC  HYPERTROPHY. 


of  alcohol,  or  perhaps  six,  will  be  re- 
quired. The  whites  of  two  or  three  eggs 
can  be  added  to  the  whey  and  the  yolks 
beaten  up  with  gin  or  brandy.  A  quarter 
of  a  pound  of  sugar  should  also  be  given 
in  the  whey.  A  sleeping  draught  may  be 
required  if  the  patient  is  restless.  On 
the  following  days  support  is  the  main 
indication.  Kaw  meat  juice,  strong 
gravy,  predigested  foods  and  eggs  beaten 
up  should  be  substituted  for  the  whey, 
and  good  milk  given  in  tea  or  thickened 
with  cocoa. 

Oxygen  must  be  continued  and  strych- 
nine frequently  injected  in  anxious  cases. 
In  safe  cases  the  latter  may  be  included 
in  a  fresh  mixture  with  carminatives, 
and  iodide  of  potassium  and  quinine 
should  also  be  administered.  In  the 
worst  cases  a  second  leeching  or  even 
venesection  may  be  indicated.  As  a  pre- 
liminary to  the  latter,  two  single  doses 
of  digitalis  might  be  given  at  an  interval 
of  two  hours,  and  the  venesection  imme- 
diately preceded  by  a  10-minim  dose  of 
a  1  in  1000  solution  of  adrenalin  under 
the  skin.  The  further  treatment  must 
be  indicated  by  the  progress  of  the  case. 
For  the  gin  or  brandy,  whisky,  rum, 
champagne,  port  wine,  or  burgundy  may 
be  substituted  as  long  as  there  is  need 
for  a  stimulant.  The  writer  says  that 
the  virtues  of  red  wines,  particularly 
when  administered  hot  and  with  plenty 
of  sugar,  are  too  much  neglected  in  pneu- 
monia. He  regards  hot  lemonade  as  of 
value  in  the  early  stages,  particularly 
when  the  outer  glandular  layer  of  the 
lemon  is  also  made  to  yield  its  previous 
contents.  William  Ewart  (Lancet,  Jan- 
uary 21,  1905). 

PROSTATIC    ENLARGEMENT,    PATHOLOG- 
ICAL CHANGES  RESULTING  FROM. 

The  general  practitioner  should  be 
prepared  at  least  to  make  a  rectal  exam- 


ination of  the  prostate  whenever  symp- 
toms point  to  that  region.  If  hyper- 
trophic changes  are  found,  and  after 
careful  treatment  the  tumor  does  not 
diminish  in  size,  surgical  intervention 
should  be  advised  and  insisted  upon.  If 
infection  has  not  preceded  catheter  life 
it  is  sure  to  follow.  The  patient's  life 
under  this  condition  is  appalling  and 
most  pitiable. 

Early  prostatic  operations  are  not  dan- 
gerous; late  ones  are  always  dangerous 
and  frequently  fatal.  The  general  prac- 
titioner has  the  fate  of  the  prostatic  in 
his  hands,  either  to  guide  him  over  his 
trouble  or  to  advise  him  to  continue  a 
life  of  miserable  suffering  which  inten- 
sifies itself  toward  the  end.  C.  E.  Bar- 
nett  (Cincinnati  Lancet-Clinic,  Feb- 
ruary 25,  1905). 

PROSTATIC      HYPERTROPHY,      SURGICAL 
TREATMENT  OP. 

Literature  on  prostatic  surgery  has 
been  very  confusing  owing  to  the  large 
number  of  methods  of  operation  advo- 
cated by  prominent  surgeons.  Supra- 
pubic drainage  of  the  bladder  is  advised 
in  those  cases  too  weak  to  withstand  an 
operation;  if  improvement  follows  this 
procedure,  then  a  radical  operation  is  in- 
dicated. There  are  three  radical  methods 
that  are  without  doubt  the  most  valuable 
— suprapubic  prostatectomy,  perineal 
prostatectomy,  and  the  Bottini  opera- 
tion, and  each  of  these  has  a  definite 
place  in  prostatic  surgery. 

The  relative  advantages  and  dangers 
of  each  method  should  be  well  known,  as 
the  pathology  and  conditions  are  so 
varied  that  no  routine  treatment  for  all 
cases  can  be  advisable.  All  patients 
should  be  operated  on  before  the  break- 
down in  catheter  life,  and  the  earlier  the 
operation  the  fewer  will  be  the  compli- 
cations   encountered.      The    suprapubic 


PRURIGINOUS  DERMATOSES,  X-RAYS  IN. 


PRURITIS  ANI,  INVETERATE.        127 


route  is  indicated  when  there  is  a 
large  intravesicular,  mobile,  adenomatous 
growth,  with  general  health  and  bladder 
and  kidneys  in  a  satisfactory  condition. 

The  perineal  operation  is  more  desir- 
able for  small,  dense,  fibrous  prostates 
firmly  attached,  and  those  where  the 
growth  is  largely  along  the  urethra  or 
back  toward  the  rectum.  The  Bottini  is 
indicated  in  those  cases  where  prostatec- 
tomy is  refused,  and  in  selected  cases, 
where  the  general  health  and  kidneys 
contraindicate  more  radical  measures. 
Of  course,  it  is  never  to  be  used  for  a 
large,  rapidly  growing  hypertrophy. 

In  the  suprapubic  operations  haemor- 
rhage is  to  be  avoided  by  keeping  care- 
fully between  the  capsule  and  sheath.  In 
the  perineal  operations  the  central  ten- 
don of  the  perineum  should  be  carefully 
cut  close  to  the  rectum,  but  with  the 
finger  in  it  to  prevent  injury.  Lacera- 
tion of  membranous  urethra  should  be 
avoided,  as  incontinence  of  urine  will 
follow. 

Marked  improvement  results  in  the 
large  majority  of  cases  where  the  opera- 
tion has  been  properly  selected  and  care- 
fully performed.  E.  G.  Ballenger  (Med- 
ical Eecord,  February  4,  1905). 

PRURIGINOUS  DERMATOSES,  X-RAYS  IN 
THE  TREATMENT  OF. 
The  skin  should  absorb  as  quickly  as 
possible  the  quantity  of  rays  necessary 
for  a  cure,  provided  always  that  this 
quantity  is  compatible  with  the  main- 
tenance of  the  integrity  of  the  skin.  If 
this  should  not  be  possible  the  maximum 
dosage  that  can  be  employed  with  safety 
should  be  administered  at  each  session  or 
series  of  sessions.  An  interval  of  fifteen 
or  twenty  days  should  elapse  between  any 
two  applications.  Treatment  should  not 
be  resumed  until  the  reaction  has  nearly 
or  quite  subsided,  the  relative  condition 


of  the  tissues  and  the  lesion  being  the 
guide  as  to  the  dosage  to  be  administered. 
By  observing  the  foregoing  method  the 
author  has  entirely  avoided  the  produc- 
tion of  severe  accidents  in  all  the  150 
cases  which  he  has  treated  by  radio- 
therapy. Belot  (Archives  of  the  Roent- 
gen Bay,  January,  1905). 

PRURITUS    ANI,     INVETERATE,     TREAT- 
MENT OP. 
The  author's  method,  a  surgical  one, 
is    as    follows:     The   skin   having   been 
closed,  a  curved  incision  is  made  on  each 
side  of  the  affected  area,  enclosing  the 
entire  ellipse,  with  the  exception  of  a 
narrow  neck  in  front  and  behind;   these 
incisions  are  carried  down  the  sphincter 
muscles  and  the  flaps  raised  by  careful 
dissection  with  scissors  from  the  surface 
of  the  muscle,  round  its  anal  origin  and 
up  the  anal  canal  to  above  the  muco- 
cutaneous   junction,    the    dissection   ex- 
tending round  the  entire  circumference, 
all  connections  with  the  subjacent  tissue 
being  divided.    The  pedicles  in  front  and 
behind  are  now  undercut  to  a  point  well 
beyond  the  area  of  irritation,  and  the 
outer  concave  edges  of  the  incision  are 
also  undercut  to  a  distance  of  at  least 
a  quarter  of  an  inch  free  of  the  involved 
skin  all  round.     Care  must  be  taken  to 
stop  all  bleeding  before  the  flap  is  re- 
placed, as  the  formation  of  a  hematoma 
in  the  wound  might  interfere  with  the 
vitality    of    the    flaps.      The    flaps    are 
finally  replaced  and  retained  by  sutures, 
a  few  intervals  being  left  between  them 
for  drainage.     The  immediate  result  of 
this   operation   is   to    render   the   entire 
ellipse  included  between  the  incision,  the 
pedicles  and  outer  edges  as  far  as  they 
have  been  undercut,  superficially  anaes- 
thetic, and  the  itching  is  at  once  relieved. 
Throe  eases  in   which   this  method  was 
used  demonstrate  that  the  operation  gives 


128 


PURGATION,  ABUSE  OF. 


RENAL  CALCULUS,  DIAGNOSIS. 


immediate    relief,    and    that    superficial 

sensation  may  be  destored  without  recur- 
rence of  pruritus.  Should  recurrence  of 
pruritus  supervene  after  the  operation, 
the  removal  of  the  posterior  roots  of  the 
third  and  fourth  sacral  nerves,  with  their 
ganglia,  would  have  to  be  considered. 
Charles  Ball  (British  Medical  Journal, 
January   21,   1905). 

PURGATION  BEFORE  AND  AFTER  OPER- 
ATION, THE  ABUSE  OF. 

Excessive  purgation  should  be  re- 
stricted because  it  is  enervating  to  the 
general  system.  It  produces  great  irri- 
tation to  the  mucous  lining  of  the  bowel. 
It  may  add  to  some  of  the  dangers  most 
anxiously  avoided :  ileus  and  paresis. 
Purgatives  have  very  little  effect  in  lim- 
iting the  amount  of  extraperitoneal  exu- 
date and  fluids.  Instead  of  calomel  and 
saline  purgation,  bland  evacuants  such 
as  castor-oil  should  be  used  before  abdom- 
inal section.  The  use  of  suitable,  bland 
non-fermentative  foods  is  desirable  until 
just  before  operation  in  weak  patients. 
After  operation  peristalsis  should  be  lim- 
ited ;  only  small  quantities  of  food  and 
drink  given  by  the  mouth.  Opium  should 
rarely  be  given.  Enemas  should  be  ad- 
ministered to  relieve  distention  and  cause 
peristalsis  in  downward  direction.  After 
normal  peristalsis  laxatives  should  be 
given  as  required.  I.  S.  Stone  (Amer- 
ican Medicine.  February  25,  1905). 

RENAL  AND   URETERAL   CALCULI,    DIAG- 
NOSIS OF. 

The  writer  wishes  to  emphasize  the  im- 
portance of  early  diagnosis  in  renal  and 
ureteral  calculi  for  the  following  reasons: 
By  early  surgical  interference  the  kidney 
can  be  saved  and  the  patient  given  relief 
from  a  disease  which,  "though  swift  and 
fatal  in  anuria,  torturing  in  colic,  and 
slowly,  grimly   progressive   in   suppura- 


tion, also  presents  possible  vistas  of  years 
of  comparative  health  and  comfort,  a  de- 
lusive prospect  with  which  the  timorous 
sufferer  would  fain  brace  his  refusal  ol 
the  knife." 

The  operation  of  nephrolithotomy 
offers  a  perfect  cure.  No  opera-ion  in 
surgery  is  attended  with  more  brilliant 
success.  The  mortality  of  this  operation 
is  about  the  same  as  that  of  lithotrity, 
while  the  dangers  of  nephrotomy  and 
nephrectomy  are  many  times  greater. 

By  an  early  diagnosis  and  operation, 
alarming  and  distressing  complications 
and  a  final  resort  to  these  more  serious 
operations  may  be  avoided.  H.  A.  Fow- 
ler (Medical  Eecord,  February  I,  1905). 

RENAL     CALCULUS,     DIAGNOSIS     OF,     BY 
MEANS  OF  X-RAYS. 

The  writer  details  his  experience  based 
on  the  examination  of  125  patients.  In 
30  of  these  a  positive  diagnosis  was  made 
by  means  of  one  or  more  plates,  and  the 
presence  of  stone  was  confirmed  by  oper- 
ation. In  26  the  deposits  were  in  the 
renal  pelvis  or  extreme  upper  end  of. the 
ureter;  in  I  in  the  pelvic  portion  of  the 
ureter.  The  author's  conclusions  are  as 
follows:  The  positive  diagnosis,  of  kid- 
ney stone  by  the  x-rays  is  reliable  and  of 
great  practical  value.  The  negative  diag- 
nosis of  kidney  stone  by  the  x-rays  is 
reliable  and  valuable  up  to  a  certain 
limit.  If  pictures  of  a  proper  quality 
are  obtained,  calculi  of  oxalate  of  lime 
and  phosphates  can  be  excluded.  Pure 
uric  acid  calculi  cannot.  Pictures  of  a 
proper  quality  can  be  obtained  with  ease 
in  children,  and  slender  adults  of  both 
sexes.  Such  pictures  can  usually  be  ob- 
tained by  repeated  trials  in  well-nour- 
ished adults.  When  patients  are  un- 
usually stout,  when  the  abdomen  is  very 
thick  and  the  buttocks  are  large,  the 
conditions    are   extremely    difficult,    and 


RENAL  CAPSULE,  THE  FUNCTION. 


RHEUMATISM,  RARER  FORMS.       129 


only  occasionally  will  a  satisfactory  re- 
sult be  obtained  with  the  present  form 
of  apparatus.  A.  B.  Johnson  (New 
York  Medical  Journal  and  Philadelphia 
Medical  Journal,  February  1,  1905). 

RENAL  CAPSULE,  THE  FUNCTION  OF  THE. 
The  recent  therapeutic  application  of 
decapsulation  of  the  kidney  with  bene- 
ficial  results   in   cases   of  colicky   pains, 
hematuria,  and  albuminuria,  and  the  still 
more  recent  cures  of  simple  Brighfs  dis- 
ease reported  by  the  use  of  this  simple 
surgical  procedure,  impart  a  peculiar  in- 
terest to  the  research  conducted  by  the 
author  in  the  role  of  the  renal  capsule 
for  the   function   of   the   kidney.     The 
fibrous  coverings  of  the  liver,  spleen,  pan- 
creas, and  all  other  parenchymatous  or- 
gans, when  compared  with  that  of  the 
kidney,  show  the  following  marked  dif- 
ference, namely:    that  while  the  former 
are  very  thin  and  rightly  adherent,  form- 
ing an  integral  part  of  the  organ,  the 
latter  is  a  strong  fibrous  covering,  easily 
detached  from  the  organ.     The  author 
assumes,  a  priori,  that  the  capsule  of  the 
kidney   is   functionally   more   important 
than   the  capsules   of  the  other  organs. 
By  means  of  the  oncometric  method  of 
investigation,  which  records  the  minutest 
changes   in   the  size  of  the  kidney,  the 
author  sought  to  discover  the  influence  of 
the  capsule  on  the  kidney.    Tie  used  two 
different    agents    with    which    to    bring 
about    a   shrinkage  of  the  kidney:    ad- 
renalin,   which    actively    contracts    the 
blood-vessels   of    the   kidney   simultane- 
ously with  tin1  rise  of  the  general  blood- 
pressure,  and   stimulation   of  the  vagus 
nerve,  which  causes  a  diminished  supply 
of  blood  to  the  kidney  through  the  weak- 
ening of  the  hearl  action  and  the  conse- 
quent  fall    in   blood-pressure.     Twenty- 
four  or   forty-eight   hours   after   decap- 
sulation of  a  dog's  kidney,  the  author 


clasped  it  in  the  oncometer  and,  after 
taking  the  normal  tracing,  either  in- 
jected adrenalin  or  stimulated  the  vagus. 
On  comparing  the  resulting  tracing  with 
that  obtained  from  the  non-capsulated 
kidney,  he  finds  that  in  the  latter,  im- 
mediately after  the  injection  or  stimula- 
tion, the  tracing  falls,  then  continues  for 
some  time  on  the  same  level,  but  always 
shows  pulsation  and  returns  to  the  old 
level,  mostly  even  before  the  tracing  of 
the  carotid  becomes  normal.  In  the  de- 
capsulated  kidney  the  tracing  also  falls 
immediately  after  the  injection,  then  for 
a  considerable  length  of  time  continues 
as  a  straight  line,  showing  an  absolute 
cessation  of  pulsation  in  the  kidney,  and 
returns  to  the  normal  much  later  than 
the  carotid  blood-pressure.  From  these 
results  the  author  draws  the  following 
conclusion :  Any  stimulus,  which  either 
by  contracting  the  general  blood-pressure 
or  weakening  the  action  of  the  heart, 
diminishes  the  size  of  the  kidney,  exerts 
a  much  stronger  influence  on  the  decap- 
sulated  kidney  than  on  the  normal  one, 
and  this  influence  also  lasts  longer  on 
the  former.  The  capsule  acts  like  an 
elastic  covering.  On  the  one  hand  it 
prevents  an  undue  overfilling  of  the  kid- 
ney with  blood,  on  the  other  hand  it  does 
not  allow  the  kidney  to  remain  contracted 
and  bloodless  for  a  long  time.  T.  Levin 
(American  Journal  of  Physiology,  No- 
vember 4,  1904). 

RHEUMATISM,  THE  RARER  FORMS  OF. 

Some  interesting  comments  mi  this 
subject  are  made  by  the  author,  who  be- 
lieves that  a  sharp  line  must  be  drawn 
between  muscular  and  joint  rheumatism. 
To  secure  uniformity  and  to  avoid  con- 
fusion, the  term  muscular  rheumatism 
ought  to  he  dropped,  and  the  word  rheu- 
matism applied  to  that  inflammatory 
condition  of  the  various   locomotive  or- 


130 


RUPTURE  INTESTINES. 


SCARLET  FEVER,  INFECTIVITY. 


gans  and  their  appendages  which  result 
from  sudden  changes  of  temperature. 
Persons  inclined  to  rheumatism  need  not 
therefore  fear  intense,  uniform  cold, 
but  rather  over-heating,  especially  that 
brought  about  by  muscular  exertion,  fol- 
lowed by  sudden  rest  and  cooling.  The 
quickest  and  most  reliable  remedy  in 
cases  of  fresh  or  acute  rheumatism  is  ex- 
ercise. The  patient  may  safely  indulge 
in  all  those  movements  whicb  cause  pain, 
but  care  should  be  taken  to  exclude  joint 
rheumatism.  Chronic  rheumatism  can 
only  be  cured  by  mechanotherapy,  in 
which  active  and  passive  movements  play 
an  important  part.  Among  the  rarer 
sites  for  rheumatism,  which  are  little 
mentioned  in  the  literature,  are  the  fol- 
lowing :  A  rheumatic  process  in  the  peri- 
osteum of  the  ribs,  the  sternum,  and  the 
long  bones;  rheumatism  of  the  dia- 
phragm, isolated  rheumatism  of  the  coc- 
cyx and  the  pelvic  outlet;  and  localized 
rheumatism  of  the  muscles  of  mastica- 
tion. Instances  of  these  are  cited  and 
good  results  were  secured  in  all,  but  that 
of  the  diaphragm,  by  forcible  massage. 
For  rheumatism  of  the  diaphragm  the 
faradic  current  gave  some  relief.  A 
number  of  localities  are  mentioned  which 
are  favorite  sites  of  the  rheumatic  proc- 
ess, mostly  muscular  attachments.  J. 
Schreiber  (Berliner  klinische  Wochen- 
schrift,  November  21,  1904). 

RUPTURE  OF  THE  INTESTINES. 

The  author  has  studied  a  number  of 
cases  of  traumatic  rupture  of  the  intes- 
tine in  which  there  was  no  injury  to  the 
abdominal  wall.  Two  personal  cases  are 
reported  in  full.  The  author  considers 
the  symptomatology  and  diagnosis  of 
these  often  obscure  cases.  Any  injury 
to  the  abdomen  may  be  associated  with 
damage  to  the  intestine  or  other  viscera. 
An  exploratory  operation  is  justifiable  in 


cases  with  distinct  rigidity.  An  opera- 
tion is  absolutely  indicated  when  there 
is,  besides  rigidity,  pain,  tenderness, 
vomiting,  shock,  dullness,  or  other  symp- 
toms indicative  of  some  intra-abdominal 
disturbance.  Cases  not  operated  in  are 
lost.  The  importance  of  early  operation 
cannot  be  too  strongly  emphasized.  At 
present  the  death  rate  is  about  75  to  80 
per  cent.  When  a  greater  proportion  are 
operated  upon  early,  the  death  rate  will 
be  much  lower.  C.  P.  Flint  (Medical 
Record,  February  18,  1905). 

SCARLET  FEVER,  INFECTIVITY  AND 
MANAGEMENT  OF. 
The  infective  agent  in  scarlet  fever  has 
been  proved  definitely  to  be  present  in  the 
throat,  and  not  infrequently  in  the  nasal 
cavities  also.  The  bacterial  poison  ex- 
hibits a  selective  action,  affecting  the 
kidneys  and  the  superficial  layers  of  the 
skin,  resulting  in  desquamation,  but  in 
all  probability  the  desquamating  cuticle 
is  not  infective.  As  in  diphtheria,  it  is 
impossible  to  ascertain  definitely  by  clin- 
ical means  when  the  patient  has  been 
freed  from  infection.  It  is  probable, 
however,  that  the  majority  of  patients 
are  free  from  infection  at  the  end  of  the 
minimum  period  of  isolation  usually 
prescribed  six  weeks.  Transmission  of 
infection  is  especially  liable  to  occur 
from  those  who  suffer  or  have  suffered 
from  rhinitis,  and  a  nasal  discharge  is 
always  to  be  viewed  with  suspicion.  The 
conditions  necessary  for  the  transmission 
of  the  disease  are  the  following:  The 
contagium  must  be  present  in  a  form 
capable  of  being  carried ;  there  must  be 
a  vehicle  for  its  conveyance;  it  must  be 
actually  conveyed  to  a  mucous  mem- 
brane; the  germ  must  be  still  virulent 
when  received;  the  dose  must  be  suffi- 
ciently large;  and  the  receiver  must  be 
susceptible  to  infection. 


SCIATICA,  TREATMENT  OF.  SERUM  INJECTIONS,  EFFECT  ON  BLOOD.  131 


The  author  favors  hospital  treatment, 
especially  among  the  poorer  classes. 
Among  the  drawbacks  of  segregation. 
however,  are  the  following :  The  risk,  in 
case  of  a  wrong  diagnosis,  of  the  patient's 
acquiring  scarlet  fever;  the  possibility 
of  secondary  infection  with  some  other 
disease;  the  longer  period  of  isolation; 
differences  in  virulence  of  cases  in  the 
same  ward,  with  resulting  detriment  to 
the  milder  cases;  detention  because  of 
simple  rhinitis;  reinfection;  the  oc- 
currence of  "return"  cases  on  the  pa- 
tient's return  home.  W.  T.  G.  Pugh 
(Lancet,  February  4,  1905). 

SCIATICA,   TREATMENT    OF. 

The  author  describes  a  plan  which  he 
has  found  prompt  in  giving  relief  in  in- 
tractable cases  of  sciatica.  The  method 
consists  in  injecting  a  considerable  quan- 
tity of  fluid  into  the  nerve  itself,  and  is 
carried  out  as  follows :  The  solution  used 
contains  1  part  to  1000  of  eucaine-B  in 
8  per  cent,  salt  solution,  and  is  sterilized 
,  by  heat.  The  point  of  exit  of  the  nerve 
from  the  sciatic  foramen  is  located,  and 
the  superficial  parts  are  anaesthetized 
with  the  solution  in  a  syringe  provided 
with  a  long  needle.  The  needle  is  then 
carried  deeper  into  the  tissues  down  to 
the  nerve,  which  is  situated  at  a  depth 
of  about  7  centimeters,  and  is  not  diffi- 
cult to  strike,  as  it  is  over  a  centimeter 
in  width.  The  course  of  the  needle 
through  the  skin  and  muscle  is  not  pain- 
ful, but  as  the  nerve  sheath  is  entered  the 
patient  gives  a  convulsive  jerk.  This  in- 
dicates that  the  nerve  has  been  reached, 
but  the  pain  lasts  only  a  moment,  as  the 
fluid  is  at  once  injected,  7%oo  cubic  cen- 
timeters being  forced  in  quite  rapidly. 
The  patient  is  told  not  to  lie  on  the  af- 
fected side  for  some  time  after  the  in- 
jection, and  the  feeling  of  tension  pro- 
duced   usually    disappears    after    a  few 


hours.  In  some  cases  the  injection  must 
be  repeated  after  several  hours.  A  rise 
of  temperature  was  observed  in  some  of 
the  cases,  but  this  promptly  subsided. 

The  author's  cases  were  eleven  in  num- 
ber, and  in  five  the  treatment  was  effect- 
ual, twice  after  a  single  injection,  and 
three  times  after  two  injections.  An- 
other case  was  doubtful,  four  were  im- 
proved, and  one  was  not  influenced.  Al- 
though the  number  of  cases  is  small,  the 
dramatic  nature  of  the  prompt  and  com- 
plete cures  obtained  in  bed-ridden  pa- 
tients whose  suffering  had  not  yielded  to 
any  of  the  ordinary  anodynes,  leads  the 
author  to  publish  his  results  in  the  hope 
that  others  will  make  use  of  it  in  order 
to  determine  the  type  of  cases  amenable 
to  the  method,  and  the  permanency  of 
the  cures  thus  affected.  Lange  (Munclr 
ener  medicinische  Wochenschrift,  De- 
cember 27,  1904;  from  Medical  Eecord, 
January  21,  1905). 

SERUM  INJECTIONS,  THE  EFFECT  OF,  ON 
THE  BLOOD. 

The  writer  has  tested  the  effect  of  in- 
jections of  diphtheria,  tetanus,  and  anti- 
streptococcus  serum  on  the  blood  of 
healthy  rabbits  with  the  following  re- 
sults :  In  all  cases  the  serum  produced  a 
slight  and  transient  decrease  in  the  num- 
ber of  red  blood-corpuscles  and  in  the 
amount  of  haemoglobin.  The  specific 
gravity  of  the  blood  showed  no  constant 
change.  Small  doses  of  the  serum  pro- 
duced no  leucocyte  reaction;  larger 
doses  produced  a  leucocytosis,  lasting  a 
few  days.  The  temperature  of  the  body 
showed  no  noteworthy  alteration.  With 
the  diphtherial  serum  the  body  weight 
was  slightly  diminished,  but  not  with  the 
others.  The  general  state  of  the  animals 
showed  no  pathological  change,  even  with 
large  doses.  When  the  antitoxic  activity 
of  the  serum  was  destroyed  by  heating, 


132         SLEEP,  BIOLOGICAL  THEORY. 


STOMACH,  PASSAGE  OF  FOOD  FROM. 


precisely  the  same  effects  were  observed 
to  follow  its  injection,  and  similar  effects 
were  noticed  after  the  injection  of  normal 
horse  serum.  The  conclusion  arrived  at 
was  that  the  serums  had  no  prejudicial 
effect  on  the  animal  economy  beyond  that 
which  the  normal  serum,  free  from  any 
antitoxic  substances,  possessed.  Ku- 
charzewski  (Arch.  Internat.  de  Phar- 
macodynamic et  de  Therapie,  vol.  xii,  p. 
117,  1904;  from  British  Medical  Jour- 
nal, February  11,  1905). 

SLEEP,  BIOLOGICAL  THEORY  OF. 

The  writer  considers  as  erroneous  the 
usually  accepted  conception  according  to 
which  sleep  is  thought  to  be  the  conse- 
quence of  an  arrest  of  functioning,  by 
intoxication  and  by  asphyxia.  He  be- 
lieves, on  the  contrary,  that  sleep  is  a 
positive  function,  an  instinct  which  has 
for  its  purpose  arrest  of  functioning.  It 
is  not  because  we  are  intoxicated  or  ex- 
hausted that  we  sleep,  but  we  sleep  in 
order  to  avoid  these  conditions.  The  fact 
that  sleep  is  not  proportional  to  exhaus- 
tion is  an  argument  in  favor  of  this 
theory.  Sleep  may  be  partial.  One 
sleeps  through  certain  noises,  but  not 
through  others.  Finally,  the  curve  of 
the  profoundness  of  sleep,  inexplicable  by 
the  toxic  theory,  is  in  harmony  with  the 
theory  that  regards  this  phenomenon  as 
a  positive  nervous  function.  The  in- 
stinct, the  reflex  is  provoked  by  numer- 
ous excitants:  endogenous  (condition  of 
the  blood,  sensation  of  fatigue),  exogen- 
ous (images  empirically  associated  with 
the  idea  of  sleep).  The  phenomenon  in 
itself  is  a  reaction  produced  by  these  ex- 
citants, and  is  an  inhibition  which  mani- 
fests itself  subjectively  by  a  lack  of 
interest  in  exterior  things.  Clapar^de 
(La  Presse  Medicale,  December  21, 
1904). 


STOMACH,  THE  PASSAGE  OF  FOODSTUFFS 
FROM  THE. 
By  means  of  the  Eoentgen  rays  the 
writer  was  able  to  study  the  time  it  takes 
the  various  foodstuffs,  mixed  with  bis- 
muth snbnitrate,  to  pass  from  the  stom- 
ach. Fats  remain  long  in  the  stomach. 
The  discharge  of  fats  begins  slowly  and 
continues  at  nearly  the  same  rate  at 
which  the  fat  leaves  the  small  intestine 
by  absorption  and  by  passage  into  the 
large  intestine.  Consequently  there  is 
never  any  great  accumulation  of  fat  in 
the  small  intestine.  Carbohydrate  foods 
begin  to  leave  the  stomach  soon  after 
their  ingestion.  They  pass  out  rapidly, 
and  at  the  end  of  two  hoars  reach  a 
maximum  amount  in  the  small  intes- 
tine almost  twice  the  maximum  for  pro- 
teids,  and  two  and  a  half  times  the 
maximum  for  fats,  both  of  which  max- 
ima are  reached  only  at  the  end  of  four 
hours.  The  carbohydrates  remain  in  the 
stomach  only  about  half  as  long  as  pro- 
teids.  These  frequently  do  not  leave  the 
stomach  at  all  during  the  first  half  hour. « 
After  two  hours  they  accumulate  in  the 
small  intestine  to  a  degree  only  slightly 
greater  than  that  reached  by  carbohy- 
drates, an  hour  and  a  half  earlier.  Egg 
albumin  is  discharged  from  the  stomach 
at  about  the  carbohydrate  speed.  Doub- 
ling the  amount  of  carbohydrate  food 
increases  the  rapidity  of  the  carbohydrate 
outgo  from  the  stomach  during  the  first 
two  hours;  whereas  doubling  the  amount 
of  proteid  food  strikingly  delays  the  in- 
itial discharge  of  proteid  from  the  stom- 
ach. The  interval  between  feeding  and 
the  appearance  of  food  in  the  large  intes- 
tine is  variable,  but  the  mean  for  car- 
bohydrates is  about  four  hours,  for  pro- 
teids  about  six  hours,  and  for  fats  about 
five  hours.  W.  B.  Cannon  (American 
Journal  of  Physiology,  December  1, 
1901). 


SUBCUTANEOUS  ALIMENTATION. 


SYPHILITIC  RECRUDESCENCES.       133 


SUBCUTANEOUS   ALIMENTATION. 

The  author  has  used  subcutaneous  ali- 
mentation for  a  number  of  years  and,  in 
suitable  cases,  has  found  it  of  consider- 
able service.     His  experience  has  been 
chiefly  with  surgical  cases.     At  present 
this   method   of   administering   nourish- 
ment is  still  in  its  infancy.    His  experi- 
ence has  been  chiefly  with  isotonic  salt 
and  sugar  solutions  and  with  olive  oil. 
With  the  latter  substance  his  experience 
has  been  very  limited.     1.  Normal  salt 
solution.     This  is  used  mostly  for  fur- 
nishing fluid  to  the  tissues.     A  9/10  of 
one  per   cent,   solution   is   advised.     It 
may  be  given  either  subcutaneously  or 
intravenously.      2.  Isotonic   sugar   solu- 
tion.    This  is  given  for  its  food  value. 
A  5  per  cent,  solution  is  isotonic  to  the 
blood.     It  should  be   given  subcutane- 
ously, best,  at  the  inner  side  of  the  arm 
near  the  axilla.     The  total  quantity  to 
be  used   at   each   injection.      3.  Sterile 
olive  oil,  while  theoretically  of  high  po- 
tential food  value,  is  probably  not  very 
efficacious,  as  it  is  absorbed  very  slowly. 
A.  E.  Barker  (American  Medicine,  Feb- 
ruary 1,  1905). 

SUPPURATION,      TEMPERATURE      AS      A 
GUIDE  TO  THE  EXISTENCE   OF. 

Chronic  suppurative  processes  are  very 
frequently  unattended  by  fever.  Acute 
suppurative  processes  are  frequently  un- 
attended by  fever;  therefore,  in  a  given 
case  the  absence  of  fever  must  have  little 
weight  by  itself  in  excluding  the  possi- 
bility of  suppuration.  Since  a  rise  of 
temperature  above  100°  F.  occurs  in 
about  two-thirds  of  all  aseptic  cases,  the 
presence  of  fever  alone  must  have  little 
weight  in  making  a  diagnosis  of  sup- 
puration. Lyman  Allen  (International 
Journal  of  Surgery,  February,  1905). 


SUPRARENAL     PREPARATIONS,     EFFECT 
OF,    ON   LIVING   PROTOPLASM. 

The  author  performed  a  series  of  ex- 
periments in  order  to  determine  the  ef- 
fect of  suprarenal  preparations  on  living 
protoplasm.     The  results  of  this   work 
go  to  show  that  suprarenal  preparations 
have  a  marked  effect  on  cell  division  of 
healing  tissue  and  upon  the  proliferation 
of  cells  constituting  granulation  tissue. 
It  may  be  assumed  that  these  solutions 
will  have  an  effect  depending  upon  the 
strength  of  the  solution  as  well  as  the 
duration  of  the  exposure,  and  that  it  is 
possible  to  kill  cells  or  to  prevent  their 
activity,   or   retard   cell   division.     The 
writer  believes  that  the  vitality  of  pro- 
toplasm is  weakened  by  suprarenal  solu- 
tions.   As  to  the  effect  of  these  prepara- 
tions on  cilia,  in  solutions  of  0.000003, 
there  was  an  increase  in  the  activity  of 
the  ciliate  movement  over  the  normal,  in 
the   eggs   of   the  sea-urchins,   while   in 
other  strength  solutions  there  was  a  de- 
crease.    The  turtle  heart  was  used  to 
determine  the  effect  on  contractile  tissue. 
The  experiments  all  showed  that  supra- 
renal   solutions    were    powerful    muscle 
stimulants.    The  writer  believes  that  we 
are  warranted  in   asserting  that  supra- 
renal preparation,  at  least  in  the  lower 
animals  studied,  have  a  tremendous  in- 
fluence on  the  power  of  cell  division,  on 
the  development  of  protoplasm,  on  the 
movement  of  cilia,  and  on  contractile  tis- 
sue.   Beaman  Douglass  (American  Jour- 
nal Medical  Sciences,  January,  1905). 

SYPHILITIC    RECRUDESCENCES,    THE 
PATHOGENESIS   OF. 

The  clinical  course  of  syphilis  presents 
so  many  puzzling  features  that  it  lias 
always  furnished  a  fruitful  source  of 
speculation  to  pathologists.  The  fact 
that  a  disease  may  give  rise  to  repeated 


134 


SYPHILITIC  RECRUDESCENCES,  THE  PATHOGENESIS  OF. 


relapses  years  after  its  beginning  and 
that  serious  sequelae  not  infrequently  de- 
velop after  even  decades  of  apparent 
health,  is  sufficiently  curious  to  account 
for  the  circumstance  that  even  the  mas- 
ter minds  of  medical  science  have  not 
been  able  to  furnish  unassailable  explana- 
tions for  the  phenomenon.  At  the  pres- 
ent day  theorists  are  necessarily  ham- 
pered by  a  lack  of  knowledge  as  to  the 
contagium  concerned,  and  it  is  probable 
that  only  the  discovery  of  the  exact  char- 
acter of  the  syphilitic  virus  and  its  re- 
lationship to  the  various  pathological 
changes  manifested  by  different  phases 
of  the  malady  will  permit  a  satisfactory 
insight  into  the  nature  of  the  disease 
process.  So  long  as  this  remains  obscure 
the  problem  must  be  approached  from 
the  clinical  side,  and  the  chances  of  error 
are  necessarily  large. 

Virchow  considered  that  the  spasmodic 
character  of  the  outbreaks  indicated  an 
irregular  outpouring  of  active  virus  into 
the  blood,  thus  giving  rise  to  virtually 
fresh  infections.  The  lymph  nodes  were 
to  be  regarded  as  the  depositories  of  the 
latent  virus,  which  from  time  to  time  was 
set  free,  entered  the  blood,  and  brought 
about  a  renewal  of  the  symptoms. 

Finger  adopted  a  radically  different 
stand  and  assumed  a  bacterial  nature  of 
the  virus  as  his  point  of  departure.  In 
an  extensive  critical  study,  published  in 
1890,  he  came  to  the  conclusion  that  the 
primary  and  secondary  lesions  were 
caused  by  the  virus  itself,  but  that  the 
immunity  and  tertiary  symptoms  were 
the  result  of  metabolic  products  of  the 
virus  which  gave  rise  to  special  reactions 
of  the  organism  leading  to  the  develop- 
ment of  the  late  manifestations.  Tbis 
view  was  supported  by  the  quasi  chemical 
affinities  of  the  two  types  of  lesions,  the 
early  ones  due  to  the  virus  responding  to 
mercury,  whereas  the  others,  depending 


on  the  reaction  products,  are  most  easily 
influenced  by  iodine. 

Lesser,  in  a  contribution  to  the  recent 
Festschrift,  dedicated  to  Senator,  adopts 
the  older  hypothesis  of  Lang.     This  au- 
thor presupposes  that  at  the  time  of  in- 
fection the  virus  is  carried  by  the  blood 
into  all  the  tissues,  and  occasions  the 
early  manifestations.     The  virulence  of 
the  deposited  contagium  gradually  abates, 
but  it  still  for  a  time  retains  the  ability 
to  incite  recrudescences  of  the  symptoms. 
After  a  variable  period  it  is  either  par- 
tially or  entirely  destroyed,  and  in  the 
former  cases  is  modified  to  such  a  degree 
that  it  loses  its  infectious  nature.    Dur- 
ing this  period  of  dormancy  it  remains 
quiescent   unless    some,    often    external, 
stimulus   provokes    it   into    action,    and 
gives  rise  to  the  late  manifestations  of 
the  disease.     This  view  is  in  harmony 
with    the    clinical   observation   that   the 
early  lesions  are  apt  to  be  symmetrical, 
while  the  late  symptoms  are  characterized 
by  asymmetry.    Lesser  cites  several  cases 
in  support  of  this  theory,  in  which  recur- 
rences of  the  skin  eruption  took  place  in 
the  pigmented  spots  left  behind  by  the 
first  exanthem.    He  summarizes  his  con- 
ception of  the  matter  by  stating  that  in 
the    eruptive    stage    the    entire   body    is 
flooded  with  syphilitic  poison,  and  that 
this  is  deposited  more  or  less  uniformly 
in  numerous  foci,  which  serve  as  sources 
of  relapse  during  the  course  of  the  dis- 
ease.   As  the  length  of  time  after  infec- 
tion increases,  more  and  more  of  these 
persisting  germs   perish   and   they   may 
finally  disappear  completely. 

The  practical  bearing  of  this  assump- 
tion lies  in  its  application  to  the  thera- 
peutical management  of  the  disease.  In 
order  to  hasten  the  diniinution  and  neu- 
tralization of  these  depots  of  latent  virus, 
frequent  repetitions  of  the  course  of 
medication  are  necessary,  and  the  advo- 


TENDON  REFLEXES  IN  INFECTIONS. 


THYROIDISM,  POSTOPERATIVE.       135 


cates  of  intermittent  mercurial  treat- 
ment should  find  a  potent  argument  for 
their  cause  in  this  theory  of  the  pathog- 
enesis of  late  syphilitic  manifestations. 
Editorial  (Medical  Record,  January  28, 
1905). 

TENDON  REFLEXES,  INCREASED,  IN  IN- 
FECTIONS. 

The  writer  takes  the  view  that  the 
ideas  concerning  the  significance  of  in- 
creased tendon  reflexes  in  diseases  other 
than  affections  of  the  brain,  the  cord  or 
the  nerves,  are  in  sad  want  of  revision. 
He  has  paid  special  attention  to  the 
hypertonia  of  infections  and  intoxica- 
tions of  various  kinds,  and  while  mak- 
ing allowances  for  the  individual  equa- 
tion in  observations,  the  following  con- 
clusions are  drawn  from  experience  in 
this  field:  In  acute  infectious  disease 
(his  observations  included  only  typhoid 
fever  and  pneumonia)  the  tendon  re- 
flexes are  often  increased.  This  is  not 
seen,  however,  throughout  the  entire 
course  of  these  affections,  and  the  occur- 
rence of  an  epileptoid  tremor  is  excep- 
tional. The  exaggeration  of  the  reflexes 
usually  is  seen  at  the  acme  of  the  dis- 
ease, and  declines  during  convalescence. 
When  this  order  is  reversed  and  the  re- 
flexes are  exaggerated  during  convales- 
cence, the  disease  is  apt  to  assume  a  se- 
vere form  and  complications  are  apt  to 
arise.  There  is  no  relation  between  the 
exaggeration  of  reflexes  and  the  fever, 
and  the  former  has  no  diagnostic  sig- 
nificance whatever.  Acute  alcoholic, 
uraemic,  and  acetonemic  intoxications 
are  followed  by  increased  reflexes,  an 
exception  being  the  acetonaemia  of  dia- 
betes. In  about  two-thirds  of  all  the 
cases  of  chronic  affections  of  the  liver 
and  kidneys  there  arc  increased  reflexes, 
and  these  are  always  associated  with 
other  evidences  of  toxsemia.     In  cardiac 


disease,  exaggerated  reflexes  are  more 
apt  to  be  present  in  the  arterial  cases 
than  in  the  endocardial,  and  in  both 
types  they  are  most  apt  to  occur  rather 
early  in  the  disease.  Increased  reflexes 
are  an  important  and  often  an  early  diag- 
nostic sign  of  arteriosclerosis.  The  au- 
thor regards  this  sign  as  an  evidence  of 
intoxication.  E.  Massalongo  (Riforma 
Medica,  December  14,  1904;  from  New 
York  Medical  Journal  and  Philadelphia 
Medical  Journal,  February  4,  1905). 

THYROIDISM,  ACUTE  POST-OPERATIVE. 
Acute  post-operative  thyroidism  is 
very  rare.  Few  cases  are  reported,  and 
many  possibly  are  unrecognized.  All  the 
cases  cited  by  the  author  proved  fatal 
except  personal  case  and  one  other.  The 
use  of  cactus  grandifloris,  never  before 
recommended  in  cases  of  this  or  like 
nature  seemed  to  be  a  great  aid  in  bring- 
ing: about  a  favorable  termination.  The 
peculiar  pigmentation,  following  the 
turgescence  and  being  different  on  the 
two  halves  of  the  body,  is  of  interest  in 
the  author's  case.  A  pulse  of  over  200 
can  be  counted  in  thyroidism,  because  of 
the  nature  of  the  pulse.  When  the 
writer's  patient  presented  herself  for  the 
first  time,  she  was  carefully  examined  to 
note  all  deviations  from  the  normal  of 
health.  The  most  urgent  trouble  seemed 
to  be  chronic  appendicitis.  The  vrriter 
cannot  say  at  this  time  that  she  was  then 
suffering  from  exophthalmic  goiter — at 
any  rate,  as  such  it  was  overlooked.  Her 
pulse  was  rapid,  but  not  more  so  than  is 
often  found  in  patients  having  appendi- 
citis, or  in  patients  who  are  nervous. 
The  pigmentation  of  the  skin  attracted 
the  author's  attention  especially.  He 
could  not  satisfy  himself  as  to  its  origin 
or  cause,  bnt  considered  it  of  no  special 
moment  in  reference  to  her  need  of  an 
operation,  or  in  regard  to  her  being  in 


136 


TONSIL,  GROWTH  OF  BONE  IN. 


TUBERCULOSIS  OP  LARYNX. 


a  condition  to  undergo  the  operation. 
She  had  already  undergone  one  operation 
a  few  months  before.  It  was  felt  safe 
for  her  to  undergo  another,  especially  as 
the  operation  was  necessary.  Acute  post- 
operative thyroidism  is  an  exceedingly 
grave  complication  in  patients  calling  for 
operative  care,  and  we  should  ever  be  on 
our  guard  to  recognize  the  presence  of 
the  condition  which,  if  lighted  up,  will 
produce  acute  thyroidism.  The  symp- 
toms of  this  condition  most  likely  to  be 
seen  are  (a)  rapid  pulse,  (b)  enlarged 
thyroid,  (cj  nervousness,  (d)  a  marked 
tendency  to  blush,  (e)  prominence  of 
the  eyes,  with  (fj  pigmentation  or  other 
alteration  of  the  skin.  S.  E.  Sanderson 
(American  Medicine,  February  4,  1905). 

TONSIL,  GROWTH  OF  BONE  IN  THE. 

From  a  study  of  personal  case,  and  of 
the  cases  reported  in  literature,  the  au- 
thor is  inclined  to  believe  that  the  bone 
originates  from  metaplastic  changes  in 
the  connective  tissue,  and  not  from  the 
branchial  arch,  for  the  following  reasons : 
At  the  time  that  the  tonsil  develops  the 
branchial  arch  has  disappeared.  If  the 
bone  came  from  the  arch,  it  should  be 
uniformly  distributed  through  the  organ, 
and  not  confined,  as  it  usually  is,  to  the 
connective  tissue.  The  natural  sequence 
of  development  of  osteomata  is  from  con- 
nective tissue,  through  cartilage  to  bone. 
This  process  is  clearly  shown  in  the  speci- 
men taken  from  personal  case.  Analogy 
with  other  organs  shows  that  cartilage 
and  bone  are  frequently  found  in  the 
connective  tissue  framework  of  such 
glands  as  the  parotid,  the  mammary 
gland  and  the  testis,  when  these  have 
been  subject  to  chronic  inflammation. 
But  since  bone  does  not  develop  in  every 
tonsil  that  has  been  subject  to  prolifera- 
tive connective  tissue  changes,  when  it 
does  occur  some  local  predisposing  tend- 


ency to  its  formation  must  be  assumed. 
W.  W.  Carter  (Medical  Eecord,  Feb- 
ruary 4,  1905). 

TUBERCULOSIS  OF  THE  LARYNX,  TREAT- 
MENT OF,  WITH  SUNLIGHT. 

Very  favorable  results  were  obtained 
in  the  treatment  of  tuberculosis  laryn- 
gitis by  the  reflection  into  the  glottis  of 
sunlight  by  means  of  mirrors.  The  pa- 
tient is  seated  with  the  back  to  the  sun, 
and  in  front  of  him,  about  the  height  of 
the  mouth,  an  ordinary  toilet  dressing 
mirror  is  affixed  to  a  suitable  standard, 
at  such  an  angle  as  to  throw  the  light 
directly  into  the  pharynx.  The  patient 
pulls  forward  the  tongue  with  one  hand, 
and  with  the  other  manipulates  a  laryn- 
geal mirror  in  such  a  way  as  to  render 
the  image  of  his  larynx  visible  in  the 
large  mirror. 

The  best  time  for  the  treatment  is 
early  in  the  forenoon  and  late  in  the 
afternoon,  as  the  sun's  rays  are  more 
easily  utilized  when  slanting,  and  it  is 
desirable  to  eliminate  the  heat  ways  as 
much  as  possible.  The  patients  soon 
learn  the  technique  of  the  procedure  and 
become  much  interested,  as  they  are  en- 
abled to  watch  the  improvement  them- 
selves. The  length  of  each  sitting  varies 
from  five  minutes  to  an  hour,  according 
to  the  strength  of  the  patient.  The 
treatment  is  contraindicated  in  cases  of 
cedematous  swelling  of-  the  larynx,  which 
appear  to  be  unfavorably  influenced  by 
the  heat  rays.  The  author  gives  the 
histories  of  fourteen  cases  in  which  the 
treatment  was  found  of  marked  benefit, 
and  he  believes  that  improvement  follows 
ibis  method  more  rapidly  than  any  other 
form  of  treatment.  Kunwald  (Miinch- 
ener  mcdicinische  Wochenscbrift,  Jan- 
uary 10,  1905;  from  Medical  Eecord, 
February  4,  1905). 


TUBERCULOSIS,  SUGAR  IN. 


TYPHOID  FEVER,  TREATMENT  OF. 


137 


TUBERCULOSIS,   SUGAR  IN. 

A  method  which  has  given  results  far 
beyond  expectation  is  the  overfeeding  of 
patients  with  sugar.  Ordinary  sugar  is 
not  only  a  promoter  of  heat,  but  also  a 
dynamogenous  food  which  is  well  adapted 
to  the  requirements  of  the  cachectic  con- 
sumptive. The  authors  recommend  large 
doses,  from  100  to  500  grams  of  sugar 
daily;  in  other  words,  from  5  to  12 
grams  of  sugar  per  kilo  of  body  weight. 
The  patients  gain  weight  rapidly,  in 
some  cases  faster  than  the  actual  weight 
of  the  sugar  ingested  would  warrant. 
They  never  suffer  from  fermentation  or 
other  gastric  complications.  Sugar  gives 
the  best  results  in  the  febrile  cases.  It 
may  be  diluted  with  milk  or  disguised 
with  coffee  or  bitter  tinctures.  Sugar 
diet  is  well  borne  by  those  tuberculous 
patients  who  are  otherwise  difficult  to 
feed,  and  even  by  those  who  cannot  take 
codliver-oil.  R.  Massalongo  and  G. 
Danio  (Eiforma  Medica,  December  21, 
1904). 

TYPHOID  AND  COLON  BACILLI  IN  WATER, 
THE  EFFICIENCY  OF  COPPER  FOIL 
IN  DESTROYING. 

From  experiments  thus  far  conducted, 
the  author  draws  the  following  conclu- 
sions: The  intestinal  bacteria,  like  colon 
and  typhoid,  are  completely  destroyed  by 
placing  clean  copper  foil  in  the  water 
containing  them.  The  effects  of  colloidal 
copper  and  copper  sulphate  in  the  puri- 
fication of  drinking  water  are  in  a  quan- 
titative sense  much  like  those  of  filtra- 
tion, only  the  organisms  are  completely 
destroyed.  Pending  the  introduction  of 
the  copper  treatment  of  water  on  a  large 
scale,  the  householder  may  avail  himself 
of  a  method  for  the  purification  of  drink- 
ing water  by  the  use  of  strips  of  copper 
foil  about  3  1/2  inches  square  to  stand 
over  night,  or  from  six  to  eight  hours, 


at  the  ordinary  temperature,  and  then 
the  water  drawn  off  or  the  copper  foil 
removed.  Henry  Kraemer  (American 
Medicine,  February  18,  1905). 

TYPHOID  FEVER,  TREATMENT  OF. 

In  the  treatment  of  no  disease,  unless 
perhaps  it  is  pneumonia,  is  there  such 
a  variety  as  in  that  of  typhoid  fever — 
and  yet  at  the  same  time  in  none  is  there 
greater  monotony.  Almost  every  physi- 
cian who  is  called  upon  to  see  many  cases 
of  this  disease,  after  trying  various  meth- 
ods and  testing  one  new  or  popular 
theory  after  another,  gradually  settles 
down  into  a  more  or  less  unvarying 
routine — not  always  to  the  advantage  of 
his  patients.  But  with  most  of  us  there 
is  still  an  uneasy  feeling  that  perhaps 
we  are  not  doing  the  best  we  can  for 
those  who  place  their  lives  in  our  keep- 
ing, and  for  this  reason  perhaps  there  is 
nothing  more  interesting  than  to  learn 
how  others  are  doing  and  what  success 
they  are  having. 

Dr.  F.  Foord  Caiger,  who  was  the 
Bradshaw  lecturer  for  1904,  took  for  his 
theme  the  treatment  of  typhoid  fever,  or 
enteric  fever,  as  it  is  usually  called  in 
England.  In  his  introductory  remarks 
he  referred  to  the  fact  that  the  case  mor- 
tality of  typhoid  fever  in  England  re- 
mains at  a  height  of  more  than  15  per 
cent.  The  treatment  of  typhoid  fever  is 
necessarily  conducted  on  one  or  two  lines, 
viz.,  an  active  remedial  method  or  a 
passive  or  so-called  expectant  method, 
each  of  which  has  its  firm  adherents. 
The  three  methods  of  treating  enteric 
fever  by  means  of  remedies  which  are 
assumed  to  be  capable  of  exerting  a  di- 
rect controlling  influence  over  the  nat- 
ural course  of  the  disease  may  be  desig- 
nated as  the  specific,  the  antipyretic,  and 
the  antiseptic,  according  to  the  nature  of 
the  agents  employed. 


138 


TYPHOID  FEVER,  TREATMENT  OF. 


The  hope  that  the  serum  treatment  of 
typhoid  fever  would  prove  as  valuable  as 
in  the  case  of  diphtheria  has  not  been 
fulfilled.  However,  in  this  connection  it 
should  be  mentioned  that  Chantemesse 
claims  to  have  prod  viced  a  serum,  the 
nature  of  which  is  not  known,  the  use 
of  which  in  enteric  fever  is  said  to  have 
met  with  remarkable  success.  Wright's 
method  has  also  had  some  considerable 
degree  of  success. 

An  antipyretic  effect  may  be  produced 
either  by  drugs  or  by  the  direct  appli- 
cation of  cold  to  the  body  surface  by 
baths,  packs,  sponging,  etc.,  or  by  a  com- 
bination of  both.  Quinine  is  undoubt- 
edly the  best  drug  for  this  purpose.  It 
possesses  a  marked  antiseptic  influence 
over  living  cultures  of  the  typhoid  ba- 
cillus, and  its  administration  is  not  at- 
tended with  cardiac  depression.  For  the 
purpose  of  lowering  the  temperature,  qui- 
nine must  be  given  in  large  doses — 15  to 
20  grains  or  more — twice  in  the  twenty- 
four  hours.  Or  a  still  better  method  is 
to  give  it  in  four  7  V2  grain  doses,  re- 
peated at  intervals  of  fifteen  minutes  in 
the  evening  of  every  third  day  during 
the  first  fortnight  of  the  fever.  In  cases 
of  moderate  fever,  the  writer  does  not 
favor  the  use  of  antipyretic  drugs,  at 
least  in  antipyretic  doses.  He  believes 
such  pyrexia  to  be  a  natural  element  of 
defense  against  bacterial  invasion.  In 
cases  of  excessive  pyrexia,  however,  vig- 
orous antipyretic  measures  are  indicated. 
The  cold  bath  is  the  most  effective 
method  of  applying  cold  to  the  surface. 
Its  contraindications  are  well  known.  It 
is  probable  that  the  cold  bath  owes  its 
superiority  over  all  other  therapeutic 
measures  of  which  the  chief  aim  is  re- 
frigeration to  its  salutary  influence  on 
the  nutrition  of  the  skin  and  kidneys. 
The  "graduated  bath"  has  been  widely 
recommended. 


Although  it  is  now  recognized  that  any 
attempt  to  destroy  the  bacilli  in  the  lower 
intestinal  canal  by  the  administration  of 
antiseptic  drugs  by  the  mouth  is  futile, 
unless  given  in  such  doses  or  in  such 
strength  as  greatly  to  injure  the  patient, 
still  it  is  not  unreasonable  to  expect  that 
they  might  be  capable  of  exerting  some 
restricting  influence  on  the  multiplica- 
tion of  bacteria  in  the  mucous  membrane 
and  contents  of  the  bowel.  This  is  posi- 
tive in  respect  to  the  various  putrefac- 
tive organisms,  for  there  is  a  decided  de- 
crease in  the  fetor  of  the  stools  after  the 
use  of  antiseptics.  The  writer  calls  at- 
tention to  the  good  effects,  in  suitable 
cases,  of  calomel  before  there  is  much 
diarrhoea.  But  in  certain  cases,  even 
when  it  is  given  not  later  than  the  end 
of  the  first  week,  it  causes  intestinal  irri- 
tation which  is  prejudicial  to  the  patient. 
The  writer  has  been  so  impressed  with 
the  fact  that  he  has  given  up  the  routine 
use  of  calomel  in  the  early  stage  of  ty- 
phoid fever,  and  limits  himself  to  its  use 
in  cases  in  which  there  exists  some  special 
indication  for  this  drug.  Perchloride  of 
mercury  has  been  highly  recommended 
as  an  intestinal  antiseptic.  Although  Dr. 
Caiger  believes  that  some  of  the  antisep- 
tic remedies  distinctly  influence  in  a 
favorable  manner  the  course  of  an  at- 
tack of  typhoid  fever,  still  he  does  not 
believe  that  they  are  capable  of  cutting 
short  the  attack  or  of  lessening  to  any 
appreciable  degree  the  risk  of  haemor- 
rhage, perforation,  or  relapse,  as  some 
have  contended.  He  mentions  some 
other  antiseptic  remedies,  among  which 
are  sulphurous  acid,  oil  of  turpentine, 
the  combination  of  quinine  and  nascent 
chlorine,  and  the  essential  oil  of  cin- 
namon. His  results  so  far  with  the 
oil  of  cinnamon  haye  been  favorable. 
Among  147  cases,  there  was  a  mortality 
of  9.5  per  cent.     The  temperature  ran 


TYPHOID  FEVER,  TREATMENT  OF. 


139 


lower  in  these  cases  than  the  average  in 
typhoid  cases,  the  patients  for  the  most 
part  remained  drowsy  throughout  their 
illness,  thus  enjoying  mental  rest,  and 
delirium  was  less  frequent.  Intestinal 
decomposition  was  controlled  in  a  strik- 
ing manner,  no  single  instance  of  meteor- 
ism  occurring  among  the  147  cases  in 
which  this  remedy  was  used.  It  is  well, 
the  author  says,  to  begin  with  small 
doses,  for  example,  2  1/2  minims,  increas- 
ing this  to  4  or  5  minims  in  the  course 
of  a  few  days.  Laboratory  experiments 
with  this  oil  have  been  likewise  encour- 
aging. In  cases  in  which  there  is  any 
suspicion  of  circulatory  failure,  he  gives 
a  grain  of  sulphate  of  quinine  with  each 
dose. 

Dr.  Caiger  believes  that  the  adoption 
of  an  entirely  expectant  treatment  is  not 
only  fallacious  in  its  conception,  but  very 
mischievous  in  practice.  In  the  absence 
of  a  specific,  he  would  treat  a  case  of 
typhoid  fever  on  symptomatic  lines,  and, 
in  addition,  would  employ  from  the 
earliest  possible  date  either  antipyretic 
or  antiseptic  remedies,  or  both,  as  might 
appear  especially  suited  to  the  attack 
and  to  the  individual  in  question.  In 
the  treatment  of  toxaemia  it  is  always 
well  as  a  preliminary  measure  to  rid  the 
lower  bowel  of  its  putrid  and  offensive 
contents.  Calomel  is  most  effective  for 
this  purpose.  Soap  and  water  enemata, 
with  the  addition  of  turpentine,  are  also 
useful,  as  is  the  oil  of  cinnamon.  The 
cinnamon  treatment  is  also  especially 
serviceable  in  cases  with  nervous  mani- 
festations. It  is  most  important  for  the 
victim  of  typhoid  fever  to  obtain  mental 
rest.  For  this  purpose  opium  is  valuable. 
In  ataxic  cases,  a  combination  of  quinine 
and  chlorine  is  excellent.  In  the  treat- 
ment of  pyrexia,  Dr.  Caiger  much  prefers 
the  cold  pack  to  the  cold  bath.  If  the 
effect  of  this  treatment  proves  temporary, 


the  pack  should  be  repeated  and  sulphate 
of  quinine,  15  to  20  grains,  combined 
with  15  to  20  minims  of  laudanum, 
should  be  given.  The  administration  of 
quinine  usually  prolongs  the  effect  of 
mechanical  refrigeration.  In  cases  in 
which  restlessness  and  insomnia  do  not 
yield  to  cold  sponging,  one  of  the  nu- 
merous hypnotic  drugs  may  be  tried.  If 
diarrhoea  and  abdominal  pain  are  pres- 
ent, the  preparations  of  opium  are  espe- 
cially useful.  If  the  number  of  stools 
exceeds  more  than  four  or  five  in  the 
course  of  twenty-four  hours,  the  diar- 
rhoea should  be  controlled.  If  the  feed- 
ing is  not  at  fault,  a  starch  and  opium 
enema  is  indicated.  Cold  abdominal 
compresses  are  of  value  when  definite 
tenderness  exists.  Constipation  is  well 
treated  by  a  soap  and  water  enema,  not 
exceeding  a  pint,  in  the  morning  of 
every  third  day.  In  cases  of  cardiac 
failure,  strychnine,  quinine,  or  digitalis 
may  be  given.  There  are  special  indica- 
tions for  the  employment  of  alcohol,  but 
the  lecturer  thought  that  in  most  cases 
of  enteric  fever,  alcohol  is  not  only  not 
required,  but  its  employment  is  occa- 
sionally distinctly  harmful.  In  cases 
of  intestinal  haemorrhage,  he  said,  that 
after  having  seen  that  the  patient  re- 
ceives a  full  dose  of  opium  and  that  an 
icebag  is  carefully  applied  to  the  abdo- 
men, the  treatment  may  be  summed  up 
in  the  simple  word  "precaution."  The 
complete  deprivation  of  fluids,  except  an 
occasional  fragment  of  ice  is  most  im- 
portant in  these  cases.  As  to  the  man- 
agement of  perforation,  the  lecturer  was 
in  complete  accord  with  those  who  hold 
that  a  moribund  condition  of  the  pa- 
tient should  he  the  only  contraindication 
to  operation  in  such  cases.  And  as  to 
the  most  favorable  time  for  operation, 
"there  is  no  time  like  the  present."  A 
careful     examination    of    the    abdomen 


140       TYPHOID  FEVER,   WATER-DRINKING  IN.     URETERS.  OPERATIONS  ON. 


should  be  made  daily  in  the  course  of 
typhoid  fever,  as  then  any  change  in 
its  condition  will  be  more  accurately 
perceived.  Editorial  (Medical  Eecord, 
January  28,  1905). 

TYPHOID  FEVER,  WATER-DRINKING  IN. 

Large  quantities  of  water  internally, 
a  gallon  or  more  in  twenty-four  hours, 
may  easily  be  taken  by  typhoid  fever 
patients,  if  administered  in.  small  quan- 
tities at  frequent  and  definite  intervals. 
A  copious  elimination  of  watery  urine 
at  once  follows,  the  degree  of  polyuria, 
day  by  day,  closely  corresponding  to  the 
quantity  of  fluid  ingested.  Patients  are 
more  comfortable  by  this  mode  of  treat- 
ment and  toxic,  nervous  symptoms  are 
lessened.  The  mortality,  as  well  as  the 
severity,  of  typhoid  fever,  seems  to  be 
still  further  diminished  by  this  method 
of  hydrotherapy  employed  as  an  acces- 
sory to  the  cool-bath  treatment  of  the 
disease.  E.  F.  Cushing  and  T.  W. 
Clarke  (American  Journal  of  the  Med- 
ical  Sciences,  February,  1905). 

URETERS,  OPERATIONS  ON  LOWER  ENDS 
OF. 

In  favor  of  the  use  of  a  general  anaes- 
thetic it  may  be  said  that  the  patient  is 
unconscious  of  everything  associated  with 
the  operation,  including  the  pain.  There 
is  complete  relaxation,  thus  permitting 
a  better  exposure  of  the  field  of  opera- 
tion, which  is  especially  desirable  in 
operations  in  the  pelvis.  The  operation 
takes  a  much  shorter  time  than  a  similar 
operation  under  a  local  anaesthetic.  The 
operation  is  easier,  and  all  the  above 
render  it  possible  usually  to  do  better 
work  than  under  a  local  anaesthetic. 

There  are  many  disadvantages,  how- 
ever, in  the  use  of  a  general  anaesthetic. 
In  certain  cases  it  is  contraindicated.  A 
small  percentage  of  the  cases  die  on  the 


table  from  the  anaesthetic  alone.  In  all 
cases  it  lowers  the  general  resistance  of 
the  individual,  thus  predisposing  the 
patient  to  many  post-operative  compli- 
cations. The  taking  of  the  anaesthetic  is 
usually  very  unpleasant,  and  the  recovery 
from  it  still  more  so. 

If  certain  operations  do  not  cause  any 
pain  and  very  little  discomfort,  why 
should  patients  be  subjected  to  the  dan- 
gers and  discomforts  of  a  general  anaes- 
thetic in  these  operations?  And  if  cer- 
tain steps  in  a  long  operation,  where  a 
general  anaesthetic  is  contraindicated, 
are  painless,  why  not  use  a  temporary 
general  anaesthetic,  such  as  nitrous  oxide, 
or  a  local  anaesthetic,  as  cocaine,  only  for 
that  part  of  the  operation  which  causes 
pain? 

A  knowledge  of  the  distribution  of 
the  sensation  of  pain  in  the  various  parts 
of  the  body  is  not  only  interesting  from 
a  physiological  standpoint,  but  especially 
valuable  in  the  diagnosis  of  diseased  con- 
ditions, and  the  intelligent  use  of  a  local 
or  temporary  anaesthetic  in  those  cases 
in  which  a  general  anaesthetic  is  contra- 
indicated. 

Pathological  conditions  of  the  lower 
ends  of  the  ureters  usually  impair  the 
function  of  the  ureters,  either  interfering 
with  the  passage  of  urine  from  the  kid- 
neys to  the  bladder  or  permitting  a  reflux 
of  urine  from  the  bladder  into  the  kid- 
neys. In  either  instance  the  result  is 
interference  with  the  function  of  the 
kidneys,  and  a  condition  of  actual  or 
unstable  renal  insufficiency  results,  thus 
lowering  the  general  resistance  of  the 
individual,  and,  in  addition,  predispos- 
ing the  kidneys  to  infection.  The  result 
of  the  above  is  that  such  individuals  may 
not  be  well  suited  to  a  long  operation 
under  a  general  anaesthetic,  which  may 
be  necessary  to  cure  the  local  condition. 

In  four  operations  on  the  lower  ends 


URETHRAL  STRICTURE,  TREATMENT  OF. 


141 


of  the  ureters  by  the  inguinal  extra- 
peritoneal route  under  local  anaesthesia, 
lasting  from  four  hours  and  thirty  min- 
utes to  six  hours  and  ten  minutes,  the 
only  apparent  effect  of  the  operation, 
aside  from  postural  discomfort  and  at 
times  some  pain  (endurable),  was  that 
of  fatigue,  as  of  a  similar  length  of  time 
spent  in  a  dentist's  chair. 

The  success  of  these  operations  is  de- 
pendent on  a  knowledge  of  what  does 
and  what  does  not  hurt,  and  on  proceed- 
ing slowly  and  carefully,  remembering 
that  anything  causing  traction  on  the 
parietal  peritoneum  is  painful.  Pinch- 
ing, cutting,  and  suturing  the  ureter  in 
these  cases  apparently  did  not  cause  any 
pain,  and  similar  treatment  of  the  blad- 
der in  one  case  was  painless,  but  painful 
in  another  (bladder  much  thickened; 
chronic  cystitis).  Closing  the  abdom- 
inal incision  was  the  most  painful  step 
in  all  four  operations. 

The  extraperitoneal  route  is  a  very 
satisfactory  way  of  reaching  the  lower 
ends  of  the  ureters,  and  would  be  less 
painful  than  the  intraperitoneal,  and 
has  many  advantages  over  the  other. 
The  danger  from  infection  is  less;  by 
draining  freely,  the  retroperitoneal  tissue 
is  well  protected  and  the  intestines  are 
kept  back  by  the  peritoneum,  thus  giving 
one  a  good  exposure;  and  there  must  be 
less  shock  associated  with  the  extraperi- 
toneal than  with  the  intraperitoneal  op- 
eration. 

Many  incisions  through  the  abdominal 
wall  have  been  used  for  the  extraperito- 
neal route,  and  the  intramuscular  incis- 


ions can  be  recommended  as  doing  little 
harm,  rendering  the  liability  of  post-oper- 
ative hernia  small,  and  affording  a  good 
exposure.  Two  incisions  are  very  goodi; 
a  "gridiron  incision"  lateral  to  the  rectus 
similar  to  the  well-known  McBurney, 
only  a  little  lower;  and,  secondly,  a 
longitudinal  incision  through  the  rectus 
muscle.  Through  either  incision  the 
ureter  can  usually  be  exposed  from  the 
pelvic  brim  to  the  bladder,  and  if  more 
room  is  desired,  the  muscles  may  be  cut 
at  any  time.  John  A.  Sampson  (Annals 
of  Surgery,  February,  1905). 

URETHRAL  STRICTURE,  TREATMENT  OF. 
The  meatus  must  be  cut  to  a  caliber 
2  millimeters  larger  than  that  of  its  nor- 
mal urethra  previous  to  properly  carry- 
ing out  any  form  of  treatment.  Internal 
urethrotomy  yields  the  most  permanent 
results  of  any  method,  and  for  strictures 
of  the  anterior  urethra,  irrespective  of 
their  character,  is  the  operation  of 
choice.  All  resilient,  intractable,  non- 
dilatable,  and  impassable  strictures  of  the 
bulbo-membranous  or  membranous  ure- 
thra are  best  treated  by  external  perineal 
urethrotomy.  With  the  exception  of 
these,  all  strictures  so  situated  are  best 
treated  by  gradual  dilatation,  unless, 
during  its  course,  constitutional  disturb- 
ances of  importance  arise,  in  which  case 
it  is  safer  to  divide  them  at  once  by  an 
external  perineal  urethrotomy.  Divul- 
sion  and  electrolysis  are  not  methods  to 
be  commended.  F.  S.  Watson  (Boston 
Medical  and  Surgical  Journal,  Decem- 
ber 8,  1904). 


CORRECTION. 

My  attention  has  been  called  to  a  typographical  error  in  my  editorial  on  "Suprarenal  Extract 
in  the  Treatment  of  Cardio-Vascular  Disease,"  in  the  "Monthly  Cyclopedia"  for  February,  1905, 
in  which  it  is  stated  that  40  minims  of  a  1  to  1000  solution  of  adrenalin  equals  5fo  of  a  grain.  It 
should  read  4  minims.  JAMES  TYSON. 


142  BOOK  REVIEWS. 

A  COURSE  OF  PUBLIC  HEALTH  AT  THE  UNIVERSITY  OF  PENNSYLVANIA. 

A  course  of  instruction  in  public  health  is  to  be  offered  by  the  University  of  Pennsylvania 
for  the  first  time  in  the  academic  year,  beginning  October  1,  1905.  The  authorities  of  the 
University  of  Pennsylvania  realize  the  efforts  which  are  being  made  in  communities  through- 
out the  country  to  obtain  officials  who  have  had  some  special  training  in  matters  pertaining 
to  public  health.  Each  year  the  demands  for  men  of  this  type  (either  as  chiefs  of 
departments  or  in  some  subordinate  position)  is  increased,  and  at  the  present  time  there  is 
a  lack  of  men  qualified  to  fill  such  positions.  To  meet  the  needs  of  such  instruction,  the 
University  will  introduce  into  its  curriculum,  beginning  October  1,  1905,  a  course  in  public 
health,   which   will  include   instruction  under   the   following  headings: — 

Sanitary  Engineering. — Including  the  subject  of  water  supplies,  sewerage  systems,  street 
cleaning,  disposal  of  waste,  etc. 

Sanitary  Legislation. — A  study  of  the  movement  for  sanitary  reform,  and  of  the  laws 
enacted  relating  to  public  health,  and  the  methods  of  enforcement  employed  in  Great 
Britain  and  the  United  States. 

Inspection  of  Meat,  Milk  and  Other  Animal  Products.— The  methods  of  preparation  and 
preservation  of  the  same,  the  conduct  of  dairies,  creameries,  etc.,  and  demonstrations  of  the 
diseases  of  animals  transmissible  to  man. 

The  Sanitary  Engineering  of  Buildings.— Including  demonstrations  of  systems  of  heating, 
ventilation,  plumbing  and  drainage,  the  study  of  plans,  etc. 

Social  and  Vital  Statistics  in  the  United  States. — An  examination  of  statistical  methods 
and  their  results,  with  special  reference  to  vital  statistics  and  to  city  populations. 

Practical  Metlwds  Used  in  Sanitary  Work.— Including  water,  air,  and  milk  analyses, 
studies  in  ventilation  and  heating,  investigation  of  the  soil,  methods  of  disinfection,  steriliza- 
tion, etc.     (This  is  purely  laboratory  instruction.) 

General  Hygiene.— As  applied  to  the  community,  including  lectures  upon  the  causation  of 
disease— exciting  and  predisposing  methods  of  prevention— including  isolation,  quarantine, 
natural  and  acquired  immunity,  protective  inoculation,  vaccination,  and  the  antitoxic  state, 
methods  of  house  disinfection  and  the  means  employed,  suggestions  for  the  organization  of 
sanitary  work,  the  influence  of  water  supplies  and  sewage  disposal  on  the  public  health,  etc. 

Personal  Hygiene.— Including  the  physiology  of  exercise,  the  adaptation  of  exercise  to  the 
various  physical  requirements,  the  use  of  exercise  for  the  prevention  and  correction  of 
deformities,  the  methods  of  examination  and  record  keeping,  the  routine  physical  examination 
of  growing  children  and  the  relation  of  air,  food,  bathing,  etc.,  to  health  and  development; 
the  hygiene  of  the  school  room. 


5©ol<  Reviews. 


Surgical  Treatment  of  Brigiit's  Disease.  By  George  M.  Edebohls,  A.M.,  M.D.,  LL.D. 
New  York:      Frank  F.  Lisieske,  1904.      320  Pages.      First  Edition. 

Since  Edebohls,  some  years  ago,  first  proposed  to  treat  chronic  nephritis  by  removing  the 
capsule  of  the  kidneys,  this  subject  has  been  widely  discussed.  He  first  observed  the  favorable 
effects  upon  the  disease  when  it  was  found  necessary  to  do  a  nephropexy.  It  has  been 
suggested  that  a  new  capsule  is  soon  formed  from  the  remnants  of  the  old  one.  This 
Edebohls  acknowledges,  but  argues  that  the  new  is  more  succulent  than  the  old  capsule 
and  always  more  vascular.  He  does  not  believe  that  there  is  any  danger  from  the  contraction 
of  the  new  capsule,  but  should  a  return  of  symptoms  justify  a  second  operation,  he  does  not 
hesitate  to  perform  it. 

The  book  forms  one  of  the  most  elaborate  treatises  on  this  subject  ever  presented  as  the 
experiences  of  any  one  writer.  The  first  part  of  the  work  comprises  the  author's  contribu- 
tions to  the  literature,  which  have  previously  appeared  in  the  medical  journals.  The  second 
part,  three-fifths  of  the  entire  work,  is  entirely  new  and  comprises  tluT  detailed  histories  of 
seventy-two  cases  operated  upon  by  the  author,  and  his  conclusions. 


BOOKS  AND  MONOGRAPHS  RECEIVED.  143 

The  operation  is  charged  with  seven  deaths,  all  in  advanced  cases,  but  this  number,  he 
claims,  is  offset  by  the  nine  patients  who  were  moribund  when  operated  upon,  whose  lives 
were  prolonged  and  some  of  whom  are  alive  at  the  present  day  and  are  voiding  normal 
urine. 

Of  the  twenty-two  ulterior  or  remote  deaths,  none  was  due  to  the  operation.  Thirteen 
died  from  the  chronic  nephritis  and  its  complications,  and  in  six  of  these  the  operation  had 
done  no  good,  but  the  remainder  were  benefited.  Of  the  seventy-two  patients  it  appears 
that  thirteen  received  no  benefit  from  the  operation,  while  fifty-nine  received  amelioration 
varying  all  the  way  from  slight  or  temporary  improvement  to  complete  cure.  In  nine  cases 
the  operation  proved  life  saving,  by  rescuing  the  patient  from  impending  death.  The  author 
has  successfully  treated  eclampsia  by  his  operation.  He  believes  that  he  has  submitted 
sufficient  evidence,  not  only  to  justify  the  surgical  treatment  of  Bright's  disease,  but  has 
established  surgery  to  be  at  present  the  main,  if  not  the  only,  hope  of  sufferers  from  a  hitherto 
incurable  disease.  Whether  other  surgeons  shall  be  rewarded  by  such  favorable  results 
remains  to  be  seen. 

The  author  has  kept  his  patients  under  observation  wonderfully  well,  and  his  book  is  an 
extremely  interesting  and  a  very  valuable  work,  due  to  the  fact  that  sufficient  time  has 
elapsed  since  operation  to  prove  the  value  of  his  treatment. 

It  will  probably  be  a  long  time  before  so  many  cases  can  be  reported  by  any  one  surgeon. 
Medical  men  have  been  rather  backward  in  recommending  this  operation,  as  other  surgeons 
have  not  always  met  with  the  success  of  Edebohls.  This  is  probably  due  to  the  fact  that 
they  have  had  but  few  cases,  and  these  happened  to  be  bad  ones,  operation  having  been 
resorted  to  as  a  last  resort.  M.  B. 


IJooks  and  ponographs  Received. 


The  editor  begs  to  acknowledge,  with   thanks,   the  receipt  of  the   following  books  and 
monographs: — 

Annual    Report    of    the    Surgeon-General    of    the    Public    Health    and    Marine    Hospital 

Service  of  the  United  States  for  the  Fiscal  Year  1904. First  Annual  Report  of  the  Henry 

Phipps  Institute  for  the  Study,  Treatment,  and  Prevention  of  Tuberculosis.     February  1,  1903, 

to  February   1,  1904. Transactions  of  the  American  Ophthalmological  Society.      Fortieth 

Annual  Meeting.      Vol.  X,  Part  II.      1904. Politics   in   New  Zealand.      By   C.   F.  Taylor. 

1904. A  Case  of  Tuberculosis  with  Some  Unusual  Points  of  Interest.      By  S.  E.  Earp,  M.S., 

M.D.,  Indianapolis,  Ind.      1905. Management  of  the  Acute  Stages  of  Abdominal  Inflamma- 
tion.     By  G.  E.  Shoemaker,  M.D.,  Philadelphia.      1904. The  Climate  and   Waters  of  Hot 

Springs,  Va.     By  Guy  Hinsdale,  A.M.,  M.D.,  Hot  Springs,  Va.     1904. New  Etiology  and 

Prophylaxis   of  Appendicitis.      By   A.   F.   A.   King,   M.D.,   Washington,   D.   C.       1904. On 

Uniformity  in  Pelvic  and  Cranial  Measurements.    By  A.  F.  A.  King,  M.D.,  Washington,  D.  C. 

1904. The    Climate   Treatment    of    Pulmonary   Tuberculosis.       By    A.    F.    A.    King.    M.D., 

Washington,  D.  C.      1904. The  Treatment  of  Pneumonia.      By  R.  S.  Thornton,  Delorainc, 

Manitoba.      1904. Fistula    in   Ano   in   Phthisis   and   Actinomycosis.      By    Heneage    Gibbes, 

Detroit,  Mjch. Physometra;    Pyomctra;    Hematometra.      By  E.  J.  Mellish,  El  Paso,  Texas. 

1905. Nasal    Deformities    and    Paraffin    Prothesis.      By    A.    C.    Heath,    St.    Paul,    Minn. 

1905. The  Significance  of  Tuberculous  Deposits  in  the  Tonsils.     By  George  B.  Wood,  M.D., 

Philadelphia.     1904. Erotomania:     A  Case  of  Exhibitionism.     A  Medico-Legal  Study.     By 

David  S.  Booth,  M.D.,  St.  Louis,  Mo.     1905. Influenza  a  Toxemic  Disease.    By  A.  B.  Conk- 

lin,  M.D.,  Ambler,  Pa. The  Expectant  Plan  in  the  Treatment  of  Typhoid  Fever.      By  R.  E. 

Coughlin,   Brooklyn,  N.   Y.      1904. A   Plan   to  Eradicate   Syphilis,   Chancroids,   and   Gon- 
orrhoea. "  By  A.  W.  Herzog,  Ph.B.,  A.M.,  M.D.,  New  York  City.     1905. Relevfi  Statistique 

de  500   Interventions   Faites   sur   l'Apophyse   Ma9toide.      Annexe   an   Travail   des   Drs.   E.   J. 
Moure  et  A.  Brindel,  Paris,  France.      1904. 


EDITORIAL  STAFF. 

Sajous's  Analytical  Cyclopaedia  of   Practical  Medicine. 


ASSOCIATE,  EDITORS. 


J.  GEORGE  ADAMI,  M.D., 

MONTREAL,  P.  «. 


LEWIS  U.  ADLER,  M.D., 

PHILADELPHIA. 


JAMES  M.  ANDERS,  M.D.,  LL.D., 

PHILADELPHIA. 


THOMAS  G.  ASHTON,  M.D., 
PHILADELPHIA. 


A.  D.  BLACKADER.  M.D., 

MONTKEAL,  P.  Q,. 


E.  D.  BONDURANT,  M.D., 

MOBILE,  ALA. 


DAVID  BOVAIRD,  M.D., 
NEW  YORK  CITY. 


WILLIAM  BROWNING,  M.D., 

BROOKLYN,  N.  Y. 


WILLIAM  T.  BULL,  M.D., 
NEW  YORK  CITY. 


CHARLES  W.  BURR,  M.D., 

PHILADELPHIA. 


HENRY  T.  BYFORD,  M.D., 

CHICAGO,  ILL. 


HENRY  W.  CATTELL,  M.D., 
PHILADELPHIA. 


WILLIAM  B  COLEY,  M.D., 
NEW  YORK  CITY. 


FLOYD  M.  CRANDALL,  M.D., 
NEW  YORK  CITY. 


ANDREW  F.  CURRIER,  M.D.. 

NEW  YORK  CITY. 


ERNEST  W.  CUSHING,  M.D.. 

BOSTON,  MASS. 


GWILYM  G.  DAVIS,  M.D., 

PHILADELPHIA. 


N.  S.  DAVIS,  M.D., 

CHICAGO,  ILL. 


AUGUSTUS  A.  ESHNER,  M.D., 
PHILADELPHIA. 


SIMON  FLEXNER,  M.D, 

PHILADELPHIA. 


LEONARD  FREEMAN,  M.D., 
DENVER,  COL. 


8.  O.  GANT,  M.D., 
NEW  YORK  CITY. 


J.  McFADDEN  GASTON,  SB.,  M.D.. 

ATLANTA,  GA. 


J.  McFADDEN  GASTON,  Jr.,  M.D., 

ATLANTA,  GA. 


E.  B.  GLEASON,  M.D., 

PHILADELPHIA. 


EGBERT  H.  GRAN  DIN,  M.D., 
NEW  YORK  CITY. 


J.  P.  CROZER  GRIFFITH,  M.D., 

PHILADELPHIA. 


C.  M.  HAY,  M.D., 

PHILADELPHIA. 


FREDERICK  P.  HENRY,  M.D., 

PHILADELPHIA. 

L.  EMMETT  HOLT,  M.D., 

NEW  YORK  CITY. 

EDWARD  JACKSON,  M.D., 

DENVER,  COL. 

W.  W.  KEEN,  M.D., 

PHILADELPHIA. 

EDWARD  L.  KEYES,  Jr.,  M.D., 

NEW  YORK  CITY. 

ELWOOD  R.  KIRBY,  M.D., 

PHILADELPHIA. 

L.  E.  LaFETRA,  M.D., 

NEW  YORK  CITY. 

ERNEST  LAPLACE,  M.D.,  LL.D., 
PHILADELPHIA. 

R.  LEPINE,  M.D., 

LYONS,  FRANCE. 

F.  LEVISON,  M.D., 

COPENHAGEN,  DENMARK 

A.  LUTAUD,  M.D., 
PARIS,  FRANCE. 

G.  FRANK  LYDSTON,  M.D., 

CHICAGO,  ILL. 

F.  W.  MARLOW,  M.D., 
SYRACUSE,  N.  Y. 

SIMON  MARX.  M.D., 

NEW  YORK  CITY. 

ALEXANDER  McPHEDRAN,  M.D.. 

TORONTO,  ONT. 

E.  E.  MONTGOMERY,  M.D., 

PHILADELPHIA. 

HOLGER  MYGIND,  M.D., 

COPENHAGEN,  DENMARK. 

W.  P.  NORTH  RUP,  M.D.. 
NEW  YORK  CITY. 

RUPERT  NORTON,  M.D., 
WASHINGTON,  D.  C. 

H.  OBERSTEINER,  M.D., 

VIENNA,  AUSTRIA. 

CHARLES  A.  OLIVER,  M.D., 
PHILADELPHIA. 

WILLIAM  OSLER,  M.D., 
BALTIMORE,  Mil. 

LEWIS  S.  PILCHER,  M.D.,  " 

BROOKLYN,  N.  Y. 

WILLIAM  CAMPBELL  POSEY.  M.D., 
PHILADELPHIA 


W.  B.  PRITCHARD.  M.D., 

NEW  YORK  CITY. 


JAMES  J.  PUTNAM,  M.D., 

BOSTON. 


B.  ALEXANDER  RANDALL,  M.D  . 

PHILADELPHIA. 


CLARENCE  C.  RICE,  M.D., 

NEW  YORK  CITY. 


ALFRED  RUBINO,  M.D., 

NAPLES,  ITALY. 


REGINALD  II.  SAYRE,  M.D., 
NEW  YORK  CITY. 


JACOB  E.  SCHADLE,  M.I)., 

ST.  PAUL,  MINN. 


JOHN  B.  SHOBER.  M.D., 

PHILADELPHIA. 


J.  SOLIS-COHEN.  M.D., 

PHILADELPHIA. 


SOLOMON  SOLIS-COHEN,  M.D., 

PHILADELPHIA. 


11.  W.  STELWAGON,  M.D., 

PHILADELPHIA. 


D.  D.  STEWART.  M.D., 
PHILADELPHIA. 


LEWIS  A.  STIMSON,  M.D., 

NEW  YORK  CITY. 


J.  EDWARD  STUBBERT,  M.D., 

LIBERTY,  N.  Y. 


A.  E.  TAYLOR,  M.D., 

SAN  FRANCISCO,  CAL. 


J.  MADISON  TAYLOR,  M.D., 

PHILADELPHIA. 


M.  B.  TINKER.  M.D., 

PHILADELPHIA.  ' 


CHARLES  S.  TURNBULL,  M.D.. 

PHILADELPHIA. 


HERMAN  F.  VICKERY,  M.D., 

BOSTON,  MASS. 


F.  E.  WAXHAM,  M.D., 
DENVER,   COL. 


J.  WILLIAM  WHITE,  M.D., 

PHILADELPHIA. 


JAMES  C.  WILSON,  M.D., 

PHILADELPHIA. 


C.  SUMNER  WITHERST1NE.  M.D, 
PHILADELPHIA. 


ALFRED  C.  WOOD,  M.D., 

PHILADELPHIA. 


WALTER  WYMAN,  M.D, 

WASHINGTON,  D.  0. 


[End  of  the  Editorial  Department  of  the  Monthly  Cyclopaedia  for  March  1904.] 


THE    MONTHLY   CYCLOPEDIA 

OF 

PRACTICAL   MEDICINE 


(Published  the  Last  of  Each  Month) 


Vol.  XVIII. 
Old  8eries. 


PHILADELPHIA,  APRIL,  1905. 


Vol.  VIII,  No.  4. 
New  Series. 


TABLE  OF  CONTENTS. 


PAGE 

EDITORIALS 

THE  FUTURE  OF  DRUG  MEDI- 
CATION.    Edward  C.  Hill U5 

PERICOLITIS  SINISTRA.     H.  D.  Rol- 

leston 149 

ALBUMIN  IN  THE  URINE  OF  AP- 
PARENTLY HEALTHY  CHILD- 
REN.    William  A.  Edwards 152 

THE  PRACTICAL  UTILITY  OF  THY- 
ROID EXTRACT  IN  PUERPE- 
RAL ECLAMPSIA.  J.  Madison 
Taylor 155 

CYCLOPAEDIA    OF   CURRENT 
LITERATURE 

ABDOMINAL  INJURIES.    C.  P.  Flint.  157 

ACNE  AND  ITS  TREATMENT.    G.  T. 

Jackson  _ ~ 158 

ADENOID  VEGETATION?  THE 
CURE  OF  EXOPHTHALMOS 
AND  CHOREA  BY  REMOVAL 
OF.     Holz. 158 

ALBUMINURIA  DUE  TO  PALPA- 
TION. "  Journal  American  Medi- 
cal Association."- 150 

ALCOHOLISM,  BORDERLINE  PSY- 
CHOSES OF.     F.  P.  Xorbury 160 

APPENDICITIS,     TREATMENT      OF. 

C.  A.  Porter ICO 

ARTHRITIS     DEFORMANS.      F.    L. 

Richardson 162 

BLADDER,  PAPILLOMA  OF,  DIAG- 
NOSIS OF.     C.  G.  Cnmston 162 

CANCER,  EFFECTS  OF  ROENTGEN 
RAY8    ON.      R.  H.  Yose  and  W. 

C.  Howe 164 

DIABETES  MELLITIS,  ADRENALIN 

AND    THYROID   EXTRACT  IN. 

D.  N.  Paton 165 

ECLAMPSIA.    Allen 165 

EPILEPSY,  TREATMENT  OF.     W.  A. 

Turner-. 166 

FORMALDEHYDE  AND  FORMALIN, 
TOXIC     EFFECTS     OF.     H.    M. 

Fischer 166 

GASTRIC  ULCER,  MEDICAL  TREAT- 
MENT OF.     F.  P.  Henry 166 


PAGE 

GASTRO-ENTERITIS,  BUTTEEMI1K 
IN  THE  TREATMENT  OF.  E. 
Deeherf. 167 

GONOCOCCUS      INFECTIONS     IN 

CHILDREN.     L.  E.Holt 167 

GOUT,  EXCESSIVE  MEAT  DIET  IN 
THE  INDUCTION  OF.  D.  C. 
Watson 168 

HEMORRHAGES,  SODIUM  BICAR- 
BONATE INFUSIONS  IN  SE- 
VERE.    E.M.Dawson 168 

HEART,  CHANGE  IN  SIZE  OF,  ON 
CHANGE  OF  POSITION.  F. 
Moritz 169 

HEART       LE8IONS      AND      KIDNEY 

AFFECTIONS.     F.  Bronowski 169 

INFANT    FEEDING,  ALKALIES   IN. 

T.  S.  Southworth 170 

INGROWN  TOENAIL,  BIMPLE 
TREATMENT  OF.  Alberto  Gas- 
parini... li  1 

INTESTINAL  CATARRH,    DIETETIC 

TREATMENT  OF.     Rosenheim...  171 

LECITHIN,  ROLE  OF,  IN  ACTION 
OF  RADIUM  AND  X-RAYS.  R. 
Werner 172 

LOCOMOTOR  ATAXIA,  TREATMENT 
OF,  BY  ULTRA-VIOLET  RA^S. 
J.  M.  Liebermann 172 

LYMPHATIC    LEUKEMIA,    ACUTE. 

Thomas  McCr  e 173 

NITROGLYCERINE,  THE  LIMITA- 
TIONS OF,  AS  A  THERAPEU- 
TIC AGENT.     H.  P.  Loomis 173 

OPTIC  NEURITIS  DURING  LACTA- 
TION.    G.  S.  Derby 174 

PANCREAS,  EFFECTS  OF  REMOV- 
ING.    Torindo  Silvestri 175 

PERNICIOUS  ANEMIA,  PATH- 
OLOGY OF.  G.  L.  Gulland  and 
A.  Goodall 175 

PNEUMONIA  AND   PREGNANCY.   R. 

C.  Ransdell 176 

PNEUMONIA,  LOBAR,  IN  INFANCY. 

J.  L.  Morse 176 


Editorials. 


PAGE 
PREGNANCY,  TOXEMIA  OF. 

Ewing „  177 

PREPUKRPERAL    AND    PUERPERAL 

HEMORRHAGES.        C.  J.  C.  O. 

Hastings 178 

PREVENTIVE  MEDICINE  :  HOW  CAN 

THE    PHYSICIAN    PROFIT    BY 

IT?     J.  Madison  Taylor 179 

PUERPERAL    FEVER,    PREVENTION 

OF.     B.  Crede 180 

RINGWORM,     TREATMENT    OF.      J. 

L.  Bunch 181 

SCARLET  FEVER,  EAR  COMPLICA- 
TIONS OF.     Herman   Jareckv....  181 

SPRAINS      OF      THE      KNEE      AND 

ANKLB  JOINTS.     J.  T.  Wilson.  181 

STERILITY,    TREATMENT    OF.      E. 

Bumm 182 

SUBCUTANEOUS  NOURISHMENT 
AFTER  SURGI0AL  OPERA- 
TIONS.    Friedrich 183 

THYROID  AND  PANCREAS,  RELA- 
TION BETWEEN.   Alfonso  Pirera  183 

TUBERCULOSIS,     ACID     SALT8     IN 

BLOOD  IN.     C.  Canter 1S4 

TYPHOID  FEVER,  CHLORIDE  AND 
WATER  EXCRETION  IN,  WITH 
COPIOUS  DIURESIS.  Tor  Id 
Sollmann  and  J.  A.  Hofmann 184 

URIC    ACID:    ITS     INFLUENCE     IN 

GOUT.    C.C.Ransom... 185 

VISCEROPTOSIS.      H.  A.  McCallum...  185 

WATER-DRINKING,   INFLUENCE 

OF.     P.  B.  Hawk  1S6 

WHOOPING-COUGH,        TREATMENT 

OF.     H.  Stepp. 1>7 

X-RAYS,  DANGERS  OF  THE.     Milton 

Franklin 188 

ZINC  CHLORIDE,    CAUTERIZATION 

BY.     L.  Brose 188 

BOOK  REVIEWS 188 

BOOKS  AND  MONOGRAPHS  RE- 
CEIVED   190 

8TAPF  LIST 192 


DEPARTMENT    IN   CHARGE   OF 

J.  MADISON  TAYLOR,  A.M.,  M.D. 


THE  FUTUKE  OF  DRUG  MEDICATION. 

The  ideal  of  medical  practice  would  be  prophylaxis  in  the  widest  sense,  the 
family  physician  serving  as  a  guide  and  instructor  rather  than  as  a  prcscriber  of 
drugs.     Since  ideal  conditions  are  rarely,  if  ever,  attained,  we  and  our  successors 

(145) 


146  THE  FUTURE  OF  DRUG  MEDICATION. 

must,  in  all  probability,  rely  largely  upon  the  action  of  medicines  in  the  treatment 
of  the  sick,  and  we  can  affirm,  with  Shakespeare,  that  "by  medicine  life  may  be 
prolonged." 

Nearly  all  drugs  used  by  medical  men  may  have  unpleasant  or  injurious  by- 
actioris  and  after-effects,  which  detract  from  their  direct  curative  value.  A  pow- 
erful remedy  in  the  hands  of  a  semi-educated  or  unwise  practitioner  is  liable  to  do 
far  more  harm  than  good.  With  the  exception  of  a  very  small  number  of  specifics, 
drugs  are  certainly  secondary  in  importance  to  a  judicious  hygienic  and  dietetic 
management  of  the  patient,  and  to  the  therapeutic  utilization  of  heat,  cold,  light, 
electricity,  and  manipulation. 

The  trend  of  scientific  progress  is  nearly  always  toward  simplicity.  The  intri- 
cate epicycles  of  Ptolemaic  astronomy  have  given  way  to  Newton's  few  and  plain 
laws  of  motion  and  attraction.  The  principles  of  evolution  are  the  warp  and  woof 
common  to  all  living  beings.  The  greatest  inventions  are  remarkable  no  less  for 
their  simplicity  than  for  their  value  to  the  human  race. 

So  in  the  practice  of  medicine  let  us  hope  that  the  day  is  near  at  hand  when 
we  shall  use  fewer  drugs  and  with  greater  wisdom.  Are  not  a  hundred  standard 
nu'dicincs  amply  sufficient  for  onr  professional  needs?  In  the  human  economy 
hydrochloric  acid  answers  every  practical  object  of  a  mineral  acid.  Sodium  nitrite 
fulfills  every  vasodilator  requirement,  except  when  amyl  nitrite  inhalations  are  pre- 
ferred for  immediate  and  transient  effect.  Calomel,  conjoined  with  a  limited  diet 
and  colonic  flushings,  excels  all  other  "intestinal  antiseptics/'  Antipyrin  (phenyl- 
dimethyl-pyrazolon)  is  an  effective  antipyretic,  analgesic,  antispasmodic,  and  haem- 
ostatic. 

It  goes  without  saying  that  our  medicines  should  be  as  definite  in  strength  as 
possible,  and  hence  the  active  principles  (alkaloids,  glucosids,  etc.)  are  generally 
preferable  where  systemic  effects  are  desired.  When  we  compare  the  attractive, 
definite,  and  convenient  medicaments  of  the  present  day  with  the  crude  muddy 
mixtures  and  nauseous  draughts  of  the  not  remote  past,  we  have  every  reason  to 
felicitate  both  ourselves  and  our  patients.  That  the  achievements  of  synthetic 
chemistry  are  now  only  well  begun,  is  certain.  Our  most  cherished  remedies  may 
be  made  in  this  way  in  the  future,  and  much  more  satisfactorily  than  they  are  now 
obtained  from  natural  sources.  An  illustrative  instance  is  the  artificial  product, 
methylaminoorthodioxyacetophenon,  which  is  similar  in  properties  and  effects  to 
the  active  chromogen  principle  of  the  suprarenal  medulla.  Probably  the  majority 
of  prescriptions  nowadays  call  for  proprietary  products.  The  number  of  these  prepa- 
rations is  legion,  and  is  ever  increasing.  A  partial  list,  with  chemic  composition, 
compiled  by  me  during  the  past  year,  comprises  530  different  remedies.  Many  of 
these  are  convenient  for  dispensing  and  pharmaceutically  elegant,  and  some  are 


THE  FUTURE  OF  DRUG  MEDICATION.  147 

therapeutically  valuable,  but  hardly  any,  if  any,  are  indispensable  to  the  scientific 
physician.  The  distinction  made  between  definite  chemic  compounds  and  physic 
mixtures  is  not  of  much  importance.  The  molecular  formula  given  is  unintelligible 
to  most  practitioners,  and,  on  the  other  hand,  some  of  our  most  trustworthy  medi- 
cines, Dover's  powder,  for  example,  are  mere  mechanical  admixtures.  Object  ons 
to  the  medical  patronage  of  proprietary  products  are  their  high  price  (one  highly 
vaunted  preparation  sells  at  two  dollars  per  grain);  the  routine  and  haphazard 
methods  which  their  frequent  use  induces;  and,  above  all,  the  growing  tendency 
among  the  manufacturers  of  these  drugs,  foods,  and  devices  to  advertise  directly 
to  the  laity  encouraging  self-medication.  When  certain  patent  medicines,  adver- 
tised in  the  public  press  for  a  generation,  are  accepted  as  advertisements  by  reputable 
medical  journals,  the  practical  difference  between  proprietary  and  patent  medicines 
becomes  even  less  appreciable. 

Novelty  has  always  a  certain  attractiveness,  even  when  it  consists  merely  in  the 
name,  as  exemplified  by  the  many  changes  rung  upon  hexamethylentetramin  and 
solutions  of  formaldehyde.  Hence,  before  we  have  mastered  the  clinical  use  of  one 
remedy,  we  are  tempted  to  try  another  recommended  for  the  same  purpose,  and 
probably  neither  better  nor  worse. 

It  is  true  that,  except  where  a  psychic  effect  is  desired,  the  question  of  pala- 
tability  is  of  considerable  consequence.  In  the  case  of  nauseous  powders  and  liquids 
capsules  afford  a  ready  means  of  obviating  the  disagreeable  taste.  Compressed  tab- 
lets, let  us  say  of  salicylates,  quickly  washed  down  with  water,  leave  scarcely  any 
taste  behind,  and  are  usually  sufficiently  soluble  in  the  alimentary  tract.  A  pepper- 
mint lozenge,  a  slice  of  orange,  a  sip  of  coffee,  or  a  salt  wafer,  following  a  dose  of 
codliver-oil,  makes  the  oral  savor  normal  again.  Such  simple  measures  are  gener- 
ally as  efficient  in  promoting  eugeusia  as  more  ambitious  pharmaceutic  attempts. 
The  questions  of  dosage  and  frequency  of  administration  of  drugs  have  not  been 
worked  out  to  very  definite  conclusions.  In  giving  arsenic,  for  example,  shall  we 
begin  with  the  maximum  dose  and  gradually  diminish,  or  shall  we  commence  with 
a  minimum  dose  and  slowly  increase  the  amount  until  physiologic  symptoms  arise? 
In  the  administration  of  laxatives,  shall  we  give  an  anti-constipation  granule  every 
hour  throughout  the  day,  or  one  Full  dose  at  bedtime  of  the  drug  or  drugs  selected? 
Concerning  quantity,  it  appears  to  the  writer  that  we  should  give  whatever  dose 
i8  needed  in  the  individual  ease,  ranging  from  a  placebo  effervescent  lithium  tablet 
in  a  glass  of  much  needed  water,  to  an  ounce  or  more  daily  of  potassium  iodide  in 
cases  of  cerebral  syphilis.    When  the  condition  requires,  medicines,  Like  the  surgeon  s 

instruments,  should   be  used    fearlessly,  hut   with   precision. 

Above  all,  the  medicaments  and  the  mode  of  treatment  should  he  adapted  as 
closely  as  possible  to  the  patient's  condition,  as  it  varies  from  day  to  day,  with  special 


148  THE  FUTURE  OF  DRUG  MEDICATION. 

reference  to  the  emunctories  and  the  vasomotor  system.  The  nature  of  the  disease 
is  mainly  a  matter  of  prognosis  and  prophylaxis.  The  state  of  the  pulse,  aeration, 
elimination,  and  cerebration  are  of  vital  importance.  We  should  aim  to  stimulate  or 
to  moderate  functions,  rather  than  open  up  our  pharmaceutic  batteries  upon  im- 
aginary disease  entities  comparable  to  the  demons  of  the  ancients. 

Medicinal  agents  acting  locally  or  reflexly  have  the  advantage  of  producing 
hardly  any  objectionable  by-effects,  and  I  think  that  their  use  should  be  extended. 
A  mustard  paper  or  an  ice-bag  on  the  epigastrium  relieves  nausea  and  vomiting  more 
certainly  than  internal  remedies.  The  nasal  douche  followed  by  the  instillation  of 
a  bland  oil  is  about  the  best  treatment  for  the  nocturnal  throat  coughs  of  children. 
Steam  inhalations  with  terebene  are  very  effective  in  the  winter  cough  of  chronic 
bronchitis. 

How  often  to  use  our  remedies  is  a  question  for  every  doctor  with  each  patient. 
Tt  is  generally  accepted  that  small  doses  frequently  repeated  are  best  in  the  acute  dis- 
eases of  children,  and  perhaps  in  such  severe  conditions  in  adults  every  hour  or  two 
is  not  too  often  to  disturb  the  patient  with  food  or  medicine.  Even  in  chronic  cases 
one  cannot  deny  the  suggestive  benefit  of  frequent  medication.  But  here  it  is  gen- 
erally impracticable,  and  one  must  also  doubt  the  wisdom  of  maintaining  a  constant 
tension  or  irritation  through  the  use  of  drugs.  Nature  is  highly  rhythmic,  and  we 
should  seek  to  imitate  her  undulations.  A  single  large  dose  of  digitalis  at  each  bed- 
time has  often  seemed  to  me  to  yield  the  best  results  in  many  cases  of  cardiac  defects. 

In  conclusion,  we  can  hardly  hope  that  therapeusis  will  keep  pace  with  pre- 
ventive medicine  and  with  surgical  progress  as  long  as  it  is  so  largely  on  an  empiric 
basis.  When  we  know  the  precise  effects  of  any  drug,  then  we  can  employ  it  with 
equal  confidence  and  satisfaction.  The  science  of  the  underlying  physics  and  chem- 
istry of  drug  action  is  barely  risen,  but  already  it  sheds  light  in  dark  places.  Take 
digitalis,  for  example.  As  Sajous  has  shown,  this  drug  calls  forth  in  greater  quan- 
tity the  adrenal  secretion,  which  is  directly  responsible  for  the  tonic  action  on  the 
cardio-vascular  system.  Vasomotor  tension  from  digitalis  is  therefore  allied  to  the 
high  tension  pulse  of  kidney  disease,  due  to  oversecretion  from  the  suprarenal  glands, 
owing  to  irritation  by  contiguous  inflammation;  and  when  this  tension  is  excessive 
(above  140  millimeters  of  mercury),  either  in  renal  disorders  or  from  the  adminis- 
tration of  digitalis,  it  should  be  lowered  by  the  use  of  aconite  or  sodium  nitrite. 

Edward  C.  Hill,  M.D.,* 

Denver. 


Professor  of  Chemistry  in  the  Denver  and  Gross  College  of  Medicine. 


PERICOLITIS  SINISTRA, 


In  the  following  brief  remarks  attention  will  be  specially  called  to  a  group  of 
cases,  examples  of  which,  not  being  particularly  rare,  have  probably  occurred  in 
the  practice  of  most  medical  men.  Apology  is  perhaps  needed  for  the  title,  though 
it  is  not  mine,  but  it  has  the  advantage  of  describing  both  the  nature  and  the  posi- 
tion of  the  morbid  process.  In  order  to  indicate  the  nature  of  the  cases  here  grouped 
together  it  may  at  once  be  stated  that  the  condition  is  like  appendicitis  or,  rather, 
for  the  most  prominent  feature  in  both  is  the  involvement  of  the  visceral  peritoneum, 
perityphlitis ;  only  it  is  on  the  left  instead  of  on  the  right  side  of  the  abdomen. 

The  cases  here  grouped  together  may,  like  perityphlitis,  give  rise  to  different 
conditions;  thus  there  may  be  (1)  local  peritonitis  of  comparatively  slight  intensity 
around  the  descending  colon  or  the  sigmoid  flexure;  (2)  a  local- abscess  in  connec- 
tion with  the  descending  colon  which  may  eventually  burst  into  the  general  peritoneal 
cavity  and  set  up  (3)  general  peritonitis. 

1.  In  the  commoner  and  less  severe  form  the  clinical  features  are  often  spoken 
of  as  faecal  accumulation  or  impaction  and  have  been  described  as  sigmoiditis  or 
perisigmoiditis.  Bittorf2  described  four  cases  as  acute  circumscribed  sigmoiditis, 
but  since  the  process  is  not  necessarily  confined  to  the  sigmoid  flexure  the  inclusive 
term  of  pericolitis  sinistra  is  perhaps  more  suitable.  Hemmeter,3  however,  gets  over 
the  difficulty  by  describing  the  cases  included  in  the  group  as  sigmoiditis  and  peri- 
colitis. 

The  clinical  manifestations  are  briefly  as  follows:  After  constipation  of  some 
duration  the  patient  experiences  pain  in  the  left  iliac  fossa,  usually  has  a  somewhat 
raised  temperature,  and  may  vomit.  On  palpation  there  are  deep  tenderness,  mus- 
cular resistance,  and  a  more  or  less  cylindrical  tumor  palpable  in  the  left  iliac  fossa, 
features  which  suggest  appendicitis  on  the  left  side.  Leucocytosis  and  indicanuria 
have  been  noted  in  some  instances  (Bittorf).  The  following  is  a  case  of  this 
category : 

Case  I. — A  man,  aged  23  years,  was  admitted  into  St.  George's  Hospital  under 
my  care  on  August  18,  1904,  with  acute  rheumatism.  It  is  noteworthy  that  he  had 
been  in  the  hospital  with  a  previous  attack  of  rheumatism  also  complicated  by 
abdominal  manifestations,  similar  to  those  described  below,  in  1902.  As  the  result 
of  treatment  the  temperature  rapidly  fell,  but  after  his  bowels  had  been  obstinately 
confined  for  four  days  he  was  seized  with  abdominal  pain  in  the  left  iliac  fossa,  where 
there  was  much  resistance  and  an  oval  patch,  three  by  two  inches,  of  hyperesthesia. 
There  was  no  tenderness  or  pain  in  the  right  iliac  fossa.    The  abdomen  moved  badly 


*A  paper  read  before  the  Medical  Society  of  London  on  March  27,  1905.      (To  be  pub- 
lished simultaneously  in  London  Lancet  of  April   1st.) 

1  Bittorf:     Miinchener  Medicinische  Wochenschrift,  1904,  S.  147. 

•Hemmeter:     "Diseases  of  the  Intestines,"  vol.  i.,  p.  504,  1901. 

3  (149) 


150  PERICOLITIS  SINISTRA. 

and  the  patient  lay  with  the  legs  drawn  up.  Next  day  the  pain  was  worse  and  vom- 
iting occurred  twice,  the  pulse  was  92,  and  the  temperature  was  101°  F.,  but  the 
latter  was  probably  due  to  a  relapse  of  the  rheumatic  pains  and  not  to  the  abdominal 
condition.  On  the  following  day,  after  the  bowels  had  been  freely  open,  as  the  result 
of  enemata,  the  abdominal  pain  diminished,  and  after  this,  the  bowels  being  kept 
regularly  open,  the  abdomen  became  natural. 

The  symptoms  are  relieved  by  removing  the  faecal  accumulation,  preferably  by 
repeated  enemata  at  first,  and  then  by  purgatives  such  as  castor-oil.  For  the  pain 
Hemmeter  recommends  an  ice-bag  in  the  early  stages,  followed,  if  swelling  persists 
for  four  days,  by  hot  poultices. 

I  have  no  data  from  my  own  experience  to  bring  forward  as  to  the  morbid 
changes  in  these  cases ;  it  might  a  priori  be  supposed  that  f aecal  accumulation  gives 
rise  to  inflammation  of  the  mucous  membrane  and  other  coats  of  the  colon,  and  so 
by  extension  to  local  peritonitis,  and  that  the  process  is  much  the  same  as  that 
described  by  Mr.  W.  Arbuthnot  Lane4  in  the  ascending  colon  as  the  result  of  chronic 
constipation.  Pal,5  however,  regards  the  lesion  as  a  primary  circumscribed  inflam- 
mation of  the  mucous  membrane  of  the  colon  and  not  as  a  pericolitis.  Eixford6  has 
recorded  two  cases,  allied  to  this  class,  in  which  inflammation  of  an  appendix  epi- 
ploica  was  due  to  infection  conveyed  from  a  neighboring  false  or  acquired  diver- 
ticulum of  the  colon.  In  his  cases  the  inflamed  appendices  epiploicae  were  palpable 
as  tumors,  of  the  size  of  a  walnut  in  one  case  and  of  a  hen's  egg  in  the  other,  and 
were  removed.  It  does  not  appear  that  there  were  abscess  cavities  in  the  inflamed 
appendices  epiploicae  as  there  were  in  Mr.  J.  Bland-Sutton's7  cases  of  faecal  abscesses 
in  appendices  epiploicae,  due  to  the  passage  of  small  but  sharp  foreign  bodies  from 
the  colon  into  the  appendices  epiploicae.  Rixford's  cases  suggest  that  inflammation 
extending  from  a  sacculus  of  the  descending  colon  may  be  the  cause  of  the  peri- 
colitis. This  explanation  would  be  compatible  with  the  absence  of  diarrhoea  which 
ordinary  inflammation  of  the  mucous  membrane  of  the  surface  of  the  descending 
colon  would  probably  tend  to  set  up,  and  also  with  the  undoubted  fact  that  peri- 
colitis only  occurs  in  a  very  small  percentage  of  individuals  with  chronic  and  obsti- 
note  constipation.  In  fact,  necropsies  show  how  rarely  adhesions  around  the  sig- 
moid flexure  and  colon  are  set  up  by  constipation  alone.  Marked  sacculation  of  the 
colon  is  by  no  means  constant  in  constipation  and  it  is  conceivable  that  it  is  only 
in  those  cases  in  which  sacculation  is  present  that  the  conditions  favorable  to  the 
development  of  pericolitis  are  satisfied.     It  is  highly  probable  that  this  condition 


4  Lane:     The  Lancet,  1903,  vol.  ii.,  p.  1073. 

6  Pal,   quoted    in    Nothnagel's    "Diseases    of    the    Intestines    and    Peritoneum;"  American 
Translation,  p.  930. 

"Rixford:     California  State  Journal  of  Medicine,  October,  1904,  p.  29G. 

7  Bland-Sutton:     The  Lancet,  1903,  vol.  ii.,  p.  1148. 


PERICOLITIS  SINISTRA.  151 

may  pass  into  that  of  the  second  category  in  which  there  is  a  localized  abscess  in 
connection  with  the  colon. 

2.  A  localized  abscess  in  connection  with  perforation  of  a  stercoral  ulcer,  either 
in  a  false  diverticulum  or  in  the  wall  of  the  colon,  may  be  either  intra  or  extra- 
peritoneal, and  in  both  cases  may  extend  widely  along  the  side  of  the  colon,  thus 
resembling  the  spread  of  an  appendicular  abscess.  The  method  of  formation  of 
this  form  of  pericolic  abscess  is  analogous  to  that  of  a  localized  abscess  above  a  malig- 
nant stricture  of  the  bowel.  It  appears  probable  from  a  case  recorded  by  Mayor8 
that  a  pericolic  abscess  due  to  perforation  of  a  stercoral  ulcer  may  discharge  into 
the  colon  by  ulcerating  the  coat  of  the  colon  from  without  (exogenous  ulceration). 
A  fistulous  communication  between  the  bowel  and  the  urinary  bladder  may  also  be 
set  up.  The  clinical  features  of  a  pericolic  or  perisigmoid  abscess  may  be  difficult 
to  interpret  correctly,  especially  when  no  definite  swelling  can  be  felt  and  the  diag- 
nosis of  carcinoma  of  the  colon  is  very  likely  to  be  made  when  a  mass  is  palpable. 

The  two  following  cases  illustrate  the  formation  of  intra  and  extra-peritoneal 
abscesses  respectively  in  connection  with  stercoral  ulceration  of  diverticula  in  the 
descending  colon. 

Case  II.  Intraperitoneal  Pericolic  Abscess. — A  woman,  aged  71  years,  who 
had  had  a  femoral  hernia  for  many  years,  was  attacked  with  diarrhoea  a  month 
before  her  death  and  subsequently  had  abdominal  pain  followed  by  increase  in  size 
of  the  hernia  and  vomiting.  Herniotomy  was  performed  in  St.  George's  Hospital, 
but  it  did  not  appear  that  there  was  any  strangulation  of  the  bowel.  Death  occurred 
a  few  days  later.  At  the  necropsy  there  was  an  intraperitoneal  abscess  to  the  outer 
side  of  the  descending  colon,  the  boundaries  of  the  abscess  being  the  descending 
colon,  the  abdominal  wall,  and  some  coils  of  the  jejunum.  There  was  no  general 
peritonitis  but  the  abscess  extended  down  along  the  side  of  the  descending  colon  into 
Douglas's  pouch.  The  part  of  the  colon  in  immediate  contact  with  the  abscess  was 
cedematous,  inflamed,  and  dilated.  The  sigmoid  flexure  was  contracted  and  showed 
a  number  of  false  diverticula,  many  of  which  contained  rounded  faecal  masses.  The 
intraperitoneal  abscess  was  due  to  perforation  of  a  false  diverticulum  in  the  descend- 
ing colon.  No  other  cause  for  peritonitis  could  be  found.  The  vermiform  appendix 
was  partially  obliterated,  but  otherwise  normal.  There  was  a  remarkably  good 
pulsion  diverticulum  of  the  lowest  part  of  the  pharynx;  it  is  interesting  to  note  this 
association  of  acquired  diverticula  of  the  colon  and  of  the  pharynx. 

Case  III.  Retroperitoneal  Pericolic  Abscess. — A  woman,  aged  47  years,  was 
admitted,  under  the  care  of  my  colleague  Dr.  F.  G.  Penrose,  who  has  kindly  allowed 
me  to  mention  the  case,  to  St.  George's  Hospital  on  November  26,  1903,  with  abdom- 
inal tenderness  and  pain,  flatulence,  and  sickness.  These  symptoms  had  been  grad- 
ually coming  on  for  eighteen  months  but  had  been  more  marked  for  one  month.  For 
nine  days  there  had  been  thrombosis  of  the  veins  in  both  legs.  On  admission  there 
was  abdominal  swelling  rather  suggesting  ascites  with  dullness  in  the  flanks,  espe- 


'A.  Mayor:     Revue  Medicale  de  la  Suisse  Romande,  tome  xiii.,  p.  421,  1893. 


152  ALBUMIN  IN  URINE  OF  APPARENTLY  HEALTHY  CHILDREN. 

dally  on  the  left  side.  On  November  30th  the  patient  suddenly  became  much  worse, 
the  abdomen  became  distended,  and  the  temperature,  which  had  never  been  below 
99°  F.,  touched  102°.  This  was  succeeded  by  diarrhoea  and  pain  in  the  left  flank. 
The  patient  remained  very  ill  and  a  tumor  was  felt  on  the  left  side  which  was  thought 
to  be  connected  with  the  pancreas;  on  December  18th  pleural  friction  was  detected 
over  the  base  of  the  left  lung,  and  on  the  22d  death  occurred,  preceded  by  delirium. 
The  necropsy  revealed  a  large  retroperitoneal  abscess  on  the  left  side  extending  from 
the  brim  of  the  pelvis  to  the  diaphragm  containing  pus  and  clay-clored  fasces.  The 
descending  colon  showed  toward  its  lower  end  three  deeply  excavated  ulcers,  two  of 
which  opened  into  the  abscess  cavity ;  one  of  the  latter  was  at  the  tip  of  an  acquired 
directiculum. 

If  the  presence  of  an  abscess  is  reasonably  certain  it  should  be  opened.  A  faecal 
fistula,  however,  may  be  expected,  and  in  a  case  of  GeorgiV  fatal  peritonitis  fol- 
lowed exploratory  laparotomy  on  an  abscess  close  to  the  sigmoid  flexure  and  due  to 
perforation  of  a  diverticulum. 

3.  Lastly,  rupture  of  a  circumscribed  pericolic  abscess  into  the  general  cavity 
of  the  peritoneum  may  occur  and  set  up  fatal  perforative  peritonitis  as  in  the  fol- 
lowing case : — 

Case  IV.— A  man,  aged  52  years,  was  admitted  into  St.  George's  Hospital 
under  my  care  on  August  14,  1904,  moribund;  from  his  condition  and  the  history 
obtainable  it  was  surmised  that  there  was  acute  perforative  peritonitis  supervening 
on  chronic  obstruction  probably  clue  to  carcinoma  of  the  colon.  At  the  necropsy 
there  was  general  peritonitis  due  to  leakage  of  an  abscess  situated  behind  the  junc- 
tion of  the  sigmoid  flexure  and  the  descending  colon.  There  were  a  number  of 
stercoral  ulcers  in  the  sigmoid  flexure,  one  of  which  led  into  the  abscess  cavity. 
There  was  no  new  growth  in  the  abdomen  and  the  appendix  was  healthy. 

Stercoral  or  other  kinds  of  ulcers,  such  as  those  due  to  dysentery,  either  in  false 
diverticula  or  in  the  mucous  membrane  of  the  colon,  may  of  course  perforate  directly 
into  the  general  peritoneal  cavity  and  set  up  diffuse  peritonitis.    Beer10  quotes  four 
cases  of  perforation  of  a  false  diverticulum  into  the  general  peritoneal  cavity. 
By  H.  D.  Rolleston,  M.D.  Cantab.,  F.R.C.P.Lond.,* 

London. 
*  Physician  to  St.  George's  Hospital. 

ALBUMIN  IN  THE  URINE  OF  APPARENTLY  HEALTHY  CHILDREN. 

It  is  well  known  that  albumin  is  not  infrequently  found  in  the  urine  of  those 

children  who  are  apparently  healthy,  at  least  in  whom  we  cannot  demonstrate  the 

presence  of  any  disease  per  se.     Jackson1  observes  this  to  occur  after  cold  baths; 

•Georgi:     Deutsche  Zeitschrift  fur  Chirurgie,  Band  lxvii.,  p.  5,  1903. 
10  E.  Beer:     American  Journal  of  the  Medical  Sciences,  vol.  cxxviii.,  p.  142,  July,  1904. 
1  British  Medical  Journal,  1873.     Quoted  by  Landon  Carter  Gray,  American  Journal  Medi- 
cal Sciences,  October,  1894. 


ALBUMIN  IN  URINE  OF  APPARENTLY  HEALTHY  CHILDREN.  153 

the  Germans  have  noted  it  in  the  new-born,2  and  Dohrn  in  children  and  young 
people.3  I  confess  that  we  are  at  a  loss  to  correctly  interpret  these  findings,  in  the 
light  of  our  present  knowledge,  in  children  who  present  no  cardiac  or  arterial  lesions 
characteristic  of  nephritis  and  in  whom  the  arterial  pressure  is  normal;  we,  of 
course,  do  not  regard  the  transient  presence  of  albuminuria  as  evidence  of  nephritis. 
Many  times  has  Keating  discussed  this  problem  with  me,  and  during  the  latter 
years  of  his  life  our  conclusion  was  that  the  growing  kidney  occasionally  secretes  a 
urine  containing  both  albumin  and  epithelial  cells  when,  so  far  as  our  methods  of 
precision  would  take  us,  we  were  unable  to  say  that  either  the  cardio-vascular  or  the 
renal  apparatus  was  organically  at  fault.  The  future  has  shown  we  were  probably 
correct,  as  some  of  these  children  whom  Keating  and  myself  then  studied  are  now 
adults  between  25  and  30  years  of  age,  members  of  families  with  whom  I  am  per- 
sonally familiar.  They  are  now  healthy  men  and  women  without  demonstrable  renal 
or  cardiac  disease. 

We  believe  that  in  those  cases  which  will  eventuate  in  demonstrable  pathologic 
lesions  the  cardio-vascular  changes  become  recognizable  very  soon  after  the  albumin 
is  detected ;  indeed,  in  many  instances  the  cardiac  and  arterial  changes  precede  the 
renal  alterations.    This  is  as  true  in  the  child  as  in  the  adult. 

We  sometimes  asked  ourselves  whether  albumin  would  not  be  found  from  time 
to  time  in  the  urine  of  every  growing  child  if  our  tests  were  delicate  enough  and 
our  methods  sufficiently  exact.  This  should  offer  a  tempting  field  for  the  younger 
investigators. 

Albuminuria  then  appearing  in  those  in  whom  there  are  no  demonstrable  lesions 
in  infancy,  childhood,  adolescence,  or  later  life,  would  seem  to  be  of  a  different 
character  from  the  albuminuria  of  Bright's  disease.  This  is  in  accordance  with 
Semmola,  of  Naples,  who  for  more  than  thirty-five  years  has  claimed  that  the  albu- 
min in  Bright's  disease  is  a  different  form  of  albumin  from  that  occurring  in  other 
lesions. 

This,  of  course,  opens  up  too  large  a  discussion  for  the  present  communication ; 
we  must  refer  to  the  researches  of  Meissner,  Briicke,  Schiitzenberger,  Kuhne,  Neu- 
meister,  Chittenden,  Croftan,  Stewart,  and  others.  Suffice  it  to  say,  however,  that 
there  seems  to  be  no  question  at  the  present  day  that  different  albumins  appear  in 
the  urine.  Upon  the  recognition  of  these  depends  the  diagnosis  of  nephritis  from 
other  diseases. 

Many  cases  may  excrete  abnormal  amounts  of  the  terminal  products  of  nitro- 
genized  and  hydrocarbonaceous  metabolism  appearing  in  those  not  the  subject  of 
either  renal  or  cardio-vascular  change.     I  do  not  wish,  however,  to  convey  the  idea 

2Virchow's  Ges.  Abhndlug.,  1856. 

8  Dohrn,  Monat  f .  Geburtsch.,  Bd.  xxix. 


154  ALBUMIN  IN  URINE  OF  APPARENTLY  HEALTHY  CHILDREN. 

that  it  is  our  opinion  that  the  abnormal  urinary  products  are  always  due  to  faulty 
food  supply.  In  some  of  these  children  we  thought  that  perhaps  an  unstable  nervous 
system  was  responsible  for  the  albuminuria,  the  altered  metabolism.  Others  we  have 
come  to  consider  among  the  class  that  Goodhart  so  aptly  terms  "a  queer  lot,"  that 
is,  the  offspring  of  those  whose  nervous  systems  are  feeble,  or  diseased,  or  who  are 
closely  related  to,  or  have  themselves  been  the  subjects  of  fits,  hysteria,  neuralgia, 
rheumatism,  convulsions  of  infancy,  passionateness,  morbid  timidity,  or  chorea. 

A  number  of  these  cases  of  albuminuria  without  renal  lesions  come  to  Cali- 
fornia every  winter  sent  by  their  Eastern  physicians  with  a  diagnosis  of  renal  dis- 
ease. These  are  the  children  who  improve  so  quickly  in  this  climate  and  who  return 
in  a  short  time  to  their  homes,  perhaps  without  albumin  in  the  urine,  with  increased 
blood  supply,  and  with  all  the  appearances  of  good  health.  This  encourages  the 
medical  man  to  think  that  he  has  saved  the  child  from  kidney  disease,  when  a  more 
careful  study  of  the  case  would  have  placed  it  in  its  proper  category  of  transitory 
albuminuria  without  demonstrable  lesions. 

The  frequent  presence,  I  may  almost  say  normality,  of  the  appearance  of  nucleo- 
albumin  in  the  urine  in  amount  which  reacts  to  test  solutions  containing  tannin, 
mercury,  or  a  vegetable  acid,  must  never  be  forgotten.  This  applies  to  some  of  the 
most  popular  tests,  as  Tanret's,  Millard's,  Sebelein's,  and  even  to  Spiegler's  and 
Jolles,  so  recently  commended  in  the  Journal  of  the  American  Medical  Association, 
December  3,  1904. 

Three  reagents  now  much  in  fashion  will  also  often  prove  fallacious  in  this 
respect,  namely,  picric  acid,  particularly  the  citrated  solution ;  metaphosphoric  acid, 
and  trichloracetic  acid. 

D.  D.  Stewart,  of  Philadelphia,  it  was,  I  think,  who  about  ten  years  ago  pointed 
out  that  a  reaction  could  often  be  obtained  with  the  urine  of  the  healthy ;  that  unless 
this  was  remembered  it  would  be  infinitely  better  to  depend  upon  the  less  misleading, 
if  less  delicate,  tests  which  time  has  proven  to  be  reliable.  After  all  said  and  done, 
boiling  and  the  addition,  if  necessary,  of  acetic  acid  is  still  the  most  reliable  test, 
because  the  substance  reacting  to  the  more  delicate  tests  is  apt  to  be  a  mucoid  body 
originating  in  all  probability  from  the  cellular  elements  of  the  extra-renal  passages, 
as  Stewart  has  told  us,  or  a  nucleo-albumin. 

In  conclusion,  before  sending  these  little  patients  so  far  away  from  home  it 
would  be  well  to  determine  absolutely  whether  the  urine  contains  serum  albumin, 
scrum  or  para-globulin,  nucleo-albumin  from  bile,  mucin  from  bile,  or  mucin  from 
mucous  membrane,  albumoses,  or  the  so-called  urinary  peptones.  It  is  well  to  fur- 
ther remember  that  serum  globulin  is  almost  always  found  in  the  urine  which  also 
contains  serum  albumin.  If  the  contrary  obtains  the  probability  is  that  not  serum 
globulin,  but  nucleo-albumin,  is  present.     Again  must  be  remembered  the  frequent 


UTILITY  OF  THYROID  EXTRACT  IN  PUERPERAL  ECLAMPSIA.  155 

association  of  serum  albumin  with  a  mucinuria,  that  is,  a  nucleo-albuminuria  and 
a  serum  albuminuria. 

To  repeat,  then,  the  old-fashioned  test  by  boiling  is  still  the  most  reliable 
one  for  serum  albumin.  The  two  principal  fallacies  in  this  test,  besides  those  so 
well  known,  are:  first,  the  reaction  of  nucleo-albumin  after  cooling,  and  second,  an 
excess  of  earthy  phosphates  in  strongly  nucleous  albuminous  urine. 

William  A.  Edwards,  M.D.,* 

Los  Angeles,  California. 


THE  PEACTICAL  UTILITY  OF  THYEOID  EXTRACT  IX 
PUEEPEEAL  ECLAMPSIA. 

The  relief  of  puerperal  eclampsia  has  hitherto  proved  unsatisfactory  owing 
less  to  obscurities  in  its  pathology  than  inadequacy  in  our  knowledge  of  principles 
whereby  the  effects  can  be  controlled.  To  quote  from  the  most  recent  text-book  on 
practice  in  our  possession  (H.  A.  Hare)  :  "The  pathology  (of  puerperal  eclampsia) 
is  not  understood.  Without  doubt  the  condition  is  toxic;  in  some  instances  it  is 
probably  due  to  perverted  functional  activity,  or  actual  disease,  of  the  kidneys.  In 
other  instances  it  seems  to  be  dependent  upon  perverted  metabolism." 

Acting  on  the  assumption  that  toxins  circulating  in  the  blood-stream  are 
directly  at  fault,  hypodermoclysis  has  been  largely  employed  with  a  view  to  washing 
these  out,  stimulating  elimination,  and  sustaining  the  circulation.  Surgeons  have 
made  most  use  of  hypodermoclysis  of  normal  salt  solutions,  but  the  field  of  this 
remedy,  or  procedure,  in  medical  conditions  is  as  yet  only  suggested.  Sajous  has 
pointed  out  the  importance  of  supplying  the  lost  plasmatic  salines,  and  in  a  future 
paper  the  author  will  endeavor  to  show  the  practical  importance  of  supplying  to 
the  system  depleted  of  its  normal  saline  constituents  these  needed  elements.  This 
can  be  done  by  oral  administration  as  well  as  per  rectum  or  by  hypodermoclysis. 
The  subject  is  alluded  to  here  to  show  that,  as  an  adjuvant  to  more  specifically 
needed  elements  such  as  the  organic  extracts,  it  enormously  enhances  the  action  of 
whatever  else  is  imperatively  demanded. 

The  secretions  of  noble  glands,  constituting  the  chief  regulative  essences,  the 
protective  processes  of  the  body,  often  fail  of  their  effect  from  various  causes.  The 
effects  of  disease  is  to  impair  the  oxygen-carrying  power  of  the  blood  plasma,  to 
depress  the  normal  action  of  the  fluids  and  cellular  elements,  leucocytes,  the  ery- 
throcytes as  well  as  the  general  protective  center  of  the  body,  the  anterior  pituitary 
body  and  its  oocenter,  the  posterior  pituitary  body.  "It  is  only  when  the  alkalinity 
and  fluidity  of  the  blood-plasma  are  approximately  normal  that  all  cellular  elements 
of  the  organism  can  continue  their  function"  (Sajous). 


Professor  of  Pediatrics  in  the  University  of  Southern  California. 


156  UTILITY  OF  THYROID  EXTRACT  IN  PUERPERAL  ECLAMPSIA. 

He  has  further  pointed  out  that  the  phenomena  of  eclamptic  states  are  anal- 
ogous to  a  defective  action  of  the  thyroid  gland,  since  lowering  of  the  activity 
of  the  thyroid  gland  lowers,  in  corresponding  degree,  all  oxidation  processes. 
Convulsions  are  thus  ascribable  in  his  opinion  to  toxic  wastes  in  the  plasma,  poison- 
ing the  nerve  cells,  etc.,  which  excessive  over-activity  of  the  pituitary  body,  by 
inducing  general  hyperoxidation,  especially  in  the  muscles,  met  curatively,  i.e.,  by 
enhancing  all  the  auto-protective  functions  of  the  body. 

The  avidity  of  the  tissues  for  oxygen  is  such  that  it  practically  depletes  of  this 
gas,  not  only  the  red  corpuscles,  but  the  plasma  as  well.  Thyroid  extract  increases 
the  absorption  of  oxygen  and  the  proportion  of  carbonic  acid  excreted;  it  also 
increases  the  excretion  of  the  end  products  of  metabolism.  A  number  of  cases  have 
already  been  reported  in  which  the  convulsions  ceased  when  under  the  influence 
of  thyroid  extract,  and  when  the  oxidation  processes  were  brought  to  a  sufficiently 
high  level.  Thus  is  the  blood  purged  of  its  toxic  properties;  through  increased 
tissue  respiration  they  are  made  into  benign  eliminable  products,  the  spasmogenic 
poison  is  thus  overcome  by  the  protective  element  of  the  organism,  a  product  of 
one  of  its  chief  ductless  glands,  "and  this  applies  to  any  form  of  convulsion,  whether 
it  be  due  to  accumulated  waste  products  or  to  a  specific  toxic;  whether,  in  a  word, 
it  occur  during  puerperal  septicemia,  epilepsy,  hydrophobia,  or  tetanus"  (Sajous). 
The  remedies  commonly  employed,  those  which,  like  the  bromides  and  chloral,  are 
depressants  of  temperature  (H.  C.  Wood,  Richardson,  Hammerstein,  etc.),  drugs 
which,  by  reducing  the  excitability  of  the  motor  elements,  simply  favor  the  accu- 
mulation of  the  spasmogenic  toxics  by  inhibiting  the  oxidation  processes  through 
which  these  are  destroyed,  and  augment  the  chances  of  a  lethal  result. 

Clearly  such  measures  or  medicines  are  indicated  as  can  be  relied  upon  to 
increase  the  functional  activity  of  the  adrenal  system;  to  do  what  the  use  of  thy- 
roid extract  achieves  after  removal  of  the  thyroid  gland. 

"Nicholson  has  not  only  found  that  in  puerperal  eclampsia  the  normal  en- 
largement of  the  thyroid — to  which  Lange  called  attention  after  examining  133 
women — which  betokens  increased  functional  activity,  was  not  present,  but  that 
the  nitrogenous  metabolism  was  lowered.  He  obtained  excellent  results  by  the 
use,  with  pure  milk,  of  7  V2-grain  doses  of  thyroid  extract  every  three  or  four 
hours,  and  morphine  (a  drug  which  in  therapeutic  doses  stimulates  the  adrenal 
system)  as  an  adjunct.  Now,  if  the  adrenal  system  is  involved  in  such  processes,  its 
general  center,  the  pituitary  body,  should  give  evidence  of  excessive  activity.  In 
1898  L.  Comte  examined  the  pituitary  body  in  a  number  of  women  who  had  died 
during  pregnancy,  and  found  not  only  that  this  organ  was  hypertrophied  in  every 
case,  but  that  the  anterior  lobe  was  alone  the  seat  of  the  hypertrophy.  P.  E. 
Launois  and  P.  Mulon  recently  examined  histologically  the  pituitary  of  two  eclamp- 


ABDOMINAL  INJURIES.  157 

tic  women,  each  aged  about.  30,  and  were  brought  to  conclude  by  histologic  exami- 
nation that  during  pregnancy  the  pituitary  body  gives  evidence  of  marked  over- 
activity. This  exemplifies,  it  seems  to  me,  the  condition  involved  in  all  toxaemias 
attended  with  convulsions.  The  increasing  tendency  to  use  iodine,  mercurial  in- 
unctions, and  other  agents  which  tend  powerfully  to  increase  oxidation  and  general 
metabolism  by  enhancing  the  functional  activity  of  the  organism's  protective  sys- 
tem, seems  to  me,  therefore,  to  merit  encouragement"  (Sajous). 
As  sustaining  these  postulates  the  following  cases  are  cited: — 
"Baldowsky,  W.  G.  (Vratch.,  vol.  ii,  1904;  and  Australasian  Medical  Gazette, 
January  20,  1905)  has  confirmed  the  value  of  thyroid  extract  in  two  cases.  In 
the  first  case,  fits  came  on  in  a  multipara  at  the  seventh  month  of  pregnancy,  and 
18  grains  of  thyroid  extract  was  given.  The  fits  ceased.  The  thyroid  was  continued 
for  two  days  longer — 10  grains  daily — and  the  patient  seemed  quite  recovered.  A 
fortnight  later,  however,  she  again  developed  severe  eclamptic  fits,  sixteen  seizures 
altogether,  which  were  treated  by  thyroid  extract,  with  narcotic  remedies  in  addi- 
tion, and  recovery  followed.  The  other  case  was  that  of  a  primipara  at  term,  who 
was  suddenly  seized  with  eclamptic  convulsions  at  the  commencement  of  labor. 
Thyroid  alone  was  given,  and  the  attacks  ceased  before  rupture  of  the  membranes. 
The  labor  took  place  without  any  unusual  symptom  and  the  puerperium  was  normal" 

It  may  be  remarked  that  the  saline  supplement  need  not  be  introduced  directly 
into  the  circulation,  but  can  be  supplied  by  the  mouth.  A  convenient  method  I 
myself  employ  is  to  use  the  tablets  for  saline  infusion,  made  by  several  of  the 
manufacturing  chemists,  the  formula  of  G.  E.  Fowler,  or  Trunecek,  or  Leopold 
Levi,  and  place  one  or  more  of  these  into  a  half-gallon  bottle  oi  pure  water,  to 
which  it  gives  little  or  no  taste,  and  direct  the  patient  from  the  outset  of  the  disease 
to  drink  at  least  a  glassful  four  or  five  times  daily,  in  acute  cases  not  less  than  every 
three  or  four  hours.  If  the  condition  be  urgent  then  hypodermoclysis  or  entero- 
clysis  affords  a  prompt  and  powerful  means  of  administration. 

J.  Madison  Taylor.* 


Cyclopaedia  of  Current  literature. 

abdominal  injuries.  pain,  tenderness,  vomiting,  shock,  dull- 
Any  injury  to  the  abdomen  may  be  ness,  or  other  symptoms  indicative  of 
associated  with  damage  to  the  intestine  some  intra-abdominal  disturbance.  Cases 
or  other  viscera.  An  exploratory  opera-  not  operated  upon  are  lost.  The  impor- 
tion  is  justifiable  in  cases  with  distinct  tance  of  early  operation  cannot  be  em- 
rigidity.  An  operation  is  absolutely  in-  phasized  too  strongly.  At  present  the 
dicated  when  there  is,  besides  rigidity,  death-rate  is  about  75  to  80  per  cent. 


Physician  to  the  Philadelphia  Hospital  (Children's  Department). 


158 


ACNE,  TREATMENT.  ADENOID  VEGETATIONS. 


When  a  greater  proportion  are  operated 
upon  early,  the  death-rate  will  be  much 
lower.  C.  P.  Flint  (Medical  Kecord, 
February  18,  1905). 

ACNE   AND   ITS   TREATMENT. 

Acne  is  even  commoner  than  eczema, 
and  while  it  is  true  that  the  disease  is 
often  stubborn,  the  majority  of  cases  can 
be  greatly  benefited  in  a  short  time,  and 
very  many  of  them  cured  promptly.  The 
indications  for  treatment  are  as  follows : 
The  condition  of  the  skin  should  be  im- 
proved so  that  it  will  no  longer  be  a  suit- 
able culture  ground  for  the  bacillus. 
The  follicles  of  the  skin  should  be  emp- 
tied of  the  colonies  of  bacilli.  The  skin 
should  be  constantly  kept  aseptic  so  that 
any  bacilli  that  escape  on  it  will  be 
killed,  and  no  new  infection  of  the  skin 
will  be  possible.  The  first  indication  is 
met  by  attention  to  the  patient's  general 
health  by  means  of  baths,  diet,  exercise, 
attention  to  hygiene,  and  lastly,  drugs. 
The  follicles  are  emptied  by  the  use  of 
the  curet,  the  acne  lancet,  and  the  com- 
edo expressor.  The  best  local  applica- 
tion is  sulphur,  preferably  in  the  form 
of  the  old  Lotio  Alba,  the  formula  for 
which  is:  Zinc  sulphate  and  potassium 
sulpheret,  of  each,  3i-ij ;  rose  water,  q.  s. 
ad  §iv.  This  is  to  be  shaken  up  before 
using.  Eesorcin  is  also  useful,  as  well 
as  sulphur  soap.  The  use  of  the  Eoent- 
gen  ray  should  be  limited  to  intractable 
cases,  and  requires  great  caution  to  pre- 
vent doing  harm.  G.  T.  Jackson  (Med- 
ical Becord,  March  18,  1905). 

ADENOID  VEGETATIONS,  THE  CURE  OF 
EXOPHTHALMOS  AND  CHOREA  BY 
REMOVAL  OP. 

The  writer  agrees  with  Bamberger, 
Moebius,  and  other  authors  in  believing 
that  exophthalmos  alone,  if  not  due  to 


mechanical  causes,  is  sufficient  ground 
for  making  the  diagnosis  of  Basedow's 
disease.     He  describes  two  cases  of.  ex- 
ophthalmos which  were  completely  re- 
lieved by  removal  of  adenoid  vegetations. 
The  first  case  was  that  of  a  boy  of  7 
years,  with  well-marked  exophthalmos, 
accompanied  by  both  Graefe's  and  Stell- 
wag's  signs,  and  who  further  presented 
the  clinical  picture  typical  of  adenoids. 
Ten  days  after  removal  of  the  pharyn- 
geal tonsil  the  exophthalmos  had  com- 
pletely disappeared.    Two  years  later  the 
patient  reappeared  with  a  return  of  all 
his  symptoms,  as  a  recurrence   of  the 
adenoids  was  again  accompanied  by  bi- 
lateral exophthalmos.     Badical  extirpa- 
tion of  the  vegetations  was  followed  by 
permanent  cure  of  the  ocular  protrusion. 
The  second  patient  was  also  a  boy  of 
the  same  age,  who,  in  addition  to  ade- 
noids and  exophthalmos,  suffered  from 
hypertrophy  of  the  tonsils.    Amputation 
of  the  latter  structures  was  not  followed 
by   improvement   in   the   exophthalmos, 
but  a  week  later  the  adenoids  were  re- 
moved, and  in  the  course  of  the  next  two 
weeks     the    exophthalmos     disappeared 
completely.     The  author  is  of  the  opin- 
ion that  Basedow's  disease  represents  an 
intoxication  of  the  central  nervous  sys- 
tem  through    abnormal    internal    secre- 
tions, and  that  adenoid  vegetations  are 
capable  of  eyoking  the  malady.    Epilepsy 
and  chorea  probably  have  some  etiolog- 
ical similarity  to  Basedow's  disease,  and 
the  author  thinks  that  -they  also  may  be 
produced  by  the  presence  of  adenoids. 
An  illustrative  case  is  cited  in  which 
clearing  of  the  nasal  pharyngeal  space 
in  a  boy  of '7  years  was  followed  by  the 
cure  of  a- well-marked  chorea  minor.    It 
therefore  appears  advisable  to  look  for 
adenoids  in  all  cases  of  these  three  dis- 
eases, and  to  remove  them,  even  if  there 


ALBUMINURIA  DUE  TO  PALPATION. 


159 


is  no  respiratory  obstruction.  Holz 
(Berliner  klinische  Wochenschrift,  Jan- 
nary  23,  1905). 

ALBUMINURIA  DUE  TO  PALPATION. 

The  prompt  reaction  of  the  kidneys  to 
circulatory  disturbances  has  long  been 
known,  and  albuminuria  of  a  transitory 
character  dependent  on  such  changes  is 
not  infrequently  seen.  It  has  also  been 
shown  experimentally  that  thoracic  com- 
pression, general  or  confined  to  the  lower 
thorax,  and  general  abdominal  compres- 
sion will  cause  transitory  albuminuria. 
That  direct  manual  compression  of  the 
kidneys  may,  under  certain  circum- 
stances, cause  albuminuria  has  not  been 
so  widely  recognized. 

Schreiber  (Zeits.  fiir  klin.  Med.,  p. 
55)  has  recently  called  attention  to  this 
form  of  albuminuria,  which  he  charac- 
terizes as  renal  palpatory  albuminuria. 
It  was  first  described  by  Menge  in  1880, 
but  its  clinical  possibilities  do  not  seem 
to  have  been  appreciated  at  that  time. 
Schreiber  restudied  the  phenomenon, 
and  endeavored  to  find  out  how  normal 
and  movable  kidneys  reacted  under  pal- 
pation. Dividing  movable  kidneys  into 
three  grades,  according  to  the  classifica- 
tion suggested  by  Hilbert,  he  found  that 
in  the  medium  and  severe  grades  palpa- 
tion was  always  followed  by  albuminuria, 
and  in  the  mild  grades  palpatory  albu- 
minuria was  almost  constant. 

The  degree  of  albuminuria  varied  in 
different  cases,  and  did  not  necessarily 
correspond  to  the  grade  of  dislocation,  to 
the  palpability  of  the  kidney,  nor  to  the 
duration  of  the  palpation,  as  might  have 
been  expected  a  'priori.  In  41  cases  in 
which  albuminuria  was  present,  there 
was  only  a  trace  in  14,  while  in  the  other 
27  the  amount  varied  from  a  slight  floc- 


culent  precipitate  to  3  per  mille  by 
Esbach's  method.  The  duration  of  the 
albuminuria  was  usually  very  short,  and 
in  this  it  differed  from  the  albuminuria 
of  organic  disease.  Schreiber  states  that 
the  urine  should  never  be  examined  later 
than  ten  minutes  after  the  palpation  has 
been  done,  as  in  one  of  his  cases  the  albu- 
min had  disappeared  after  twelve  min- 
utes. In  some  cases  albumin  was  still 
present  two  hours  after  the  palpation, 
but  such  cases  were  exceptional. 

The  urine  generally  showed  physical 
and  microscopic  changes  when  albumin 
was  present.  After  palpation  it  was 
often  lighter  in  color  than  previously, 
and  in  some  cases  an  excess  of  phosphates 
was  present.  The  microscope  always 
showed  an  increase  in  the  epithelial  cells, 
and  frequently  red  blood-cells  and  leu- 
cocytes were  found.  The  leucocytes  were 
generally  partly  polynuclears  and  parti)' 
mononuclears,  but  in  one  or  two  in- 
stances were  almost  entirely  lymphocytes. 
In  no  instance  were  true  casts  found, 
though  occasionally  pseudo-casts  were 
present. 

Schreiber  discusses  various  possibilities 
regarding  the  origin  of  the  albumin.  It 
cannot  be  due,  he  thinks,  to  actual  in- 
jury to  the  kidney  tissue,  for  it  is  too 
transient,  nor  can  it  be  due  to  injury 
of  the  vessels  with  rhexis,  because  red 
blood-cells  are  not  constantly  present. 
He  inclines  to  the  belief  that  a  variety 
of  factors  are  concerned,  and  he  cites,  as 
the  most  important,  pressure  of  blood- 
serum  from  the  blood-vessels,  pressure  of 
lymph  from  the  lymph  channels  and 
changes  in  the  blood-pressure.  The  not 
infrequent  presence  of  blood-cells  sho\v> 
the  likelihood  of  the  first  cause,  the  occa- 
sional exclusive  presence  of  lymphocytes 
the  second,  and  the  fact  that  the  albu- 
minuria is  at  times  out  of  all  propor- 


160 


ALCOHOLISM,  PSYCHOSES  OF.    APPENDICITIS,  TREATMENT. 


tion  to  the  intensity  of  palpation  the 
third. 

Schreiber  also  discusses  the  effect  on 
the  kidney  of  indirect  compression  such 
as  is  exerted  on  the  kidney  in  palpating 
the  liver.  He  also  cites  cases  to  show 
the  value  of  the  procedure  in  dystopia  of 
the  kidney  and  in  doubtful  abdominal 
tumors.  So  far  as  indirect  palpation  is 
concerned  he  comes  to  the  conclusion 
that  it  very  seldom  produces  albuminuria, 
and  when  it  does  the  albumin  is  very 
slight  in  amount.  His  cases  demonstrate 
that  palpatory  albuminuria  may  be  of 
distinct  value  in  differentiating  obscure 
abdominal  tumors.  He  suggests  that  in 
some  cases  the  use  of  his  method  may 
obviate  the  necessity  of  more  serious 
procedures,  such  as  catheterization  of  the 
uterus,  or  exploratory  laparotomy. 
Schreiber  does  not  claim  marvelous  re- 
sults from  his  method,  but  simply  re- 
gards it  as  an  aid  to  other  methods  which 
at  times  may  be  of  value;  as  such  it  is 
worthy  of  extended  trial.  Editorial 
(Journal  of  the  American  Medical  Asso- 
ciation, February  4,   1905). 

ALCOHOLISM,     BORDERLINE     PSYCHOSES 
OF. 

From  a  study  of  several  hundred  cases 
of  minor  psychoses  of  alcoholism,  in- 
cluding the  "polyneuritic  psychoses," 
marked  by  amnesia,  paramnesia,  and  con- 
fusion with  marked  hallucinations,  the 
writer  was  led  to  the  following  conclu- 
sions regarding  these  mental  disorders: 
They  are  rare  in  acute  alcoholism,  but 
may  appear  in  adolescents  of  neurotic 
type.  They  are  more  frequent  after 
adolescence  and  up  to  40  or  45  years  of 
age.  They  occur  both  in  continuous 
drinkers  and  in  periodic  delinquents. 
The  prognosis  is  variable,  depending  on 


inherited   frailties   and   moral   develop- 
ment. 

Early  treatment  is  advisable  as  a  pre- 
vention of  major  psychoses.  The  treat- 
ment is  successful  in  the  majority  of 
cases,  providing  the  earnest  co-operation 
of  the  patients  can  be  obtained,  and  that 
they  can  be  had  under  the  physician's 
immediate  care  for  a  protracted  period. 
Such  cases  should  be  distinguished  from 
ordinary  chronic  alcoholics  and  should 
be  treated  from  the  standpoint  of  mental 
disease.  F.  P.  Norbury  (Journal  of  the 
American  Medical  Association,  March 
18,  1905). 

APPENDICITIS,  TREATMENT  OF. 

Purgatives  should  never  be  given  in 
acute  appendicitis  before  operation. 
Ochsner's  treatment  is  the  best  treat- 
ment to  adopt  from  the  onset  of  an  at- 
tack of  appendicitis,  and  to  carry  out 
when  operation  is  refused,  and  is  the 
best  treatment  to  employ  in  almost  all 
cases  of  appendicitis,  after  operation. 

A  careful  examination  of  Ochsner's 
statistics  show  results  after  delayed  op- 
eration superior  to  those  obtained  by 
immediate  operation.  Should  his  results 
be  confirmed  by  a  larger  experience  in 
the  hands  of  other  surgeons,  the  advan- 
tages of  delay,  with  evidence  of  infection 
beyond  the  appendix,  contrasted  with 
immediate  operation,  must  be  granted. 
Until  the  superiority  of  conservative 
treatment  has  been  satisfactorily  demon- 
strated, immediate  operation  will  be 
urged  by  the  majority  of  surgeons  in 
most  cases  of  acute  appendicitis  in  all 
stages. 

The  harm  which  may  result  from  an 
exaggeration  of  the  advantages  of  delay, 
and  the  misapplication  of  Ochsner's 
treatment  to  early  acute  appendicitis,  is 
obvious  and  important."    Owing  to  the 


APPENDICITIS,  TREATMENT  OF. 


161 


bad  results  of  operation  in  desperate 
cases,  and  the  improvement  which  Ochs- 
ner  claims  may  occur  under  his  treat- 
ment, the  present  tendency  of  surgery  is 
becoming  more  and  more  conservative; 
borderland  cases,  in  which  general  irri- 
gation, etc.,  was  advised  in  the  past,  are 
now  drained  locally,  or  no  operation  is 
advised.  In  consequence,  operation  will 
no  longer  be  the  scapegoat,  blamed  for  a 
death  in  reality  due  to  ignorance  or  de- 
lay. 

Conservative  treatment  may  be  ad- 
vised in  certain  cases  of  acute  appendi- 
citis, in  which  the  symptoms  of  rapid 
septic  absorption  (peritoneal  sepsis) 
are  out  of  all  proportion  to  the  evidence 
of  peritonitis.  Such  cases  are  usually 
caused  by  a  streptococcal  retroperitoneal 
lymphangitis  or  diffuse  intraperitoneal 
infection.  The  results  of  operation  are 
most  unsatisfactory. 

Ochsner's  treatment  should  be  advised 
in  most  cases  of  spreading  or  diffuse 
peritonitis  when  a  reasonably  good  sur- 
geon cannot  be  obtained.  Under  such 
circumstances  the  results  of  his  teach- 
ing have  probably  accomplished  their 
greatest  good. 

Irrigation  of  the  general  peritoneal 
cavity  is  a  major  operation,  not  to  be  un- 
dertaken unless  the  conditions  are  such 
that  it  can  be  thoroughly  performed.  It 
is  especially  difficult  when  distention  is 
extreme,  and  almost  impossible  unless 
anaesthesia  is  profound.  It  is  indicated 
in  recently  diffused  processes,  particu- 
larly if  the  previously  unirritated  peri- 
toneal cavity  has  been  suddenly  infected 
through  rupture  of  an  abscess.  It  may 
be  used  in  some  cases  of  spreading  in- 
fections without  adhesions,  though  local 
operation  is  probably  preferable.  Gen- 
eral irrigation  should  not  be  employed  in 
cases  of  general  peritonitis   of  several 


days'  duration,  with  circumscribed  col- 
lections of  pus  among  the  intestines. 

After  irrigation  the  danger  of  in- 
creased absorption  is  best  prevented  by  a 
tube  or  cigarette  drain  to  the  bottom  of 
the  pelvis,  or,  in  women,  vaginal  drain- 
age, with  exaggerated  Fowler's  position 
for  twenty-four  to  thirty-six  hours. 

Local  operation  with  pelvic  drainage 
and  Fowler's  position,  without  regard  to 
the  degree  of  peritoneal  infection,  is  pre- 
ferred by  many,  if  not  most,  surgeons, 
to  general  irrigation,  and,  on  the  whole, 
is  tending  to  supplant  the  latter.  The 
rapidity  with  which  it  can  be  performed 
makes  it  the  method  of  choice  in  very 
sick  cases,  in  those  with  marked  disten- 
tion, and  particularly  in  operations  out- 
side of  hospitals.  There  are  certain 
cases,  however,  in  which  it  is  inferior  to 
general  irrigation. 

On  an  analysis  of  the  statistics  of  some 
operators  in  appendix  peritonitis,  though 
the  methods  of  operation  (local  or  gen- 
eral irrigation)  and  the  minor  details  of 
technic  may  vary,  the  results  are  often 
found  to  be  approximately  the  same. 
The  author's  conclusion  is,  therefore, 
justified  that  natural  peritoneal  resist- 
ance is  a  most,  if  not  the  most,  important 
factor  in  overcoming  infection,  provided 
the  abscess  and  the  pelvis  are  drained  or 
the  appendix  removed  in  the  shortest 
possible  time,  with  the  least  amount  of 
trauma  and  without  spreading  infection. 
The  question  whether  the  operation 
should  stop  at  this  point  or  be  followed 
by  a  general  saline  irrigation  appears  to 
be  one  of  secondary  importance ;  it  may 
be  that  the  one  advantage  of  irrigation  is 
neutralized  by  its  disadvantages. 

In  the  post-operative  treatment  of  these 
cases  the  author  thinks  too  much  atten- 
tion has  been  given  to  the  condition  of 
the  bowels.    When  the  intestinal  walls  are 


162 


ARTHRITIS  DEFORMANS.     BLADDER,  PAPILLOMA  OF. 


paralyzed,  and  distention  is  extreme,  en- 
terotomy  or  colotomy  may  be  occasion- 
ally beneficial;  enemata  or  the  rectal 
tube  may  be  of  use  in  relieving  the  large 
intestine  from  gas,  but  as  the  disten- 
tion is  chiefly  due  to  paralysis  of  the 
small  intestines,  the  effect  is  usually 
slight.  Cathartics  by  mouth  are  always 
almost  ineffectual;  calomel,  with  obsti- 
pation, may  be  positively  dangerous. 
Many  patients  are  exhausted  by  repeated 
and  vain  attempts  to  move  the  bowels. 
Ochsner's  routine  with  turpentine  stupes 
to  the  abdomen  is  the  best  treatment  for 
the  first  forty-eight  hours  after  opera- 
tion. When  intestinal  movements  can- 
not be  heard,  cathartics  very  rarely  in- 
dice  peristalsis.  When  the  paralysis  has 
passed  away  and  intestinal  sounds  can  be 
heard,  then  cathartics  should  be  given 
and  will  be  found  efficient.  C.  A.  Porter 
(Boston  Medical  and  Surgical  Journal, 
March  23,  1905). 

ARTHRITIS  DEFORMANS. 

The  analogy,  which  Bradford  has 
suggested,  between  arthritis  deformans 
and  arteriosclerosis  appears  to  be  a  very 
close  one.  In  arteriosclerosis  the  causes 
to  which  the  disease  has  been  ascribed 
are  innumerable  and  the  manifestations 
may  be  widely  varied.  The  condition 
may  be  widely  distributed,  or  narrowly 
circumscribed ;  there  may  be  a  condition 
of  hyperplasia  only  or  there  may  be 
ulceration,  calcification,  or  even  forma- 
tion of  true  bone.  Because  of  these  nu- 
merous manifestations  it  cannot  be  said 
that  we  are  dealing  with  many  diseases. 
The  writer  has  come  to  this  conclusion, 
not  only  from  clinical  cases,  but  also 
from  the  study  of  many  pathological 
specimens  from  cases  of  arthritis  de- 
formans. Why  in  one  case  there  is  new 
formation  of  bone  and  in  another  ab- 


sorption is  at  present  as  much  unknown 
as  are  the  varied  conditions  that  give  rise 
to  the  disease.  That  the  disease  often  is 
the  result  of  some  general  alteration  in 
the  body  metabolism  seems  possible.  F. 
L.  Eichardson  (Boston  Medical  and  Sur- 
gical Journal,  March  9,  1905). 

BLADDER,     PAPILLOMA     OF,     DIAGNOSIS 
OF. 

In  subjects  otherwise  healthy,  who 
have  never  presented  bladder  symptoms, 
papilloma  of  the  urinary  reservoir  will 
make  its  presence  known  by  the  sudden 
appearance  of  blood  in  the  urine,  occur- 
ring without  other  conceivable  cause. 
The  haemorrhage,  of  varying  intensity, 
arises  without  any  prodromes;  the 
amount  of  blood  voided  is  sometimes 
only  small.  The  haemorrhage  recurs  sev- 
eral times  in  decreasing  quantity  and 
may  entirely  disappear  within  three  or 
four  days,  the  patient's  health  being  un- 
affected. Weeks,  months,  or  even  sev- 
eral years  may  pass  before  the  haemor- 
rhage again  appears  or  any  symptom  of 
vesical  neoplasm  becomes  manifest. 

In  other  instances  the  bleeding  recurs 
at  short  intervals  or  may  be  continuous. 
Now,  the  manner  and  form  of  the  haem- 
orrhage are  so  characteristic  that  it  can 
easily  be  distinguished  from  that  arising 
in  other  parts  of  the  genito-urinary  sys- 
tem. When  the  seat  of  the  haemorrhage 
is  in  the  urethra,  the  loss  of  a  few  drops 
of  blood  or  a  long,  narrow  clot,  followed 
by  perfectly  clear  urine,  is  quite  charac- 
teristic, but  after  micturition  one  will 
be  able  to  press  out  a  drop  or  two  of 
blood  from  the  urethra  or  it  may  be 
voided  spontaneously. 

When  a  renal  lesion  exists,  the  urine 
will  be  uniformly  red  in  color,  because 
there  has  been  an  almost  perfect  blend- 
ing of  the  two  fluids-  but  in  neoplasms 


BLADDER,  PAPILLOMA  OF,  DIAGNOSIS  OF. 


163 


of  the  bladder  the  urine  is  at  first  not 
mixed  with  the  blood,  or  only  slightly  so, 
but  toward  the  end  of  micturition  it  be- 
comes more  and  more  so,  and  the  last 
part  voided  may  consist  of  almost  pure 
blood.  Microscopically  one  may  recog- 
nize whether  the  source  of  the  haemor- 
rhage is  the  kidney  or  the  bladder.  In 
the  former  we  have  the  so-called  shadows 
of  the  red  corpuscles,  while  in  the  latter 
they  show  all  the  evidence  of  fresh  blood. 
The  amount  of  bleeding  depends  on 
the  type  of  neoplasm;  if  slender  villi 
compose  the  growth,  bleeding  will  be 
more  persistent  and  repeated,  because 
they  are  easily  torn  off,  while  in  the 
fibrous  form  of  papilloma  this  symptom 
will  be  much  less  marked  on  account  of 
the  coarser  structure  of  the  growth. 
Then,  again,  the  seat  of  the  tumor  exer- 
cises an  influence  on  the  haemorrhage, 
because  papilloma  situated  at  the  ure- 
thral orifice  is  certainly  more  prone  to 
bleed  than  when  developing  in  the  walls 
of  the  bladder,  on  account  of  the  greater 
pressure  brought  to  bear  on  the  growth 
in  the  former  situation  during  micturi- 
tion. 

Pain  is  another  symptom  frequently 
occurring  in  papilloma  of  the  bladder, 
and  it  may  be  present  at  an  early  stage 
of  the  affection.  It  is  dull  and  steady 
in  the  region  of  the  perinaeum;  tenes- 
mus is  frequent,  with  a  severe  stinging 
sensation  in  the  urethra  and  glans,  which 
is  more  particularly  pronounced  when 
clots  or  pieces  of  the  growth  are  passed. 
Painful  erections  may  also  trouble  the 
patient. 

If  the  growth  has  a  long  pedicle  or  is 
situated  near  the  orifice  of  the  bladder, 
it  may  occlude  it  and  oblige  the  patient 
to  resort  to  various  attitudes  in  order  to 
overcome  the  obstruction.  Should  the 
neoplasm  develop  near  the  ureteral  ori- 


fices, hydronephrosis  in  one  or  both  kid- 
neys may  develop,  leading  to  serious  sec- 
ondary lesions  of  the  organ,  and  death 
has  been  known  to  take  place  from 
uraemia. 

A  fairly  common  complication  of 
papilloma  is  cystitis,  which  may  arise 
spontaneously  or  result  from  instrumen- 
tal interference ;  it  is  often  chronic,  pro- 
ducing a  necrobiotic  change  in  the 
growth,  and  may  extend  to  the  kidney. 

Bits  of  the  tumor  passed  with  the 
urine  are  of  essential  importance  for 
diagnosis,  for  they  allow  one  to  conclude 
with  certainty  that  a  tumor  exists,  but 
they  do  not  always  throw  much  light  on 
the  nature  of  the  neoplasm,  because  in 
many  cases  microscopical  examination 
cannot  distinguish  between  papilloma 
and  carcinoma.  The  reason  is  this,  that 
they  are  to  be  found  in  the  midst  of 
tissue  spaces  filled  with  epithelium. 
They  are  usually  narrow  alveoli  and 
thickly  filled  with  polymorphous  epithe- 
lium, which  at  first  sight  gives  one  the 
impression  of  carcinomatous  alveoli,  but 
close  examination  will  show  the  error. 
In  larger  sections,  including  the  entire 
length,  it  at  once  becomes  evident  that 
these  alveoli  are  simply  transverse  sec- 
tions of  the  fissures  existing  between  the 
villi,  and  this  consequently  accounts  for 
the  mistakes  arising  in  the  examination 
of  particles  voided  in  the  urine,  for  here 
the  tips  of  the  villi,  and  rarely  the  base 
of  the  neoplasm  are  obtained. 

From  the  presence  of  the  above-named 
symptoms  one  can  naturally  diagnosti- 
cate a  tumor  of  the  bladder,  but  when 
hematuria,  often  of  a  temporary  kind, 
exists  without  any  other  symptom,  the 
nature  of  the  case  is  more  difficult  to 
recognize.  Palpation  is  usually  negative, 
especially  when  the  growth  is  a  small, 
soft,  villous  polypus,  but  irrigation  of 


164 


CANCER,  EFFECTS  OF  ROENTGEN  RAYS  ON. 


the  bladder  may  detach  some  villi.  The 
sound  is  of  little  value,  because  these 
soft,  velvety  growths  cannot  be  detected 
by  it,  and  serious  haemorrhage  and  in- 
fection of  the  bladder  may  ensue  from 
its  use. 

Cystoscopy  is  a  most  valuable  diag- 
nostic means,  for  with  it  one  can  detect 
a  bladder  neoplasm  in  its  early  stages, 
as  well  as~  its  exact  site.  Now,  without 
wishing  to  underestimate  the  value  of 
the  cystoscope,  we  must  confess  that  it 
cannot  be  relied  upon  in  cases  of  papil- 
lomata,  because  that  part  of  the  trigo- 
num  near  the  urethral  orifice,  which  is 
a  frequent  site  for  papilloma,  is  not 
readily  accessible  to  the  instrument. 
And,  what  is  more,  a  good  picture  can- 
not be  obtained,  on  account  of  the  bleed- 
ing to  which  these  growths  give  rise, 
even  after  the  bladder  has  been  repeat- 
edly washed  out  and  when  a  modern  in- 
strument with  irrigating  attachment  is 
employed. 

If  cystoscopy  fails  or  cannot  be  re- 
sorted to  for  any  reason,  suprapubic  cys- 
totomy should  be  done  for  diagnosis,  and 
since  operative  treatment  can  be  carried 
out  at  the  same  time,  this  procedure  is 
quite  justified.  Dilatation  of  the  ure- 
thra in  the  female  and  digital  explora- 
tion of  the  bladder  can  be  resorted  to, 
but,  as  elsewhere  pointed  out,  this  method 
should  be  condemned  unless  carried  out 
with  the  utmost  care,  on  account  of  per- 
manent incontinence  to  which  it  may 
give  rise.  C.  G.  Cumston  (New  York 
Medical  Journal  and  Philadelphia  Med- 
ical Journal,  March  18,  1905). 

CANCER,    EFFECTS   OF   ROENTGEN   RAYS 
ON. 

Study  of  120  cases  with  reference  to 
the  effect  produced  by  the  x-ray  on  can- 
cer.   A  uniform  technic  was  adopted  so 


as  to  be  reasonably  certain  of  the  uni- 
formity of  the  results  obtained.  The 
effect  on  ulcerated  surfaces  at  first  was 
that  of  stimulation,  as  evidenced  by  the 
formation  of  granulations,  but  under 
continued  exposure  the  epithelial  edge  is 
destroyed  and  healing  is  retarded.  It  is 
extremely  difficult  to  decided  at  "what 
point  the  beneficial  influence  ends.  The 
effect  on  scar  tissue  is  peculiar.  Certain 
contracted  and  painful  scars  have  soft- 
ened and  have  become  much  more  pli- 
able, with  diminution  of  pain,  although 
this  is  not  an  invariable  effect,  nor  can 
any  histologic  change  be  shown  to  ex- 
plain it.  Eighteen  cases  in  which  pain 
was  marked  were  treated;  of  these  9 
patients  were  temporarily  or  perma- 
nently benefited,  in  some  the  benefit 
amounting  to  almost  total  relief;  5 
others  received  a  similar  benefit  when 
the  brush  discharge  from  a  high-fre- 
quency machine  was  added,  but  the  re- 
maining 4  showed  distinct  increase  of 
pain,  and  at  least  2  patients  who  had 
no  pain  at  the  start  had  pain  later,  and 
2  patients  complained  bitterly  of  pain 
coming  on  after  exposure  and  lasting 
from  twenty-four  to  forty-eight  hours. 
The  observations  made  in  cases  of  can- 
cer showed  that  cutaneous  cancer  treated 
by  the  x-ray  undergoes  degeneration  not 
peculiar  to  this  form  of  treatment  or 
distinguishable  histologically  from  de- 
generation from  other  causes.  The  vas- 
cular changes  are  limited  to  an  end- 
arteritis ;  new  formation  of  blood-vessels 
occurs  if  healing  takes  place,  as  in  the 
process  of  repair  elsewhere;  there  is  an 
increase  of  elastic  tissue.  Taken  as  a 
whole,  the  .clinical  cases  show  that  the 
only  cure  of  cancer  by  the  x-ray  is  by 
destruction  and  exfoliation.  This  at 
once  limits  its  value  to  superficial  cases. 
This  destructive  process  is  a  slow  one, 


DIABETES  MELLITUS.     ECLAMPSIA. 


165 


and  acts  very  superficially.  Since  it  is 
well  known  that  many  essentially  chronic 
superficial  epidermoid  cancers  may  be 
removed  permanently  by  the  slightest 
surgical  procedure,  that  course  seems 
preferable  to  the  somewhat  tedious  treat- 
ment by  the  x-ray,  and  as  they  both  may 
fail,  an  extensive  surgical  operation,  if 
necessary,  may  be  undertaken  more 
promptly  in  the  former  case.  Being 
non-selective  in  its  action,  the  x-ray  can- 
not be  used  strongly  enough  to  affect  de- 
struction of  anything  but  the  shallowest 
tumors  without  serious  injury  to  the 
overlying  and  surrounding  tissue,  or,  in 
other  words,  without  producing  such  a 
burn  as  experience  shows  in  all  prob- 
ability never  would  heal.  E.  H.  Vose 
and  W.  C.  Howe  (Journal  of  Medical 
Eesearch,  January,  1905). 

DIABETES    MELLITUS,    ADRENALIN    AND 
THYROID  EXTRACT  IN. 

The  writer  was  led  by  the  fact  that 
morphine  causes  glycosuria  in  the 
healthy  and  diminishes  it  in  the  dia- 
betic, to  investigate  the  action  of  ad- 
renalin in  the  latter  condition,  animal 
experiment  having  demonstrated  that  it 
causes  glycosuria  in  normal  conditions. 
Apart  from  action  on  the  sugar-regu- 
lating mechanism  of  the  liver,  whether 
direct  or  through  the  pancreas,  theo- 
retically it  might  appear  that  a  substance 
which  has  a  tonic  effect  on  the  muscles 
should  increase  the  utilization  of  sugar, 
and  thus  decrease  its  excretion  in  dia- 
betes. Experiments  on  diabetic  patients, 
however,  prove  that  the  excretion  of  glu- 
cose and  of  nitrogen  is  markedly  in- 
creased, the  increase  in  glucose  being  out 
of  proportion  to  that  of  nitrogen.  It 
seemed  from  the  influence  of  the  thy- 
roid gland  in  increasing  the  metabolism 
of  proteids  and  fats  that  it  might  also 


increase  the  metabolism  of  sugar  in  dia- 
betes. A  patient  was  given  doses  in- 
creasing from  .5  gram  to  10  grams  daily 
for  six  days,  when  symptoms  of  thy- 
roidism  supervened  with  a  threatening 
of  diabetic  coma,  and  the  drug  was  dis- 
continued. The  excretion  of  glucose  or 
nitrogen  was  not  modified.  D.  N.  Paton 
(Scottish  Medical  and  Surgical  Journal, 
December,  1904). 

ECLAMPSIA. 

Eclampsia  is  due  to  a  toxin  which 
probably  has  its  origin  in  the  liver.  Its 
origin  is  maternal  rather  than  foetal. 
Premonitory  symptoms  are  always  pres- 
ent. The  most  constant  and  important 
premonitory  symptom  is  frontal  head- 
ache. The  diagnosis  of  toxaemia  of  preg- 
nancy should  be  made  early,  and  this  can 
generally  be  done  if  the  patient  is  under 
observation.  The  mortality  should  not 
exceed  20  per  cent. 

The  premonitory  symptoms  should  be 
treated  until  they  are  proved  ineffective. 
The  uterus  should  then  be  emptied,  and 
this  may  be  the  only  way  to  stop  the 
progress  of  the  disease.  Delivery  should 
be  accomplished  as  rapidly  as  is  consis- 
tent with  cleanlines  and  the  integrity  of 
the  soft  parts.  Prom  300  to  700  cubic 
centimeters  of  blood  should  be  drawn. 
and  then  500  to  1000  cubic  centimeters 
of  salt  solution  should  be  infused  accord- 
ing to  the  quantity  of  blood  withdrawn 
and  the  character  of  the  pulse.  It  may 
be  necessary  to  repeat  this  operation : 
Morphia,  1/4  grain  may  be  given  to  relax 
the  muscular  system,  and  Croton  oil,  1 
to  2  drops,  in  olive-oil,  1  to  2  drachms, 
followed  by  magnesium  sulphate,  */, 
ounce,  in  saturated  solution  until  free 
purging  has  resulted.  The  diet  should 
be  limited  to  milk  and  water.  Other 
symptoms    should    be    treated    as    they 


166 


EPILEPSY,  TREATMENT.  GASTRIC  ULCER,  TREATMENT. 


arise.    Allen  (American  Journal  of  Ob- 
stetrics, February,  1905). 

EPILEPSY,  TREATMENT  OF. 

The  author  wishes  to  emphasize  the 
fact  that  medicinal  treatment  of  the 
convulsions  form  only  one  item  in  the 
treatment  of  epilepsy.  The  most  satis- 
factory management  of  the  disease  is 
that  which  is  carried  out  in  special  in- 
stitutions or  under  the  care  of  a  well- 
trained  and  sensible  nurse  attendant.  In 
this  way  only  can  the  patient  be  guided 
along  hygienic  lines,  in  respect  of  the 
suitable  quantity  and  quality  of  food,  the 
proper  allotment  of  work  and  rest,  and 
the  carrying  out  of  those  physical  exer- 
cises consistent  with  the  malady.  Epi- 
leptics suffer  notoriously  from  lowered 
vitality  and  sluggish  circulation  in  the 
extremities,  for  which  warm  baths,  spi- 
nal douches,  and  massage  are  important 
remedial  agents.  In  the  treatment  of 
epilepsy,  therefore,  there  has  ever  to  be 
kept  in  mind  the  persistent  character  of 
the  malady  and  the  tendency  toward 
mental  deterioration.  As  important  as 
therapeutic  remedies  are  congenial  em- 
ployment, hygienic  modes  of  life,  and 
suitable  amusements.  W.  A.  Turner 
(Lancet,  March  18,  1905). 

FORMALDEHYDE  AND  FORMALIN,  TOXIC 
EFFECTS  OF. 

The  results  of  the  writer's  investiga- 
tions show  that  the  inhalation  of  for- 
maldehyde gas  in  even  small  quantities 
is  followed  by  bronchitis  and  pneumonia. 
Formalin  belongs  to  that  rare  group  of 
poisons  which  are  capable  of  producing 
death  suddenly  when  swallowed.  The 
introduction  of  formalin  into  the  stom- 
ach is  followed  by  the  production  of  a 
gastritis  which  varies  greatly  in   char- 


acter. The  duodenum  and  jejunum  may 
also  be  involved  in  the  inflammation. 
Intraperitoneal  injections  of  formalin 
causes  peritonitis  of  a  fibrino-hsemor- 
rhagic  character.  The  injection  of  for- 
malin into  the  lungs  is  followed  by 
pneumonia  and  bronchitis.  The  inflam- 
mation which  follows  subcutaneous  in- 
jections of  formalin  is  characterized  by 
intense  exudation.  In  whatever  way 
introduced  into  the  body,  formalin  is 
absorbed  and  is  then  capable  of  pro- 
ducing lesions  in  the  parenchymatous 
organs.  The  injection  of  formalin  or 
the  inhalation  of  the  vapors  of  formalde- 
hyde produces  cloudy  swelling  of  the 
parenchyma  of  the  kidney.  H.  M. 
Fischer  (Journal  of  Experimental  Med- 
icine, February  4,  1905). 

GASTRIC   ULCER,   MEDICAL   TREATMENT 
OF. 

The  writer  advocated  the  medical 
treatment  of  gastric  ulcer.  He  asserts 
that  the  claim  made  by  Leube  that  from 
75  to  96  per  cent,  of  all  cases  of  gastric 
ulcer  are  curable  by  medical  means  is 
well  founded.  The  important  point  to 
bear  in  mind  in  treating  gastric  ulcer, 
as  well  as  any  other  disease,  is  to  follow 
a  definite  system.  The  author's,  routine 
in  the  management  of  gastric  ulcer  is  as 
follows:  For  the  first  few  days  to  one 
week,  rectal  feeding.  For  the  next  two 
or  three  weeks,  diluted  milk,  if  it  is  well 
borne.  Eaw  or  soft-boiled  eggs,  mutton 
and  chicken  broths  follow  the  milk  diet 
for  some  weeks  more,  at  the  end  of 
which  time  a  solid  diet  is  gradually  re- 
sumed. The  most  useful  drugs  are: 
subnitrate  of  bismuth,  in  1/2-drachm 
doses,  nitrate  of  silver,  morphine,  and 
cocaine  hydrochloride.  The  use  of  Carls- 
bad salts  is  probably  of  benefit.  An 
albuminate  of  iron  may  be  often  given 


GASTROENTERITIS,  BUTTERMILK  IN.      GONOCOCCUS. 


167 


with  advantage.     F.  P.  Henry   (Amer- 
ican Medicine,  March  11,  1905). 

GASTRO-ENTERITIS,       BUTTERMILK      IN 
THE   TREATMENT    OF. 
During  a  severe  epidemic  of  gastro- 
enteritis and  of  cholera  infantum  in  the 
north  of  France,  buttermilk  was  largely 
employed  as  a  medicament.    The  conclu- 
sions which   have   been   drawn  by   Dr. 
Floquet  from  the  results  of  his  experi- 
ences are  reported  by  the  writer  as  fol- 
lows:     Buttermilk     is     generally     well 
taken  by  infants,  who  prefer  it  to  sweet- 
ened boiled  water.    Its  use  was  followed 
by  good  results,  while  in  parallel  cases, 
treated  by  other  means,  no  improvement 
was   observed.      While    acting   in   these 
cases  as  a  specific,  buttermilk  is  also  a 
food  and  causes  an  increase  in  weight. 
It  is  indicated  in  both  chronic  and  acute 
cases.     It  produces  excellent  results  in 
rickets;    it  combats   the   intestinal  fer- 
mentations  which   give   rise   to   chronic 
auto-infection.     Some  practitioners  have 
administered  the  buttermilk  raw,  but  the 
majority  who  have  used  it  prefer  to  give 
it  boiled.     The  following  is  the  method 
of  preparing  the  buttermilk :   One  table- 
spoonful  of  farina  to  a  liter  of  butter- 
milk, which  is  then  slowly  boiled  in  an 
enameled  or  porcelain  vessel,  at  the  same 
time  that  it  is  constantly  stirred.     The 
mixture  is  kept  boiling  for  several  min- 
utes, at  the  end  of  which  75  grams  of 
sugar  are  added.    It  is  then  ready  to  be 
fed  to  the  infant,  either  in  the  bottle  or 
with  the  spoon  or  cup.    In  cases  of  either 
acute  or  chronic  gastro-enteritis,   it   is 
given  in  the  same  doses  as  milk,  every 
three  hours.     In  the  beginning  it  is  best 
to  give  it  in  fractional  doses  of  a  table- 
spoonful    every    fifteen    minutes.      Al- 
though  during   the   first   few    days   the 
child  may  vomit  after  taking  the  butter- 


milk, the  stomach  soon  gets  used  to  this 
acid  food.  In  children  over  a  year  old, 
sometimes  large  doses  are  necessary. 
The  good  effects  of  buttermilk  are  to  be 
attributed  to  the  large  amount  of  lactic 
acid  present,  which  counteracts  intestinal 
fermentation.  The  small  amount  of  fat 
contained,  and  the  fine  division  of  the 
casein,  thanks  to  churning,  render  the 
preparation  very  digestible.  E.  Decherf 
(Archives  de  Medecine  des  Enfants,  Jan- 
uary, 1905). 

GONOCOCCUS  INFECTIONS  IN  CHILDREN. 

Gonococcus  vaginitis  must  be  recog- 
nized as  a  very  frequent  disease  and  one 
to  be  constantly  reckoned  with  in  insti- 
tutions for  children.  It  is  also  very  fre- 
quent in  dispensary  and  tenement  prac- 
tice and  not  uncommon  in  private  prac- 
tice of  the  better  sort. 

In  its  milder  forms  and  in  sporadic 
cases  it  is  extremely  annoying  because 
so  intractable ;  in  its  severe  form  it  may 
be  dangerous  to  life  through  setting  up 
an  acute  gonococcus  pyaemia  or  infection 
of  the  serous  membranes,  and  in  its 
epidemic  form  it  is  a  veritable  scourge  in 
an  institution. 

The  highly  contagious  character  of 
gonococcus  vaginitis  makes  it  imperative 
that  children  suffering  from  it  should 
not  remain  in  the  same  wards  or  dormi- 
tories with  other  children.  A  similar 
danger,  though  less  in  degree,  exists  with 
the  gonococcus  ophthalmia  and  acute 
gonococcus  arthritis  or  pyaemia. 

It  is  practically  impossible  to  prevent 
the  spreading  of  the  disease  if  infected 
children  remain  in  the  wards  with  oth- 
ers. They  must  either  be  excluded  from 
the  hospital  or,  if  admitted,  immediately 
quarantined. 

Cases  of  gonococcus  vaginitis  can  only 
be  excluded  from  hospital  wards  by  the 


168 


GOUT,  MEAT  DIET  IN.      HEMORRHAGES,  SODIUM  BICARB.  IN. 


systematic  microscopic  examination  of 
smears  from  the  vaginal  secretion  of 
every  child  admitted.  If  a  purulent 
vaginal  discharge  is  present,  such  ex- 
aminations are  imperative  and  should  be 
made  as  much  a  matter  of  hospital 
routine  as  the  taking  of  throat  cultures 
in  children  with  tonsillar  exudates.  In 
the  absence  of  microscopical  examina- 
tions a  purulent  discharge  in  a  young 
child  may  be  assumed  to  be  due  to  the 
gonococcus. 

The  quarantine  to  be  effective  must 
extend  to  nurses  and  attendants  as  well 
as  to  children.  Furthermore,  the  nap- 
kins, bedding,  and  other  clothing  of  in- 
fected children  must  be  washed  sepa- 
rately from  that  of  the  rest  of  the  house. 

Where  the  gonococcus  is  found  with 
no  vaginal  discharge  or  with  a  very  slight 
discharge,  children  should  also  be  quar- 
antined, although  it  is  impossible  at 
present  to  say  to  what  degree  such  cases 
may  be  dangerous  in  a  ward.  One  of  the 
greatest  difficulties  in  connection  with 
the  gonococcus  vaginitis  arises  from  the 
prolonged  quarantine  rendered  neces- 
sary from  the  fact  that  these  cases  are  of 
very  chronic  character  and  very  resistant 
to  treatment. 

The  danger  to  nurses  from  accidental 
infection,  especially  in  the  eyes,  is  con- 
siderable. At  the  present  time  they  are 
not  sufficiently  instructed  in  this  respect. 
L.  E.  Holt  (New  York  Medical  Journal 
and  Philadelphia  Medical  Journal, 
March  25,  1905). 

GOUT,    EXCESSIVE    MEAT    DIET    IN    THE 
INDUCTION  OF. 

The  author  has  sought  to  determine 
by  animal  experiments  whether  an  ex- 
cessive meat  diet  exerted  any  specific 
action  on  any  of  the  ductless  glanrls. 
Eats  and  chicken's  were  used ;  in  poultry 


a  meat  diet  induced  hypertrophy  of  the 
thyroid  gland.  In  rats  there  was  a  strik- 
ing change  in  the  character  of  the  secre- 
tion, with  catarrh  of  the  epithelium  lin- 
ing of  the  vesicles.  The  author  con- 
cludes that  in  human  beings,  as  a  result 
of  the  excessive  use  of  meat,  the  charac- 
ter of  the  thyroid  secretion  is  altered. 
This  defect  may  be  remedied  by  the  ad- 
ministration of  thyroid  gland.  He  has 
given  small  doses  of  the  extract  in  two 
inveterate  cases  of  chronic  gout,  and  in 
both  the  symptoms  were  relieved  to  a 
striking  degree.  D.  C.  Watson  (Lancet, 
February  11,  1905). 

HEMORRHAGES,    SODIUM    BICARBONATE 
INFUSIONS  IN  SEVERE. 

The  results  of  experiments  described 
by  the  writer  indicate  that  under  certain 
conditions  the  addition  of  sodium  bicar- 
bonate to  the  infused  fluid  may  be  ex- 
pected to  have  a  beneficial  action.  In 
extreme  cases  of  shock  due  to  loss  of 
blood,  the  addition  of  from  0.5  to  1  per 
cent,  of  the  bicarbonate  to  the  solution 
of  0.8  per  cent,  sodium  chloride  may  be 
of  advantage  in  two  respects.  In-  the 
first  place,  the  rise  in  all  the  pressures, 
especially  in  the  diastolic  pressure,  is 
more  pronounced  than  when  the  pure 
chloride  is  used,  and  consequently,  the 
circulation  (as  far  as  the  pressures  are 
concerned)  can  be  restored  more  nearly 
to  the  normal  condition;  secondly,  the 
quantity  of  fluid  required  is  smaller  than 
is  the  case  with  the  pure  chloride,  and 
hence  the  greater  is  the  rapidity  with 
which  the  solution  can  be  hurried  into 
the  circulation,  a  matter  of  some  impor- 
tance in  desperate  cases.  The  author 
mentions  one  possibility  which  ought 
not  to  be  overlooked  in  the  employment 
of  bicarbonate  of  soda — that  of  over- 
working the  heart.     Some  experiments 


HEART,  CHANGE  IN  SIZE.      HEART  AND  KIDNEY  AFFECTIONS. 


169 


of  a  series  not  yet  completed  show  that 
very  strong  solution  of  sodium  carbonate 
and  bicarbonate  act  as  cardiac  stimu- 
lants to  an  astonding  degree.  There- 
fore, it  is  the  duty  of  the  physician  to 
decide  in  each  case  whether  a  cardiac 
stimulant  is  or  is  not  contraindicated. 
The  writer  considers  it  a  rational  pro- 
cedure to  begin  an  intravenous  infusion 
with  a  solution  containing  bicarbonate, 
and  in  this  way  to  hurry  the  pressures 
upward,  so  to  speak,  and  then,  when  the 
pressures  reach  a  considerable  height,  the 
bicarbonate  might,  if  thought  advisable, 
readily  be  omitted  from  subsequent  in- 
fusions which  might  be  required  to  main- 
tain the  pressure  at  the  desired  level. 
E.  M.  Dawson  (Journal  of  Experimental 
Medicine,  vol.  vii,  No.  1,  1905). 

HEART,  CHANGE  IN  SIZE  OF,  ON  CHANGE 
OF  POSITION. 

On  skiagraphing  the  heart,  the  author 
has  repeatedly  observed  that  the  shadow 
is  considerably  smaller  if  the  patient 
stands,  than  when  he  lies  down.  The 
effect  is  not  a  purely  optical  one  since 
the  heart  descends  in  the  upright  posi- 
tion of  the  body  and  shortens  somewhat 
in  the  transverse  and  sagittal  diameter. 
Even  though  the  long  axis  lengthens 
slightly,  the  entire  anterior  surface  will 
be  smaller.  The  correctness  of  this  ob- 
servation on  the  human  being  has  been 
proven  without  doubt  by  animal  experi- 
ments. The  change  in  size  and  volume 
is  partially  due  to  descent  of  the  dia- 
phragm, with  the  traction  it  exerts  upon 
the  pericardium,  partially  to  the  hydro- 
static action  of  the  upright  position. 
The  inspiratory  narrowing  of  the  ortho- 
diagraph^ shadow  is  also  due  to  real 
diminution  in  size.  It  follows  that  every 
exposure  should  be  made  with  the  pa- 
tient in  the  horizontal  posture.     Other 


advantages  of  the  latter  are:  The  re- 
spiratory movements  are  less  extensive 
and  the  heart  is  more  regular,  the  dia- 
phragm occupies  a  median  position  and 
is  not  affected  by  the  liver  and  intestines, 
the  abdominal  wall  is  relaxed,  and  weak 
individuals  are  less  fatigued  by  long  ex- 
posures. F.  Moritz  (Deutsch.  f.  klin. 
Med. j  vol.  lxxxii,  Nos.  1  and  2 ;  Medical 
News,  March  4,  1905). 

HEART    LESIONS    AND    KIDNEY    AFFEC- 
TIONS. 

The  author  has  studied  the  reciprocal 
action  of  heart  defects  and  kidney  affec- 
tions, and  has  become  convinced  that  the 
routine  method  of  treating  heart  affec- 
tions is  based  on  false  premises.  In  165 
cadavers  at  Warsaw  in  which  some  heart 
or  aortic  affection  had  been  the  principal 
malady,  he  found  only  6  in  which  the 
kidney  did  not  show  some  pathologic 
changes.  In  119  there  was  chronic  and 
in  3  acute  nephritis;  in  24  there  was 
cyanotic  induration,  in  13  parenchy- 
matous congestion,  and  1  mere  hyper- 
emia. Mitral  lesions  preponderated,  54 
mitral  to  50  aortic,  and  18  in  which  the 
two  were  associated,  a  total  of  122  ac- 
companying unmistakable  nephritis. 
This  is  a  proportion  of  74  per  cent.  He 
produced  artificial  heart  lesions  in  30 
dogs,  introducing  into  the  left  ventricle 
a  fine  needle  terminating  in  a  hook,  with 
which  he  tore  some  of  the  valves.  Only 
4  survived  the  operation  long  enough  for 
definite  conclusions  to  be  drawn.  Two 
of  these  presented  distinct  nephritis. 
The  writer  accepts  as  established,  the 
fact  that  any  interference  with  the  cir- 
culation of  the  heart  modifies  the  com- 
position of  the  blood,  and  by  inducing 
stasis  in  the  kidneys  depresses  their  vi- 
tality. This  favors  the  development  of 
disease,  as  the  toxins  are  not  eliminated 


170 


INFANT  FEEDING,  ALKALIES  IN. 


naturally  by  the  kidneys.  They  pile  up 
in  the  blood  and  react  on  the  heart  in 
turn. 

The  author  believes  that  the  heart  le- 
sion is  frequently  the  first  link  in  the 
chain  which  leads  to  kidney  disease.  The 
latter  may  likewise  induce  heart  disease, 
but  this  occurs  less  frequently.  The 
practical  conclusions  are  that  the  cus- 
tomary treatment  of  heart  affections  is 
irrational  and  injurious.  Instead  of 
trying  to  stimulate  the  kidneys  to  extra 
work,  they  should  be  spared  and  the  pa- 
tient should  be  treated  as  if  nephritis 
were  already  established.  Drugs  to  regu- 
late the  circulation  should  be  prescribed 
(iodine,  iron),  mineral  waters,  dieting, 
etc.  On  the  other  hand,  in  case  of  kid- 
ney disease,  disturbance  in  the  heart 
functions  should  be  feared,  and  treat- 
ment should  aim  to  prevent  extra  de- 
mands on  the  heart.  Hot  baths,  exer- 
cise, and  pilocarpin  should  be  avoided, 
and  greater  stress  be  laid  on  mineral 
waters,  dieting,  and  a  dry,  tempered  cli- 
mate at  a  low  altitude.  The  chief  aim 
of  treatment  in  both  the  heart  and  kid- 
ney disturbances  should  be  to  regulate 
the  circulation.  P.  Bronowski  (Presse 
Medicale,  No.  100;  from  Journal  of  the 
American  Medical  Association,  February 
11,  1905). 

INFANT  FEEDING,  ALKALIES  IN. 

A  considerable  amount  of  the  alkali 
may  prevent  all  stomach  digestion,  forc- 
ing the  task  of  digestion  on  the  intes- 
tine, which,  while  often  useful  for  lim- 
ited periods,  must  necessarily  interfere 
with  the  development  of  the  gastric 
functions  so  necessary  for  the  normal 
stomach  if  it  is  to  become  fitted  to  digest 
the  solid  diet  of  the  adult.  By  adding 
a  moderate  amount  of  alkali,  the  task 
laid  on  the  stomach  may  be  limited  to 


one  it  is  able  to  perform.  The  choice 
between  these  two  measures,  or  the  pos- 
sible rejection  of  both,  depends  entirely 
on  the  type  of  case  in  hand.  Milk  di- 
luted with  plain  water  containing  no 
alkali  is  promptly  clotted  in  the  stomach 
by  the  rennet  ferment,  and  the  clot  is 
transformed  into  tougher  masses  when 
acid  is  secreted.  Lime  water  added  to 
milk  checks  the  immediate  action  of  ren- 
net on  the  whole  mass  and  makes  the 
clotting  more  gradual,  altering  the  form 
of  the  curd  and  allowing,  possibly,  of  the 
passage  of  some  unaltered  milk  into  the 
intestine,  but  leaves  no  large  amount  of 
alkali  to  inhibit  the  stomach  digestion. 
With  bicarbonate  of  soda  added  to  milk, 
the  action  of  rennet,  hydrochloric  acid, 
and  pepsin  are  all  prevented  by  the 
greater  amount  of  antacid  present  until 
this  is  finally  neutralized.  In  the  mean- 
time, portions  of  the  milk  are  not  liable 
to  get  beyond  the  fluid  state  and  con- 
tinue to  escape  into  the  intestine.  This 
reduces  materially  the  burden  of  diges- 
tion laid  on  the  stomach  or,  if  the  alka- 
linity persists  a  sufficient  time,  relieves 
it  entirely,  the  labor  falling  on  the  in- 
testine. In  the  young  infant  the  stom- 
ach is  just  beginning  its  functions,  and 
the  earliest  secretion  which  acts  on  the 
milk  is  rennet.  Hence,  it  is  not  difficult 
to  understand  the  clinical  effects  of  add- 
ing 10  per  cent,  lime  water  or  2  grains 
of  bicarbonate  of  soda  to  the  ounce,  to 
the  food  of  very  young  infants.  The 
food  is  weak  in  that  the  proportion  of 
milk  is  small.  The  milk  is  decidedly 
alkaline  so  that  the  rennet  ferment  will 
not  act  and  the  effect  is  to  promote  rapid 
emptying  of  the  stomach;  for  whereas 
curded  milk  tends  to  be  retained  by  the 
stomach,  fluid  milk  tends  to  pass  into 
the  intestine.  This  assists  in  tiding  the 
infant  over  a  period  of  undeveloped  and 


INGROWN  TOENAIL.      INTESTINAL  CATARRH. 


171 


difficult  gastric  digestion,  and,  as  later, 
the  alkali  is  reduced,  directly  from  10 
per  cent,  to  5  per  cent,  or  from  2  grains 
to  1  grain  to  the  ounce,  and  also  as  the 
amount  of  milk  in  the  mixture,  the  effect 
directly  increased  by  augmenting  the 
amount  of  milk  in  the  mixture,  the  effect 
of  the  alkali  is  gradually  lessened.  The 
effect  of  adding  alkalies  to  the  food 
seems,  then,  to  be  that  of  influencing  the 
place  and  type  of  the  digestion  of  the 
food,  and  the  problems  which  must  be 
worked  out  in  the  near  future  will  be 
to  determine  the  proper  kinds  of  alkali 
and  the  quantity  of  such  alkali  to  be 
added  if  we  desire  to  produce  certain 
specific  results;  and  also  to  determine 
more  accurately  the  indications  for  their 
use  or  non-use  in  different  types  of  cases. 
T.  S.  Southworth  (Archives  of  Paediat- 
rics, February,  1905). 

INGROWN      TOENAIL,      SIMPLE      TREAT- 
MENT OF. 

The  author  uses  with  success  a  very 
simple  treatment  for  ingrown  toenails  in 
cases  in  which  operation  is  for  some 
reason  impossible.  He  applies  a  soap 
poultice  to  the  affected  toe  for  twenty- 
four  hours,  and  then  lifts  the  edge  of 
the  nail  from  its  bed  as  much  as  pos- 
sible. He  powders  some  burnt  alum  into 
the  space  between  the  nail  and  the  ulcer- 
ated or  granulating  nail-bed,  and  then 
inserts  a  piece  of  absorbent  cotton  be- 
tween these  surfaces,  pushing  the  cotton 
as  far  inward  and  backward  as  possible 
The  patients  are  quickly  relieved  of  their 
pain,  and  the  treatment  is  repeated  for 
several  days.  He  was  able  to  obtain 
cures  within  a  week.  Afterward  the  nail 
is  scraped  to  make  it  thinner  and  to  re- 
duce its  pressure  on  the  nail-bed,  and 
the  patients  are  cautioned  to  observe  the 
strictest  cleanliness,  and  to  wear  a  strip 


of  cotton  in  the  ungal  fold.  Alberto 
Gasparini  (Gazzetta  degii  Ospedali  e 
delle  Cliniche,  January  22,  1905;  from 
New  York  Medical  Journal  and  Phila- 
delphia Medical  Journal,  March  4, 
1905). 

INTESTINAL      CATARRH,       DIETETIC 
TREATMENT   OF. 

There  would  be  difficulty  in  recom- 
mending a  suitable  routine  diet  for  all 
forms  of  gastro-intestinal  disease,  but  it 
can  safely  be  said  that  the  food  should 
be  unirritating  and  assimilable.  It  has 
been  wrongly  assumed  that  milk  is  uni- 
versally suitable  for  such  troubles  and 
the  author  has  found  that  in  the  ma- 
jority of  cases  it  is  not  suitable,  at  least 
at  the  beginning  of  the  disease.  A  milk 
diet  may  be  considered  after  the  small 
intestine  has  been  brought  to  a  quiet 
condition  by  several  weeks  of  treatment 
with  some  other  form  of  diet.  On  the 
other  hand,  the  milk  diet  is  never  con- 
traindicated  for  catarrh  of  the  large  in- 
testine. The  diet  which  is  recommended 
as  suitable  to  bring  about  a  quiet  condi- 
tion of  the  small  intestine  should  con- 
tain 120  grams  of  albumin,  200  to  250 
of  carbohydrates,  and  40  to  50  of  fats. 
It  may  be  derived  from  meat,  fish,  eggs, 
sugar,  white  bread  or  zwieback,  sago, 
macaroni,  bouillon,  thin  soups,  butter, 
tea,  and  red  wine.  Meat  is  suitable  for 
the  majority  of  cases  of  acute  catarrh, 
and  usually  causes  very  little  trouble. 
In  some  cases  in  which  the  small  intes- 
tine is  the  seat  of  chronic  inflammation 
it  cannot  be  taken.  When  the  stomach 
is  in  a  condition  of  achylia,'  the  undi- 
gested meat  being  found  in  the  stools,  or 
when  there  is  an  increased  decomposi- 
tion of  albuminoid  material  on  account 
of  the  intolerance  of  meat  or  fish  by  the 
diseased     large     intestine,     such     food 


172 


LECITHIN.     LOCOMOTOR  ATAXIA,  TREATMENT. 


should,  of  course,  not  be  administered. 
If  the  symptoms  of  disease  of  the  stom- 
ach and  large  intestine  predominate  and 
the  symptoms  referable  to  the  small  in- 
testine are  correspondingly  less  pro- 
nounced, the  use  of  milk  "will  be  proper 
to  supply  the  necessary  albuminoids.  If 
after  a  few  weeks  of  milk  diet  the  stools 
become  normal  and  the  general  symp- 
toms improve,  small  quantities  of  vege- 
tables may  be  given  every  second  or  third 
day,  including  potatoes,  carrots,  and 
spinach,  also  tea,  cocoa,  and  cereals. 
After  four  to  six  weeks  meat,  milk,  and 
fruits  may  be  added.  Eosenheim  (Fort- 
schritte  der  Medizin,  January  10,  1905). 

LECITHIN,     ROLE     OF,     IN     ACTION     OF 
•      RADIUM  AND  X-RAYS. 

Lecithin  exposed  to  the  action  of  ra- 
dium or  x-rays  changes  in  some  way  so 
that  it  is  more  readily  decomposed,  more 
easily  attacked  by  autolytic  ferments. 
The  lecithin  in  the  cells  is  thus  de- 
stroyed, and  this  in  turn  entails  the  de- 
struction of  the  cells.  The  radiochem- 
ical processes  seem  to  be  analogous  to 
the  photochemical  in  certain  respects. 
Like  the  sensitized  salts,  the  lecithins  by 
the  action  of  the  rays,  are  made  more 
easily  destructible.  Without  undergoing 
any  apparent  chemical  modifications, 
they  become  decomposed  more  rapidly 
when  exposed  to  certain  conditions  (con- 
tact with  the  developer  in  the  first  case, 
contact  with  the  autolytic  ferments  in 
the  second).  This  analogy  is  the  more 
striking  as  it  has  been  lately  proclaimed 
that  the  biologic  action  of  light  is  due 
to  the  chemically  active  rays.  Experi- 
ments with  the  different  components  of 
lecithin  showed  that  none  of  them  was 
the  specific  agent;  the  total  lecithin  was 
required  for  the  process.    It  was  further 


established   that   a   radioactive   lecithin 
lost  its  activity  after  decomposition. 

The  author's  experiments  on  animals 
have  established  the  possibility  of  using 
local  injection  of  radioactive  lecithin  as 
a  substitute  for  exposure  to  radium  and 
Eoentgen  rays.  Large  doses  by  intra- 
venous or  subcutaneous  injection  killed 
rabbits,  but  multiple  small  doses  in  loose 
connective  tissue  were  not  followed  by 
any  appreciable  local  reaction.  He  is 
convinced  that  this  suggests  the  possi- 
bility that  in  radioactivated  lecithin  we 
may  find  a  therapeutic  factor  of  incal- 
culable scope  as  an  accumulator  of  the 
biologic  action  of  the  radium  and  Eoent- 
gen rays.  E.  Werner  (Deutsche  medi- 
cinische  Wochenschrift,  vol.  xxxi,  No. 
2;  from  Journal  of  the  American  Med- 
ical Association,  February  25,  1905). 

LOCOMOTOR     ATAXIA,     TREATMENT     OF, 
BY  ULTRA-VIOLET  RAYS. 

The  author  reports  the  results  ob- 
tained in  36  cases  of  locomotor  ataxia 
treated  with  the  ultra-violet  ray.  The 
ages  of  the  patients  ranged  from  24  to 
63  years.  Four  have  been  restored  to 
good  health  and  are  now  able  to  resume 
their  usual  vocations.  Twelve  have  been 
greatly  benefited,  the  power  of  coordi- 
nation has  been  restored,  pain  abolished, 
and  the  ability  to  use  the  upper  and  lower 
limbs  without  any  assistance  has  been 
established.  All  are  able  to  rise,  to  dress 
and  to  undress  themselves  without  any 
help,  and  are  sometimes  able  to  perform 
such  delicate  operations  as  fixing  the 
necktie  or  tying  their  shoes  in  a  stoop- 
ing position.  In  18  cases  the  disease 
is  apparently  arrested  with  hope  of  fur- 
ther improvement  and  final  restoration 
of  different  functions.  Two  patients 
died  during  treatment,  one  from  lobar 
pneumonia,  the  other  "of  erysipelas  of 


LYMPHATIC  LEUKAEMIA.     NITROGLYCERINE,  LIMITATIONS. 


173 


the  head.  These  cases  had  for  years 
received  different  forms  of  treatment,  and 
while  some  improvement  had  followed 
from  these  methods,  none  of  them  had 
made  such  gratifying  progress  as  since 
submitting  to  the  ultra-violet  ray  treat- 
ment. 

For  the  purpose  of  dehematization  the 
author  uses  the  cataphoric  electrode 
(with  a  round  piece  of  lint)  saturated 
with  adrenalin  chloride  (1  to  1000). 
A  pad  with  zinc  plate  is  applied  to  the 
abdomen,  leaving  it  on  for  from  three 
to  five  or  ten  minutes.  He  uses  the 
static  machine  for  exciting  the  ultra- 
violet lamp  with  the  large  Leyden  jars 
as  condensers.  The  lamp  is  connected 
by  its  conducting  cords  to  the  outer  sur- 
face of  the  jars.  Speaking  of  the  mode 
of  action  of  the  ultra-violet  ray,  the 
author  suggests  that  it  is  possible  that 
its  powerful  stimulating  effect  induces 
more  activity  in  the  natural  healthy  cell 
and  diminishes  the  nutrition  of  connec- 
tive tissue,  setting  up  a  more  active 
local  metabolism;  or,  that  it  induces  a 
local  accumulation  of  heat  energy  and 
a  congestive  process  through  which  neu- 
trophile  leucocytes  are  caused  to  immi- 
grate in  the  vicinity  of  the  degenerated 
cellular  elements.  The  application  of 
the  ultra-violet  ray  to  dehematized  tissue 
must  be  made  with  great  care  and  judg- 
ment. It  should  never  be  applied  to 
more  than  two  localities  at  each  seance, 
and  the  area  treated  should  be  varied  so 
that  every  day  a  different  region  of  the 
cord  is  exposed.  The  cervical,  lumbar, 
and  sacral  regions  are  treated  alter- 
nately. 

The  author's  routine  treatment  is  as 
follows:  1.  A  warm  half-bath  at  night 
before  going  to  bed  with  light  massage. 
2.  Ultra-violet  rays  in  sittings  of  from 
ten   to    thirty    minutes,    three  '  times    a 


week.  Static  electricity  by  means  of  the 
Morton  wave  current  or  wooden  brush 
daily,  from  fifteen  to  twenty  minutes. 
J.  M.  Liebermann  (New  York  Medical 
Journal  and  Philadelphia  Medical  Jour- 
nal, February  18,  1905). 

LYMPHATIC   LEUKEMIA,   ACUTE. 

In  the  majority  of  cases  of  acute  leu- 
kaemia there  is  a  rapid  destruction  of  the 
red  cells  with  the  blood  features  of  a 
severe  primary  anaemia.  The  essential 
changes  are  in  the  bone  marrow.  Cer- 
tain cases  seem  to  justify  the  term  of 
"leukaemia"  suggested  by  Leube.  In  the 
study  of  future  cases  more  attention 
should  be  paid  to  the  changes  in  the  red 
cells  and  the  probable  similarity  to  per- 
nicious anaemia  definitely  decided.  The 
clinical  features  of  acute  leukaemia  sug- 
gest its  being  an  acute  infection,  and 
perhaps  a  distinct  disease  from  chronic 
leukaemia.  Thomas  McCrae  (British 
Medical  Journal,  February  25,  1905). 

NITROGLYCERINE,  THE  LIMITATIONS 
OF,  AS  A  THERAPEUTIC  AGENT. 
The  effect  of  nitroglycerine  on  arte- 
rial pressure  in  patients  tested  by  means 
of  the  sphygmomanometer,  and  also  in 
animals,  and  it  was  found  that  high  arte- 
rial pressure  in  man  is  not  perceptibly 
affected  by  it  nor  is  dilatation  of  the 
blood-vessels  apparent.  Some  of  the 
conclusions  reached  are  as  follows :  The 
usual  dose  of  nitroglycerine  of  1/100  grain 
is  too  small  to  produce  any  effect  in 
pathologic  conditions;  1/50  grain  is  a 
minimum  dose.  Its  effects  are  very 
transient,  as  shown  by  the  experiments 
on  dogs,  and  the  ordinary  dose  of  V,0(, 
grain  every  four  hours  could  not  pos- 
sibly have  any  effect  on  the  arteries. 
Nitroglycerine  is  said  to  increase  the 
quantity   of  urine  in  chronic    Bright's 


174 


OPTIC  NEURITIS  DURING  LACTATION. 


disease,  but  after  keeping  accurate  rec- 
ords of  the  daily  amount  of  urine  passed, 
the  author  was  never  able  to  satisfy  him- 
self that  any  increase  seen  was  due  to 
this  drug.  In  conditions  due  to  arterial 
spasms,  so  called,  such  as  angina  pec- 
toris, migraine,  asthma,  nitroglycerine 
may  be  of  benefit,  in  full  doses  often  re- 
peated, but  not  in  arterial  sclerosis,  in 
which  the  arteries  themselves  are  more 
or  less  changed.  H.  P.  Loomis  (Medical 
Eecord,  March  18,  1905). 

OPTIC  NEURITIS  DURING  LACTATION. 

The  writer  reports  1  case  of  optic 
neuritis  and  reviews  24  others  occurring 
during  lactation.  The  average  age  ap- 
pears to  be  about  29  years,  the  youngest 
patient  being  21,  and  the  oldest  42. 
Primiparas  and  multiparas  seem  to  be 
affected  with  equal  frequency.  Usually, 
there  is  but  a  single  attack,  although 
several  cases  give  a  history  of  dimin- 
ished vision  after  each  pregnancy.  The 
disease  affects  strong,  healthy  women  as 
frequently  as  it  does  those  who  are  less 
robust.  In  practically  all  cases  the  eyes 
were  said  to  be  healthy  previously.  The 
seventh  week  was  the  time  of  election  for 
the  process  to  begin  but  it  varied  in  wide 
limits  from  shortly  before  birth  to  over 
a  year  after.  Establishment  of  the  milk 
secretion,  not  actual  nursing,  is  regarded 
as  the  important  factor  in  the  produc- 
tion of  the  disease,  for  in  one  case  the 
child  was  premature  and  died,  while  in 
another  it  was  only  nursed  once,  dying 
a  short  time  after  birth.  Suppression 
of  the  milk  secretion  coincident  with  the 
onset  of  the  disease  has  been  reported 
twice.  Occasionally  the  patient  gave  a 
history  of  protracted  nursing,  but  in  a 
large  majority  of  cases  lactation  has  been 
entirely  within  normal  limits. 

Both  eyes  are  more  commonly  affected 


than  one  alone,  and  it  is  interesting  to 
note  that  the  monocular  cases  seem  more 
prone  to  develop  a  retrobulbar  neuritis 
than  a  papillitis.  Ophthalmoscopic  ex- 
amination shows  the  loss  of  vision  to  be 
due  to  an  inflammation  of  the  optic 
nerve,  the  signs  of  which  are  more  or 
less  apparent  at  the  disc.  Generally, 
there  is  a  well-marked  papillitis,  occa- 
sionally one  of  extreme  severity,  with 
extension  of  the  process  into  the  sur- 
rounding retina,  while  in  the  retrobulbar 
type,  there  may  be  no  visible  sign  of  in- 
flammation, although  double  blindness 
exists.  Atrophy  of  a  varying  degree 
usually  results,  but  may  be  absent.  The 
amount  of  visual  diminution  varies 
greatly,  but  commonly  reaches  a  consid- 
erable degree,  even  to  absolute  blindness. 
The  vision  bears  no  relationship  to  the 
severity  of  the  process,  since  almost  nor- 
mal sight  may  be  noted,  in  spite  of  a 
well-marked  papillitis,  while  total  blind- 
ness has  been  observed  without  changes 
visible  to  the  eye.  In  a  corresponding 
manner,  the  vision  tends  to  regain  its 
normal  acuteness,  notwithstanding  the 
development  of  atrophic  change. 

Certain  cases  have  shown  a  tendency 
to  occurrence  during  each  succeeding 
pregnancy,  and  in  these,  at  the'  end  of 
several  attacks,  there  is  likely  to  be  a 
permanent  diminution  of  sight.  Frontal 
headache  is  a  constant  precursor  of  the 
disease.  The  pain  is  often  localized  in 
the  orbit,  and  deep  tenderness  may  be 
elicited  by  pressure  on  the  eyeball,  while 
movement  of  the  eye  may  cause  consid- 
erable discomfort. 

Although,  as  a  rule,  general  disease 
does  not  accompany  this  affection,  yet 
certain  cases  have  shown  an  acute  onset 
with  headache,  chills,  fever,  vomiting, 
and  general  malaise.  In  such  cases  sup- 
pression of  the  milk  secretion  is  apt  to 


PANCREAS,   EFFECTS   OF  REMOVING.     PERNICIOUS  ANEMIA. 


175 


occur.  The  writer  is  of  the  opinion  that 
there  is  little  evidence  to  connect  this 
affection  with  lactation,  and  that  the 
term  lactation  indicates  simply;,  in  the 
absence  of  a  better  term,  the  characteris- 
tic by  which  these  cases  may  be  most 
easily  recognized. 

Being  still  in  the  dark  as  to  the  cause 
of  this  obscure  affection,  treatment  must 
be  on  general  lines.  Elimination  should 
be  stimulated.  The  power  of  resistance 
must  be  increased  in  every  way.  Wean- 
ing should  be  advised.  Eecurrent  at- 
tacks should  be  watched  carefully.  G. 
S.  Derby  (Archives  of  Ophthalmology, 
February,  1905). 

PANCREAS,  EFFECTS  OF  REMOVING. 

As  the  result  of  experiments  on  dogs, 
the  author  found  that  the  constant  ef- 
fects of  removing  the  pancreas  consisted 
of  a  transient  glycosuria,  occurring 
within  twenty-four  or  thirty-six  hours 
after  the  operation,  and  followed  after- 
ward by  a  slight  glycosuria  which  lasted 
from  forty  to  sixty  days.  There  were 
also  disturbances  of  digestion  and  nu- 
trition, emaciation,  polyuria,  excessive 
and  abnormal  appetite,  and  thirst. 
These  disturbances  were  not  fatally  pro- 
gressive, but  disappeared  after  a  time. 
The  results  seem  to  show  that  the  pan- 
creas has  an  influence  on  the  metab- 
olism, regulating  the  processes  thereof 
in  some  way.  This  is  proved  by  the  fact 
that  injections  of  the  extract  of  pancreas 
in  these  dogs  proved  of  benefit  to  the 
general  metabolism,  but  did  not  have 
any  effects  on  the  glycosuria.  The  re- 
moval of  the  spleen  and  of  other  organs 
act  in  the  same  way,  although  less  mark- 
edly. The  results  obtained  by  various 
observers  with  animals  with  removed 
pancreas  vary  greatly,  and  this  is  the 
principal  difficulty  in  solving  the  ques- 


tion as  to  the  action  of  the  pancreas. 
These  differences  in  the  results,  the  au- 
thor thinks,  are  due  to  the  individual 
predisposition  of  the  animals,  as  one  au- 
thor has  produced  glycosuria  of  various 
types  by  experimentally  inducing  neu- 
ritis in  the  peripheral  end  of  the  cut 
vagus.  The  differences  in  results  also 
depend,  in  a  measure,  on  the  ages  of  the 
animals  used,  and  also  on  the  presence 
of  various  complications,  clue  to  the  op- 
eration, etc.  The  results  which  he  ob- 
tained correspond  closely  to  the  symp- 
toms seen  in  man  in  severe  forms  of  dia- 
betes. He  pleas  for  a  broader  interpre- 
tation of  the  term  diabetes,  and  asks  that 
glycosuria  should  no  longer  be  held 
synonymous  with  that  disease.  The 
worst  clinical  forms  of  diabetes  some- 
times are  accompanied  by  very  little 
sugar,  and  the  lightest  cases  show  some- 
times the  largest  amounts.  The  author 
considers  diabetes  as  a  disease  of  auto- 
lysis, in  which  the  decomposition  of  the 
proteid  molecule  goes  on  too  fast,  in 
which  there  is,  so  to  speak,  a  gangrene 
of  the  organism.  The  bulimia  and  the 
polyphagia  are  only  results  of  this  ab- 
normal decomposition.  Torindo  Silves- 
tri  (Eiforma  Medica,  February  11, 
1905;  from  New  York  Medical  Journal 
and  Philadelphia  Medical  Journal, 
March  25,  1905). 

PERNICIOUS    ANEMIA,    PATHOLOGY    OF. 

A  histological  study  of  17  cases  of 
pernicious  amemia  was  made  by  the  au- 
thors, from  which  they  draw  the  follow- 
ing conclusions:  The  essential  feature 
of  the  disease  and  the  criterion  in  its 
diagnosis  is,  that  it  is  a  megaloblastic 
anaemia.  The  widespread  evidences  of 
blood  destruction  occurring  in  liver, 
spleen,  leucolymph  glands,  and  marrow 
indicate  abnormal   vulnerability  in  the 


176 


PNEUMONIA  AND  PEEGNANCY.      PNEUMONIA,  LOBAR. 


blood-cells  rather  than  a  pathologically 
excessive  leucolytic  action  on  the  part  of 
so  many  diverse  tissues.  The  accumula- 
tion of  iron  in  the  liver  is  due  partly  to 
the  disintegration  of  weakened  or  weakly 
blood-corpuscles  by  endothelial  cells  and 
leucocytes,  and  partly  (and  to  a  much 
greater  extent)  to  storage  of  iron,  which 
is  the  product  of  red  blood-corpuscle? 
which  have  been  disintegrated  by  phago- 
cytes elsewhere.  This  accumulation  of 
iron  in  the  liver  is  not  peculiar  to  per- 
nicious ansemia,  and  is  the  normal  result 
of  the  abnormal  amount  of  blood  de- 
struction. There  is  no  direct  evidence 
of  special  disease  of  the  intestine,  and 
the  intestine  need  not  be  the  primary 
seat  of  toxin  production,  though  in  cer- 
tain cases,  and  notably  in  bothriocephalus 
anaemia,  it  probably  is.  In  some  part  of 
the  body  a  toxin  is  produced  which  acts 
directly  on  the  bone  marrow,  interfer- 
ing with  normoblastic  blood-formation, 
leading  to  megaloblastic  formation,  and 
acting  with  negative  chemic  taxis  upon 
leucocytes,  especially  of  the  neutrophile 
variety.  The  large,  old  blood-corpuscles 
produced  by  such  a  marrow,  perhaps  as 
much  from  their  size  as  from  inherent 
weakness,  fall  a  ready  prey  to  endothelial 
cells  and  leucocytes  in  the  haemolytic 
organs,  notably  haemolymph  gland, 
spleen,  and  marrow.  It  is  quite  pos- 
sible that  certain  individuals,  from  con- 
genital defect  in  the  marrow,  may  be 
specially  prone  to  the  disease,  as  there 
is  little  doubt  that  the  megaloblastic 
degeneration  represents  a  reversion  to 
the  foetal  type.  G.  L.  Gulland  and  A. 
Good  all  (Journal  of  Pathology  and  Bac- 
teriology, January,  1905). 

PNEUMONIA  AND  PREGNANCY. 

The  death  rate  is  appreciably  higher 
in  the  pregnant  woman  than  in  the  ordi- 


nary patient.  Abortion  takes  place  in 
more  than  half  the  patients.  The  mor- 
tality is  much  higher  when  abortion  takes 
place  than  when  the  uterus  does  not 
empty  itself.  The  mortality  is  higher 
in  the  last  three  months  of  pregnancy. 
The  causes  of  death  can  be  attributed  to 
(a)  diminution  in  the  haemoglobin;  (b) 
degenerative  changes  in  heart  muscle, 
(c)  overloading  of  the  right  heart  and 
pulmonary  circulation  after  birth.  The 
high  percentage  of  abortions  is  due  to 
accumulation  of  carbonic  acid  in  the 
blood.  R*.  C.  Eansdell  (American  Med- 
icine, February  11,  1905). 

PNEUMONIA,  LOBAR,  IN  INFANCY. 

Pneumonia  is  far  more  common  dur- 
ing the  first  two  years  of  life  than  is 
generally  supposed.  Its  course  and 
prognosis  differ  materially  from  the  de- 
scriptions given  in  many  of  the  older  as 
well  as  in  some  of  the  newer  text-books. 
The  onset  is  less  stormy  than  is  usually 
described.  A  chill  practically  never  oc- 
curs; convulsions  are  very  unusual. 
Cough  rarely  amounts  to  much  in  the 
beginning.  High  fever  usually  develops 
rapidly  and  is  generally  accompanied  by 
drowsiness  and  apathy.  The  most  com- 
mon period  of  pyrexia  is  seven  days.  A 
shorter  duration  is  more  common  in  in- 
fancy than  later.  The  average  duration 
is  longer  in  the  fatal  cases.  Eemissions 
of  even  as  much  as  three  or  five  degrees 
are  not  uncommon.  Crisis  is  less  com- 
mon than  later.  Lysis  is  especially  com- 
mon in  cases  of  long  duration.  Collapse 
during  the  crisis  is  less  frequent  than  is 
usually  taught.  The  usual  pulse-rate  is 
between  150  and  170,  being  over  150  in 
75  per  cent.  The  usual  respiratory  rate 
is  between  55  and  80.  It  is  more  often 
above  80  than  below  55.  The  rate  of 
respiration  is   always   increased  out  of 


PREGNANCY,  TOXEMIA  OF. 


177 


proportion  to  that  of  the  pulse.     This 
change  in  the  pulse-respiration  ratio  is 
most  important  in  diagnosis.     Cough  is 
seldom  a  prominent  symptom.     Gastro- 
intestinal  symptoms   are   very   common 
and  very  important.    Marked  anorexia  is 
the  rule.    Vomiting  is  not  very  common. 
Diarrhoea  is  more  common  than  consti- 
pation.    Distention  of  the  abdomen   is 
frequent,  difficult  to  relieve,  and  often 
hastens  the  fatal  termination.  The  urine 
often  shows  the  evidence  of  acute  degen- 
eration and  occasionally  of  acute  inflam- 
mation of  the  kidneys.     The  usual  men- 
tal  condition   is   one   of   drowsiness   or 
apathy.     Cerebral  symptoms  are  usually 
functional  in  origin  and  are  frequently 
associated  with  a  high  temperature.    The 
nervous  symptoms   are  often  due  to   a 
complicating  inflammation  of  the  mid- 
dle ear.    The  diminution  of  the  respira- 
tory sounds  on  the  affected  side  is  often 
the  earliest  sign  and  is  of  great  impor- 
tance in  diagnosis.     The  order  of  fre- 
quency of  involvement  of  the  lobes  is  left 
lower,  right  upper,  right  lower,  and  left 
upper.    There  is  no  relation  between  the 
mortality  and  the  part  of  the  lung  in- 
volved.    The   mortality   varies   directly 
with    the    amount    of    lung    involved. 
Acute  inflammation  of  the  middle  ear 
is  the  most  common  complication. 

The  pneumonia  mortality  in  the  In- 
fants' Hospital  series  was  25  per  cent. 
This  is  higher  than  that  in  private  prac- 
tice. The  younger  the  infant,  the  worse 
the  prognosis.  The  prognosis  varies 
with  the  amount  and  not  with  the  part 
of  lung  involved.  Fever  lasting  more 
than  nine  days  is  of  serious  import.  The 
prognosis  is  good  when  the  temperature 
is  not  over  103°  F.  It  is  serious  when 
over  10G°  F.  Variations  between  these 
two  points  are  unimportant.  The  prog- 
nosis is  good  when  the  pulse  is  not  over 


140  or  the  respiration  over  55.  The 
amount  of  the  increase  above  these  lim- 
its is  of  little  importance.  The  gastro- 
intestinal are  the  most  dangerous  of  the 
more  common  complications. 

The  treatment  is  hygienic  and  sup- 
portive rather  than  medicinal.  Far  more 
harm  can  be  done  by  overmedication 
than  by  undermedicatiom  The  infant 
should  not  be  disturbed.  It  must  have 
the  greatest  possible  amount  of  fresh, 
cool  air.  The  diet  must  be  regulated  to 
suit  the  weakened  digestion  and  food 
forced  if  necessary.  Stimulation  should 
be  used  when  indicated,  and  not  as  a 
routine  measure.  Strychnine  is  most 
useful,  alcohol  next.  The  fever  should 
not  be  treated  unless  it  causes  marked 
nervous  symptom  or  depression.  It 
should  then  be  treated  by  cold  externally 
and  not  by  antipyretics  internally.  Cold 
must  be  used  cautiously,  as  infants  bear 
it  badly.  Fan  baths  and  cold  packs  are 
best  borne.  Local  applications  should  be 
used  only  for  pain ;  oxygen  for  cyanosis. 
Creosote,  the  various  serums,  and  other 
"specifics"  have  no  effect  on  the  course 
of  the  disease.  J.  L.  Morse  (American 
Medicine,  January  28,  1905). 

PREGNANCY,    TOXEMIA    OF. 

At  present  this  condition  may  be  re- 
garded as  a  functional  disturbance  of 
the  liver,  usually  accompanied  with  an- 
atomical lesions  of  that  organ,  and  with 
functional  disturbance  and  anatomical 
lesions  of  the  kidneys  and  other  organs. 
The  kidney  disease  may  become  pro- 
nounced only  when  the  poisons  resulting 
from  the  failure  of  oxidation  in  the  liver 
cause  degeneration,  congestion,  and  exu- 
dative inflammation  of  these  organs.  It 
may,  therefore,  be  far  advanced  before 
albuminuria  appears.  There  may  be 
fatal  cases  with  minimal  lesions  of  the 


178 


PREPUERPERAL  AND  PUERPERAL  HEMORRHAGES. 


liver.  The  hepatic  lesions  follow  the  dis- 
turbance of  function,  but  there  are  sev- 
eral steps  between  the  loss  of  oxidizing 
capacity  and  the  hydrolysis,  fatty  degen- 
eration, and  necrosis  of  the  liver  cells. 
Many  factors  are  concerned  in  the  dis- 
turbance of  nitrogenous  metabolism, 
such  as  the  retention  of  substances  usu- 
ally eliminated  with  menstruation,  the 
increased  metabolism  required  in  the 
growing  foetus,  the  influence  of  thyroid 
and  parathyroid,  etc.  Two  important 
observations  upon  autopsy  subjects  were 
the  distended  intestine  containing  saline 
solution  which  had  not  been  absorbed, 
and  the  remarkable  concentration  of  the 
blood.  The  inference  from  these  condi- 
tions is  that  the  blood  requires  dilution, 
but  it  should  be  by  infusion  with  saline 
solution  rather  than  by  rectal  enema. 
Pathological  study  also  shows  the  ab- 
sence of  any  necessarily  fatal  character 
in  the  disease.  We  are  dealing  primar- 
ily, at  least,  with  a  disturbance  of  func- 
tion, not  with  a  hopeless  anatomical  le- 
sion nor  an  uncontrollable  bacterial  in- 
fection. Ringer's  fluid  is  recommended 
for  infusion,  rather  than  the  usual  nor- 
mal salt  solution.  Ewing  (American 
Journal  of  Obstetrics,  February,  1905). 

PREPUERPERAL  AND  PUERPERAL  HEM- 
ORRHAGES. 
In  order  to  cope  satisfactorily  with 
these  haemorrhages  every  practitioner 
must  have  decided  positively  beforehand 
on  his  line  of  action  in  such  cases,  and 
then  make  the  best  use  of  every  minute. 
The  successful  handling  of  these  cases 
depends  largely  on  the  ability  of  the 
physician  to  classify  them  properly,  as 
no  one  method  of  treatment  can  be  sug- 
gested that  would  be  suitable  for  all 
cases.  If  the  child  is  viable,  or  if  a 
severe  haemorrhage  has  occurred,  labor 


should  be  induced  at  once.  If  the  child 
is  not  viable  and  the  haemorrhage  has 
been  slight,  the  physician  is  justified  in 
temporizing,  providing  the  patient  can 
be  watched  carefully.  The  writer  ex- 
presses the  opinion  that  no  condition  of 
the  patient  in  placenta  praevia  ever  justi- 
fies rapid  dilatation  or  rapid  emptying 
of  the  uterus.  If  the  child  is  viable,  or 
if  a  severe  haemorrhage  has  occurred,  the 
patient  a  primipara,  and  the  os  rigid,  the 
cervix  should  be  drawn  down  and  the 
cervix  and  vagina  packed  with  iodoform 
gauze.  If  properly  done  this  will  usually 
stimulate  uterine  contraction  and  satis- 
factorily control  the  haemorrhage.  In  a 
few  hours,  in  the  vast  majority  of  cases, 
the  os  will  be  sufficiently  dilated  to 
admit  of  digital  dilatation.  If  the  haem- 
orrhages are  not  severe,  pains  strong  and 
regular,  the  head  or  buttocks  engaged, 
watch  and  wait.  If  the  haemorrhage  in- 
creases, the  membranes  should  be  rup- 
tured. If  this  is  not  effectual  a  foot 
should  be  brought  down,  but  done  gently, 
so  as  to  disturb  the  placenta  as  little  as 
possible,  and  to  produce  the  least  possible 
shock  to  the  mother.  If  the  haemorrhage 
is  extensive  or  severe,  with  the  cervix 
fairly  well  dilated,  version  should  be 
performed,  the  membranes  ruptured, 
and  a  foot  brought  down.  If  the  patient 
is  not  exsanguinated  or  suffering  from 
shock,  gentle,  intermittent  traction  not 
exceeding  two  pounds  should  be  used. 
Should,  however,  either  of  the  conditions 
mentioned  exist,  restoratives  should  be 
used  at  once,  such  as  normal  saline  solu- 
tion, morphine,  strychnine,  digitalin,  or 
an  ether  or  a  whisky  hypodermic.  After 
delivery  the  placenta  and  membranes 
should  be  removed  at  once,  and  if  haem- 
orrhage continues,  the  uterus  should  be 
drawn  down,  the  entire  uterine  cavity, 
cervix,  and  vagina  packed  with  sterilized 


PREVENTIVE  MEDICINE:     HOW  CAN  PHYSICIAN  PROFIT  BY  IT? 


179 


gauze.  The  author  states  that  the  hydro- 
static and  pneumatic  methods  of  dilata- 
tion are  practically  limited  to  hospital 
practice.  The  same  may  be  said  of 
Csesarean  section.  Bossi's  dilator  and 
every  other  metal  dilator  are  condemned 
as  being  most  dangerous.  No  method  of 
treatment  should  be  adopted  that  will 
diminish  the  mother's  chances  in  the 
slightest  degree.  The  author  also  con- 
demns the  practice  of  relinquishing  old 
and  tried  methods  for  the  sake  of  ex- 
perimenting with  something  new.  The 
treatment  of  post-partum  haemorrhage  is 
largely  preventive.  If,  however,  it  does 
occur,  and  the  placenta  is  still  in  the 
uterine  cavity,  with  extensive  haemor- 
rhage and  with  a  poorly  contracting 
uterus,  the  placenta  should  be  removed 
with  the  gloved  hand,  allowing  the  hand 
to  remain  in  the  uterine  cavity  until  ex- 
pelled by  the  contractions  of  the  uterus. 
If  the  uterus  is  empty  when  the  haemor- 
rhage occurs,  a  hot  douche  should  be 
given  at  120°  F.,  or  the  same  with  a  3 
per  cent,  acetic  acid,  and  then  packed 
with  sterile  gauze,  drawing  down  the 
uterus,  as  for  vaginal  hysterectomy,  to 
do  so.  C.  J.  C.  0.  Hastings  (New  York 
Medical  Journal  and  Philadelphia  Med- 
ical Journal,  February  25,  1905). 

PREVENTIVE  MEDICINE:    HOW  CAN  THE 
PHYSICIAN    PROFIT    BY    IT? 

Dr.  Taylor  presents  evidence  to  show 
that  it  is  necessary  that  preventive  med- 
icine shall  be  exhibited  to  the  profession 
as  a  means  of  advantage  to  themselves 
as  well  as  to  the  community  and  ex- 
presses the  hope  that  the  subject  will  be 
amplified  by  others  from  various  stand- 
points. 

He  submits  certain  postulates:  First. 
That  the  relationship  of  the  physician 


to  the  patient  is  at  present,  and  has  long 
been,  on  the  wrong  basis;  that  the  cus- 
toms now  prevailing  are  false,  unfair. 

Second.  It  is  wrong  to  call  on  the 
practitioner  only  to  aid  those  suffering 
from  disease.  He  should  be  given  free 
opportunity  to  inspect  the  members  of 
a  household  at  regular  periods  or  at  will, 
thus  to  recognize  in  their  incipiency  de- 
rangements which  may  grow  into  dis- 
ease; also  the  character  of  the  hygienic 
precautions  taken,  and  systematize  these, 
pointing  out  errors  and  suggesting  im- 
provements, whereby  dangers  may  be 
limited  or  prevented. 

Third.  Disease  is  now  being  studied 
from  the  standpoint  of  economics,  hence 
prevention  is  to  be  welcomed  as  a  source 
of  general  wealth. 

Fourth.  Legislatures  can  be  made 
more  effective  if  physicians  will  take 
their  part  more  energetically  and  exer- 
cise or  organize  power  to  prevent  or  limit 
preventable  disease. 

Fifth.  Physicians  should  point  out 
the  ways  to  reform  and  educate  the  pub- 
lic more  clearly  and  emphatically  than 
they  do. 

Sixth.  They  should  acept  the  author- 
ity of  the  Health  Boards  more  cordially 
and  work  with  them  to  accomplish  re- 
sults and  not  exhibit  jealousy. 

He  recommended  that  physicians  or- 
ganize and  adopt  a  different  fee  system; 
it  is  a  false  position  for  the  physician  to 
earn  no  fee  except  by  being  invited  to 
meet  exigencies  only  when  they  have 
arisen;  better  to  adopt  the  plan  long 
since  found  necessary  by  lawyers  of  de- 
manding a  retaining  fee  of  yearly  sti- 
pend of  the  householder,  thus  giving 
them  access  to  the  house  to  learn  the 
personal  habits,  to  observe  constitutional 
peculiarities,  to  rectify  these,  and  in 
many    ways    save    from    peril    obvious 


180 


PUERPERAL  FEVER,  PREVENTION  OF. 


enough  to  them,  but  obscure  to  the  un- 
educated. 

He  suggests  many  directions  in  which 
the  physician  could  attain  vastly  better 
results  if  this  privilege  was  freely  ac- 
corded. 

He  should  be  the  expert  in  the  con- 
servation of  energy  and  the  development 
of  inherent  powers,  the  correction  of 
bodily  faults. 

He  must  become  a  practical  psychol- 
ogist and  give  attention  to  the  psychic 
variants,  ethical  peculiarities,  and  lim- 
itations. 

Most  people  are  unwilling  to  admit 
themselves  indisposed  until  they  are  def- 
initely ill,  and  thus  frequently  much 
valuable  time  is  lost  when  serious  con- 
ditions are  beginning. 

In  children,  many  conditions  could  be 
prevented  before  too  late,  such  as  de- 
formities, which  not  only  impair  activ- 
ity, but  often  strike  at  the  very  founda- 
tion of  organic  integrity  by  displacing 
vital  organs.  Psychoses  could  thus  be 
early  observed  and  a  large  series  of  dan- 
gerous results  to  mind  and  body  could 
be  remedied. 

He  finally  alludes  to  many  of  the 
duties  of  the  physician  which  are  neg- 
lected, such  as  the  duty  of  discouraging 
the  use  of  many  medicines,  bitters,  ton- 
ics, fluid  food  preparations,  cough  med- 
icines, and  the  like,  whose  chief  factor 
of  attractiveness  is  the  contained  alcohol 
or  narcotics.  This  is  the  direct  result  of 
self-medication  on  the  part  of  people 
who  rarely  or  unwillingly  consult  their 
medical  adviser  as  to  minor  ailments, 
yet  will  accept  the  allurements  of  con- 
scienceless advertisers.  Limitless  harm 
is  thus  wrought,  tastes  for  narcotics  en- 
gendered, even  drunkenness  encouraged. 
Our  failure  to  take  a  firm  ethical  stand 
lowers  professional  potential  and  detracts 


from  the  influences  of  medicine  and  en- 
courages charlatans.  J.  Madison  Taylor 
(Transactions  Philadelphia  County  Med- 
ical Society,  March  8,  1905). 

PUERPERAL  PEVER,  PREVENTION  OF. 

The  writer  thinks  that  it  is  just  as  im- 
portant to  sterilize  the  internal  genitals 
after  childbirth  as  it  is  to  instill  the 
prophylactic  silver  solution  in  the  eyes 
of  the  newly  born  child.  Conditions,  of 
course,  are  much  simpler  in  the  case  of 
the  child's  eyes,  but  the  principle  of  pre- 
vention of  development  of  lurking  germs 
is  the  same.  He  regards  Zweifel's  idea 
as  to  the  evacuation  of  all  blood  clots  as 
a  very  fortunate  one.  Extensive  experi- 
ence has  proved  that  collargol  is  per- 
fectly harmless  for  the  purpose,  and  is 
a  powerful  antiseptic  and  catalytic  rem- 
edy which  kills  or  attenuates  the  germs 
in  the  uterus  or  vagina.  If  systematic- 
ally used,  it  would  greatly  reduce  the 
number  of  deaths  from  puerperal  fever. 
Collargol  is  introduced  in  the  form  of  a 
suppository  pushed  high  into  the  va- 
gina or  cervix  or  into  the  uterine  cavity 
after  delivery,  the  opening  into  the  va- 
gina then  being  loosely  tamponed  with 
gauze.  The  formula  for  this  "collargol- 
vaginal  ball,"  as  the  author  calls  it,  is : — 

I£  Collargol, 

Talc,  pulv.,  of  each,  gr.  xv. 
Olei  cacao,  3ivss. 

M.  ft.  globuli  no.  x. 

The  suppository  and  gauze  can  be  re- 
newed at  need.  The  collargol  penetrates 
into  every  crevice,  sterilizes  the  secre- 
tions without  injuring  the  living  cells, 
and,  to  some  extent,  is  absorbed.  Even 
if  infection  be  already  present,  it  is  at- 
tenuated, but,  in  this  case,  more  ener- 
getic measures  are  necessary.  The  au- 
thor irrigates  with  a-1  to  2000  or  5000 


RINGWORM,  TREATMENT.     SPRAINS,  KNEE  AND  ANKLE  JOINTS.  181 


solution  of  collargol,  introducing  a  sup- 
pository to  act  during  the  intervals,  with 
other  measures  as  indicated,  using  as  the 
last  resource  intravenous  injections  of 
8  to  10  cubic  centimeters  of  a  2  per 
cent,  solution  of  collargol.  B.  Crede 
(Centralblatt  fur  Gynakologie,  February 
11,  1905). 

RINGWORM,  TREATMENT  OF. 

The  writer  warmly  recommends  Sab- 
ouraud's  method  of  treatment  of  ring- 
worm of  the  scalp  by  means  of  x-rays. 
All  chemical  and  antiseptic  methods  fail 
because  the  root  of  the  hair  is  inaccessi- 
ble. Radiotherapy  causes  the  hair  to 
fall  out,  but  hitherto  it  has  not  been 
successful  in  ringworm,  because  of  the 
absence  or  imperfect  measurement  of  the 
quantity  and  quality  of  the  rays  applied. 
Sabouraud  has  worked  out  a  successful 
method  of  measurement  of  the  rays,  and 
as  practiced  by  him  it  is  painless,  the 
actual  time  necessary  for  the  treatment 
is  short,  and  the  diseased  hairs  fall  out 
at  a  definite  interval  after  application 
of  the  x-rays,  and  are  replaced  after  a 
certain  time  by  a  growth  of  healthy 
hair.  J.  L.  Bunch  (Lancet,  February 
18,  1905). 

SCARLET    FEVER,    EAR    COMPLICATIONS 
OF. 

The  author  emphasizes  the  necessity 
of  paying  attention  to  the  removal  of 
hypertrophied  tonsils,  adenoid  vegeta- 
tions, and  nasal  obstructions  in  all  our 
little  patients,  so  that  when  subjected  to 
the  strain  of  scarlet  fever  they  may  avoid 
the  principal  method  of  ear  infection. 
Owing  to  the  rapidity  with  which  de- 
struction of  aural  tissue  and  extension  of 
infection  takes  place  in  this  disease,  as 
soon  as  the  tympanum  shows  signs  of 
exudation  and  the  membrane  of  bulging, 
a   paracentesis    should    be    immediately 


performed.  Bepeated  examinations  of 
the  ear,  especially  in  infants  and  chil- 
dren, should  be  made  on  account  of  the 
uncertainty  of  the  symptoms.  Herman 
Jarecky  (Medical  Record,  February  25, 
1905). 

SPRAINS     OF     THE     KNEE     AND     ANKLE 
JOINTS. 

These  sprains  for  the  most  part  in- 
volve the  ligaments  of  the  joints.  If 
forced  extension  of  the  leg  upon  the 
thigh  is  made,  injury  readily  results,  as 
in  extension  all  the  ligaments  of  the 
knee  joint,  except  the  Kgamentum  pa- 
tella?, are  put  on  the  stretch ;  conversely, 
forced  flexion  rarely  results  in  injury, 
because  the  conditions  are  reversed.  In 
injury  to  the  knee  or  ankle,  an  anaes- 
thetic may  be  necessary  to  effect  a  diag- 
nosis. The  more  promptly  treatment  is 
instituted  after  injury  to  either  of  these 
joints,  the  better  the  results  are  apt  to 
be.  Hot  applications,  as  cloths  wrung 
out  of  hot  water,  applied  about  the  joint 
for  forty  to  sixty  minutes  and  covered 
with  oiled  silk  or  wax  paper,  will  greatly 
lessen  pain  and  limit  swelling.  After 
this  Cotterell's  dressing  may  be  applied. 
This  consists  of  strips  of  adhesive  plaster 
placed  longitudinally  over  the  knee,  and 
the  whole  covered  with  a  rubber  bandage. 
If  there  is  great  effusion,  aspiration  may 
be  necessary.  At  the  ankle  joint  the 
lateral  ligaments  are  the  ones  most 
usually  involved.  If  effusions  and  pain 
are  great,  the  foot  and  ankle  should  be 
immersed  in  hot  water  for  a  time  and 
then  a  Gibney  dressing  applied  and  the 
patient  directed  to  begin  walking  under 
the  eyes  of  the  surgeon.  The  dressing 
should  be  removed  after  a  week,  the  parts 
given  massage,  and  the  dressing  reap- 
plied. J.  T.  Wilson  (Medical  News, 
February  25,  1905). 


182 


STERILITY,  TREATMENT  OF. 


STERILITY,    TREATMENT    OF. 

There  are  two  causes  for  sterility  in 
women,  if  one  disregards  rare  causes. 
The  first  is  due  to  developmental  faults 
in  the  genital  organs  and  the  second  to 
gonorrhoea.  Since  the  severe  damage 
which  gonorrhoea  is  capable  of  doing  has 
been  recognized,  the  importance  of  this 
disease  in  the  causing  of  sterility  in 
women  has  been  much  exaggerated.  At 
least  two-thirds  of  the  cases  are  caused 
by  developmental  defects.  This  is  very 
rarely  the  absence  of  the  whole  genital 
tract  or  part  of  it,  but  much  more  com- 
monly infantile  types  of  the  organs.  In 
some  cases  this  infantilism  affects  the 
whole  tract,  while  in  other  cases  only 
certain  parts  are  so  affected.  We  have 
no  knowledge  as  to  how  these  develop- 
mental defects  act  inhibitorily  on  con- 
ception. When  the  ovaries  are  ill-devel- 
oped and  more  like  foetal  organs,  one 
must  suppose  that  oculation  takes  place 
at  rare  intervals  and  is  never  profuse. 
When  the  tubes  are  much  convoluted 
and  defective  they  probably  refuse  to 
carry  out  their  function  properly  in  car- 
rying the  ovum  into  the  uterus.  The 
sperm  cells,  too,  may  have  difficulty  in 
ascending  in  such  tubes.  When  the 
uterus  is  infantile  one  supposes  that  it 
hinders  the  passage  of  the  sperm  cells, 
and  also  does  not  offer  the  impregnated 
ovum  a  chance  to  find  a  resting  place. 

A  short  anterior  wall  of  the  vagina 
and  an  insufficient  vault  renders  the  re- 
tention of  semen  in  the  vagina  almost 
impossible,  and  the  empediment  to  the 
semen  is  also  met  with  when  the  cervix 
is  sharply  bent  on  the  uterus,  when  the 
os  is  stenosed,  and  when  the  mucous 
membrane  is  defective.  In  gonorrhoea, 
the  chief  change  which  hinders  the  pas- 
sage of  the  sperm  cells  is  the  inflamma- 
tion of  the  mucosa  of  the  cervix  and 


uterus  and  the  presence  of  purulent 
material,  which  latter  acts  directly  on 
the  cells. 

In  treating  these  cases  the  writer 
thinks  it  necessary  to  investigate  in  each 
case  whether  sperm  cells  are  to  be  found 
in  the  secretion  of  each  portion  of  the 
tract.  The  prognosis  in  sterility  due  to 
infantilism  must  depend  on  the  extent 
of  the  defect.  When  the  cervix  is  alone 
affected,  it  is  good,  provided  that  the 
treatment  is  properly  carried  out.  Less 
good  results  may  be  expected  when  the 
uterus  is  affected,  and  when  the  changes 
are  well  marked,  one  may  take  it  for 
granted  that  the  ovaries  also  are  infan- 
tile, and  then  the  prognosis  is  bad.  In 
a  few  cases  it  has  been  observed  that  the 
arrested  development  can  be  continued, 
even  after  a  considerable  time,  if  this 
is  not  severe.  The  only  means  which 
gave  any  results  in  this  direction  was  the 
application  of  constant  electrical  cur- 
rents. 

In  dealing  with  defects  in  the  outer 
passages,  including  the  cervix,  much  pa- 
tience must  be  exercised,  since  the  devel- 
opmental defect  tends  to  offer  consider- 
able resistance  to  dilatation.  One  can 
choose  any  method  of  treatment,  but  one 
must  continue  it  for  a  long  time.  The 
stretching  and  dilatation  of  the  vaginal 
vault  is  difficult  and  often  very  slow. 
Some  forms  of  small  pessaries  do  good 
at  times. 

The  prognosis  in  cases  due  to  gonor- 
rhoea depends  on  when  and  in  which 
stage  the  infection  is  recognized.  If  the 
cases  are  seen  early  and  recognized  at 
once,  it  may  be  expected  that  no  ster- 
ility will'  follow.  Since  the  treatment 
must  be  directed  toward  preventing  the 
inflammatory  changes  from  spreading 
upward,  all  intrauterine  measures  must 
be  avoided.     Great  -care  must  be  exer- 


SUBCUTANEOUS  NOURISHMENT.  THYROID  AND  PANCREAS. 


183 


cised;  the  chief  points  are  to  keep  the 
parts  as  much  at  rest  as  possible,  and 
especially  during  the  period.  Careful 
vaginal  irrigation  does  good;  as  does 
discission.  When  the  infection  has  al- 
ready reached  the  tubes,  all  need  not  be 
given  up.  Cases  of  suppuration  in  the 
tubes  have  been  cured  with  rest,  appli- 
cation of  ice,  and  later  hot  packs.  The 
pus  may  become  absorbed  and  no  ster- 
ility follow.  After  the  appendages  have 
been  generally  inflamed,  one  must  wait 
until  everything  has  quieted  down  com- 
pletely before  applying  massage,  which 
they  may  do  good.  Removal  of  one 
ovary  and  freeing  the  other  from  adhe- 
sions has  led  to  conception  in  one  of  tin 
author's  patients.  Only  when  actual 
destruction  of  tissue  has  taken  place 
must  the  prognosis  be  considered  hope- 
less. E.  Bumm  (Deutsche  medicinische 
Wochenschrift,  November  24,  1904; 
from  British  Medical  Journal,  March 
4,  1905). 

SUBCUTANEOUS  NOURISHMENT  AFTER 
SURGICAL  OPERATIONS. 
The  direct  introduction  of  nutriment 
into  the  tissues  is  suggested  by  the  au- 
thor, especially  after  operations  upon 
the  abdominal  organs  in  cases  in  which 
the  digestive  organs  are  entirely  or  par- 
tially unable  to  perform  their  functions. 
He  has  been  experimenting  in  this  direc- 
tion for  years  and  has  found  that  heat 
units  can  be  satisfactorily  introduced  by 
means  of  a  2  per  cent,  sodium  chloride 
solution  containing  30  to  35  parts  per 
mille  of  chemically  pure  grape  sugar. 
This  solution  should  lie  boiled  ten  min- 
utes, and  when  cooled  to  the  temperature 
of  the  body  1  to  2  liters  may  be  in- 
jected daily  under  aseptic  precautions. 
For  the  further  production  of  heat  20 
to  100  grains  of  sterilized  oil  may  also 


be  injected.  The  production  of  a  suit- 
able albuminoid  was  extremely  difficult, 
but  he  finally  succeeded  in  producing  a 
pepsin-fibrin-peptone  which  would  not 
coagulate  and  which  could  be  sterilized 
from  ten  to  thirty  minutes  without  dis- 
integration. This  was  injected  in  20- 
gram  closes,  the  equivalent  of  100  heat 
units,  without  discomfort,  and  was  read- 
ily assimilated.  Reduced  to  a  formula 
the  author's  method  was  as  follows :  In 
the  morning  1000  grams  of  water  con- 
taining 2  grams  of  sodium  chloride,  35 
grams  of  grape  sugar,  and  15  grams  of 
peptone;  in  the  afternoon  the  same 
quantity  of  water,  sodium  chloride  and 
sugar,  and  5  to  10  grams  of  peptone. 
In  the  interval  between  these  two  injec- 
tions a  single  injection  of  20  to  100 
grams  of  olive-oil  was  injected.  By  this 
method  the  necessary  quantity  of  pro- 
teids  is  supplied  to  the  body  so  that  in 
such  conditions  as  peritonitis  and  perfo- 
ration of  the  stomach  and  intestine  suf- 
ficient nutriment  may  be  introduced  for 
as  long  a  period  as  ten  to  fourteen  days 
if  necessary.  Friedrich  (Fortschritte 
der  Medizin,  January  10,  1905). 

THYROID  AND  PANCREAS,  RELATION 
BETWEEN. 
The  author  experimented  on  dogs, 
producing  hyperthyroidism,  extirpation 
of  the  thyroid,  and  removal  of  the  pan- 
creas, then  examining  the  organs  histo- 
logically. His  conclusions  are  as  fol- 
lows: In  dogs  injected  with  thyroid  sub- 
stance, so  as  to  be  hyperthyroidized, 
there  were  destructive  lesions  in  the 
islands  of  Langerhans  in  the  pancreas. 
In  dogs  deprived  of  a  thyroid,  lesions  of 
the  pancreas  were  not  constant.  The  le- 
sions indicated  an  essential  nervous 
mechanism  for  the  pancreas.  In  dogs 
without  any  pancreas,  the  thyroid  showed 


184 


TUBERCULOSIS.    TYPHOID  FEVER. 


hypersecretion  and  increased  function. 
These  alterations  may  be  the  cause  of 
the  manifestation  of  symptoms  of  Base- 
dow's disease  in  diabetes.  Occasionally 
there  was  irritation  and  atrophy  of  the 
gland.  A  relation  between  the  thyroid 
and  pancreas  may  be  considered  demon- 
strated, and  a  vicarious  action  of  one 
for  the  other.  Alfonso  Pirera  (Giornale 
Internazionalle  delle  Scienze  Mediche, 
January  15,  1905;  from  Medical  Rec- 
ord, February  IS,  1905). 

TUBERCULOSIS,  ACID  SALTS  IN  BLOOD 
IN. 

The  writer  is  convinced  that  greater 
attention  should  be  paid  to  the  acid  salts 
in  the  organic  fluids  in  studying  tuber- 
culosis. Four  years  of  careful  research 
have  conclusively  demonstrated,  in  his 
opinion,  that  the  normal  organism  with 
its  standard  phosphatic  acidity  is  refrac- 
tory to  tuberculosis.  Hypoacidity  and 
deficiency  in  the  phosphates  are  the  pre- 
disposing causes  in  the  pretuberculous 
stages.  It  is  impossible  to  remove  this 
cause  and  to  protect  the  subject  against 
tuberculosis  by  raising  the  acidity  of  the 
proportion  of  phosphates  above  normal. 
If  the  patient  is  already  infected,  in- 
creasing the  proportion  of  phosphates 
and  raising  the  acidity  will  enable  him 
to  get  rid  of  the  tubercle  bacilli  and  to 
repair  the  lesions  if  not  too  far  advanced. 
The  bacilli  destroyed  in  their  haunts  are 
liable  to  cause  more  or  less  intoxication 
of  the  system,  and  this  intoxication  lim- 
its the  curative  powers  and  is  the  test  of 
the  gravity  of  the  morbid  process.  When 
there  is  only  a  slight  or  moderate  febrile 
reaction,  with  a  normal  or  hypernormal 
acidosis,  a  subject  with  pulmonary  tu- 
berculosis can  be  cured  easily,  no  matter 
how  apparently  extensive  the  lesions  may 
be. 


Treatment  to  increase  the  acidity  and 
phosphates  should  be  gradual  and  slow, 
with  very  small  doses  of  the  phosphates 
or  phosphoric  acid,  etc.,  gradually  accus- 
toming the  organism  to  the  struggle  be- 
fore it.  Forced  feeding  is  important, 
but  it  should  be  borne  in  mind  that  fats, 
starch,  sugar,  alcohol,  and  organic  acids 
produce  very  little  if  any  acid  and  no 
phosphate  ash. 

The  writer  gives  his  technique  for 
testing  the  acidity,  preferring  a  modified 
phenolphthalein  test  of  the  twenty-four- 
hour  urine.  He  states  that  the  blood- 
pressure,  and  also  the  secretion  of  hydro- 
chloric acid,  rise  and  fall  with  the  acido- 
sis. Tuberculous  subjects  are  invariably 
hypoacid  and  hypophosphatic.  By  in- 
creasing the  proportions  above  normal  in 
this  respect  the  organism  becomes  an 
unfavorable  medium  for  the  bacilli  and 
they  cease  to  proliferate.  This  allows 
the  organism  time  to  get  the  upper  hand. 
C.  Canter  (Revue  de  Medecine,  vol.  xxiv, 
No.  4;  from  Journal  of  the  American 
Medical  Association,  March  11,  1905). 


TYPHOID  FEVER,  CHLORIDE  AND  WATER 
EXCRETION  IN,  WITH  COPIOUS  DIU- 
RESIS. 

The  free  administration  of  water  to 
typhoid  patients  causes  a  large  polyuria, 
exceeding  three  liters  per  day  and  aver- 
aging over  five  liters.  On  isolated  days 
nine  liters  are  not  rarely  excreted.  The 
percentage  of  chlorides  and  the  total 
molecular  concentration  are  much  below 
normal,  while  the  daily  excretion  of 
total  dissolved  molecules  exceeds  that  of 
ordinary  typhoid  cases.  The  eliminating 
capacity  of  the  kidneys  is,  therefore,  not 
injured  in  typhoid  fever,  nor  by  a  pro- 
longed polyuria.  No  accumulation  of 
fluid  appears  to  Occur  in  the  body,  the 


URIC  ACID,  INFLUENCE  IN.    VICEROPTOSIS. 


185 


excretion  being  very  nearly  parallel  to 
the  income.  The  quantity  of  urine  is 
influenced  by  the  perspiration  and  to  a 
lesser  extent  by  catharsis.  It  appears 
probable  that  the  perspiration  is  freer 
under  the  influence  of  the  large  admin- 
istration of  fluid.  The  temperature  has 
no  direct  effect  on  the  diuresis.  Diu- 
retics do  not  increase  the  polyuria,  nor 
does  the  administration  of  calcium  chlo- 
ride appear  to  diminish  diuresis. 

The  effect  of  the  polyuria  on  the  chlo- 
ride excretion,  as  compared  with  ordi- 
nary typhoid  cases,  consists  in  a  diminu- 
tion of  the  percentage  and  an  increase  of 
the  amount  excreted  per  day.  Minor 
variations  in  diuresis  effect  the  percent- 
age, but  not  the  daily  output.  Perspira- 
tion acts  indirectly,  by  influencing  the 
diuresis.  The  course  of  the  fever,  the 
degree  of  hyperpyrexia,  and  the  conva- 
lescence appear  to  have  no  direct  effect. 

The  chloride  excretion  varies  strictly 
with  the  chloride  income.  The  effect  of 
calcium  chloride  is,  however,  delayed  and 
comparatively  small.  Agurin,  sodium 
acetate  and  nitrate,  and  uro'tropin  had 
no  effect  on  the  chloride  excretion,  but  it 
was  increased  by  iodide.  Moderate  ne- 
phritis was  without  effect. 

The  excretion  of  water  and  chlorides 
in  typhoid  fever  appears  to  obey  the  same 
laws  as  in  health.  There  is,  however,  a 
greater  tendency  to  chloride  retention  in 
the  fever.  The  difference  appears  to  be 
only  quantitative  and  not  qualitative.  It 
is  greatly  diminished  by  polyuria. 

The  prolonged  restriction  of  the  chlo- 
ride income  appears  to  produce  no  dele- 
terious effects,  and  the  patients  do  not 
develop  any  "salt  hunger."  Torald  Soll- 
mann  and  J.  A.  Hofmann  (American 
Journal  of  the  Medical  Sciences,  Feb- 
ruary, 1905). 


URIC  ACID:  ITS  INFLUENCE  IN  GOUT. 
The  writer  notes  the  great  variability 
in  the  amount  excreted  in  different  in- 
dividuals and  in  the  same  individual 
under  different  conditions  of  diet,  exer- 
cise, and  disease.  Uric  acid  in  the  urine 
may  be  exogenous,  from  foodstuffs,  or 
endogenous,  from  the  destruction  of  the 
body  cell.  It  may  exist  in  the  blood 
from  increased  production,  or  from  de- 
ficient elimination  and  oxidation.  De- 
ficient elimination  is  due  to  kidney  dis- 
ease, deficient  oxidation  to  disturbance 
of  liver,  kidneys,  or  other  glandular  or- 
gans, or  from  lack  of  muscular  activity. 
Garrod's  claim  of  an  excess  in  the  blood 
during  a  gouty  attack  has  been  proved 
erroneous.  If  uric  acid  were  toxic,  we 
would  expect  to  find  symptoms  from  it 
in  conditions  in  which  it  is  known  to  be 
excessive,  as  in  leukaemia,  pneumonia, 
chronic  nephritis,  etc.,  and  in  which  no 
symptoms  referable  to  it  are  ever  seen. 
The  same  is  true  of  cases  in  which  nu- 
clein  holding  food  was  fed  in  excess,  and 
the  uric  acid  output  largely  increased. 
Under  no  circumstances  have  uric  acid 
crystals  ever  been  found  postmortem  in 
the  tissues.  The  blood  is  never  satu- 
rated. It  has  been  proved  that  it  is  al- 
ways capable  of  taking  up  large  quan- 
tities. There  is  no  evidence  at  all  that 
it  causes  gout  or  any  other  disease.  C. 
C.  Ransom  (Medical  News,  March  11, 
1905). 

VISCEROPTOSIS. 

The  displacement  downward  of  any  of 
the  viscera  is  without  symptoms,  so  long 
as  the  patient  is  in  good  physical  condi- 
tion. The  disease  comes  to  notice  in 
association  with  neurasthenia,  and  no 
mechanical  replacement  can  cure  the 
neurasthenia.  On  the  other  hand,  a  cure 
of  the  neurasthenia  goes  far  to  make  a 


186 


WATER-DRINKING,  INFLUENCE  OF. 


symptomatic  cure  of  the  visceroptosis. 
Over  90  per  cent,  of  cases  of  neurasthe- 
nia in  the  female  depend  upon  viscerop- 
tosis. It  is  less  prevalent  in  male  neu- 
rasthenias. The  important  clinical  etio- 
logical factors  are  bad  standing  posture, 
badly  fitting  garments,  imperfect  use  of 
the  lower  zone  of  the  thorax,  the  absence 
of  fat,  and  the  want  of  tonicity  in  the 
abdominal  pressure.  The  symptoms, 
when  well  marked,  are  practically  those 
of  neurasthenia  with  or  without  direct 
.local  distress.  Some  form  of  gastric  dis- 
turbance is  the  one  usually  complained 
of.  Pain  may  be  felt  anywhere,  but  is 
most  frequently  referred  to  the  small  of 
the  back.  The  crisis  of  movable  kidney 
has  been  taken  for  appendicitis,  and  in- 
termittent hydronephrosis  for  ovarian 
tumor.  Gynaecologists  are  coming  to 
recognize  that  prolapse  and  displacement 
of  the  uterus  is  but  part  of  the  general 
visceroptosis.  There  is  usually  a  mild 
form  of  secondary  anaemia.  Presenility 
is  occasionally  found,  and  this  may  be 
attended  with  early  arteriosclerosis.  The 
most  constant  symptom  is  emaciation  or  - 
malnutrition.  The  skin  is  markedly 
free  from  fat,  and  devoid  of  elasticity. 
Dermography  is  a  stigma  of  the  disease. 
The  abdominal  musculature  is  flabby  and 
atrophied,  and  there  is  absence  of  the 
stomach  resonance  in  Traube's  semi- 
lunar space.  In  many  cases  the  tenth 
rib  floats. 

The  inflation  of  the  stomach  and  colon 
should  be  carried  out,  after  the  solid 
organs  have  been  palpated.  The  Weir 
Mitchell  treatment  when  applied  to  vis- 
ceroptosis is  curative,  stress  being  laid 
upon  the  following  features:  Eecumbent 
posture  in  bed,  if  possible  without  pil- 
lows, for  from  four  to -six  weeks.  Cool 
baths  before  massage  to  get  muscular 
relaxation.     General  massage,  with   an 


attempt  to  build  up  the  abdominal  wall. 
Eaiding  up  the  thorax,  so  as  to  expand 
its  lower  zone,  and  thus  make  room  for 
the  viscera.  Proper  feeding.  Training 
-  of  mind  and  body.  The  muscular  one  of 
the  levator  ani  in  bringing  the  pelvic 
viscera  to  their  normal  position.  The 
tone  of  this  muscle  is  largely  dependent 
upon  the  tonus  of  the  lower  half  of  the 
abdominal  wall.  H.  A.  McCallum  (Brit- 
ish Medical  Journal,  February  18, 1905). 

WATER-DRINKING,    INFLUENCE    OF. 

Copious  water  drinking  causes  an  in- 
creased excretion  of  nitrogen  and  phos- 
phorus by  the  urine.  The  increase  in 
the  amount  of  nitrogen  eliminated  Ls 
clue,  primarily,  to  the  washing  out  of 
the  tissues  of  the  urea  previously  formed, 
but  which  has  not  been  removed  in  the 
normal  processes,  and,  secondarily,  to  a 
stimulation  of  proteid  catabolism.  The 
increase  in  the  excretion  of  phosphorus 
is  due  to  increased  cellular  activity  and 
the  accompanying  catabolism  of  nu- 
cleins,  lecithins,  and  other  phosphorus- 
containing  bodies. 

In  man  an  increase  of  4500  cubic  cen- 
timeters in  the  daily  amount  of  water 
ingested,  after  the  organism  has  been 
brought  to  nitrogen  equilibrium  by 
means  of  constant  diet  fed  during  a 
preliminary  period  of  three  days,  caused 
an  increase  of  1.415  grams,  or  12.8  per 
cent.;  in  the  excretion  of  nitrogen  by 
the  urine  on  the  first  day,  and  the  some- 
what smaller  increase  of  0.755  gram,  or 
G.8  per  cent.,  upon  the  second  day. 
Therefore  the  total  influence  upon  the 
excretion  of  nitrogen  by  the  urine  pro- 
duced by- the  ingestion  of  9000  cubic 
centimeters  of  water  additional  in  a 
period  of  forty-eight  hours  was  to  cause 
an  increase  of  2.17  grams  during  that 
period.     This  was  aa  average  daily  in- 


WHOOPING-COUGH,  TREATMENT  OF. 


187 


crease  of  1.085  grams,  or  9.8  per  cent., 
above  the  normal  output. 

In  other  experiments  additions  of 
3100  cubic  centimeters  of  water  to  the 
constant  diet  caused  increases  in  the 
excretion  of  nitrogen  by  the  urine,  vary- 
ing from  0.83  gram,  or  5.9  per  cent., 
to  1.12  grams,  or  9.5  per  cent.,  for  the 
first  day,  and  from  0.38  gram,  or  2.7 
per  cent.,  to  0.78  gram,  or  6.6  per  cent., 
for  the  second  clay. 

The  course  of  the  S03  excretion,  while 
somewhat  irregular,  still  showed  a  gen- 
eral tendency  to  run  parallel  with  that 
of  nitrogen.  A  daily  addition  of  4500 
cubic  centimeters  of  water  for  a  period 
of  two  days  caused  an  increase  of  0.265 
gram,  or  15.6  per  cent.,  in  the  S03  ex- 
cretion by  the  urine  on  the  first  day,  and 
one  of  0.195  gram,  or  11.6  per  cent.,  on 
the  second  day.  When  the  amount  of 
water  added  daily  during  a  period  of 
forty-eight  hours  was  3100  cubic  centi- 
meters, the  increase  upon  the  first  day 
varied  from  0.205  gram,  or  10  per  cent., 
to  0.085  gram,  or  4.1  per  cent.  On  the 
second  day  there  was  an  increase  of 
0.128  gram,  or  6.2  per  cent.  In  one 
experiment  the  S03  excretion  was  de- 
creased on  the  days  in  which  3100  cubic 
centimeters  of  water  was  added  to  the 
diet,  the  decreases  varying  from  0.309 
gram,  or  20.9  per  cent.,  to  0.016  gram, 
or  0.81  per  cent.,  for  the  first  day,  and 
from  0.258  gram,  or  14.4  per  cent.,  to 
0.124  gram,  or  6.3  per  cent.,  for  the 
second  day. 

The  course  of  the  P205  excretion,  as 
influenced  by  copious  water  drinking, 
w;is  distinctly  different  from  that  of 
nitrogen  or  SO;i.  In  every  instance  the 
excretion  of  P20B  was  increased  above 
the  normal  on  each  day  of  the  water 
period,  the  maximum  excretion  occur- 
ring, with   absolute  regularity,   on   the 


second  day  of  the  increased  water  inges- 
tion. A  daily  addition  of  4500  cubic 
centimeters  of  water,  for  a  period  of 
forty-eight  hours,  caused  an  increase  of 
0.22  gram,  or  9.4  per  cent.,  upon  the 
first  day,  and  one  of  0.4  gram,  or  17.1 
per  cent.,  upon  the  second  day.  An  ad- 
dition of  3100  cubic  centimeters  of  water 
under  similar  conditions  caused  increases 
in  the  excretion  of  P205  by  the  urine 
varying  from  0.011  gram,  or  0.43  per 
cent.,  to  0.238  gram,  or  10.6  per  cent., 
for  the  first  day,  and  from  0.096  gram, 
or  3.7  per  cent.,  to  0.459  gram,  or  20.5 
per  cent.,  for  the  second  day. 

There  was  a  constant  tendency  for  the 
largest  percentage  of  the  ingested  fluid 
to  be  excreted  by  the  urine  on  the  days 
of  copious  water  drinking.  This  was 
indicated  by  an  elimination  of  28.5  per 
cent,  on  an  ingestion  of  2300  cubic  cen- 
timeters of  fluid,  as  compared  with  an 
elimination  of  90.6  per  cent,  on  an  in- 
gestion of  6400  cubic  centimeters  of 
fluid.  P.  B.  Hawk  (University  of  Penn- 
sylvania Medical  Bulletin,  March,  1905). 

WHOOPING-COUGH,  TREATMENT  OF. 

Excellent,  results  are  reported  by  the 
author  from  the  use  of  fluoroform  in 
whooping-cough.  As  a  rule,  the  disease 
lasts  about  thirty-five  days,  but  with  this 
drug  the  duration  was  reduced  to  eigh- 
teen. Another  advantage  is  that  even 
very  young  infants  show  no  bad  after- 
effects. The  solution  generally  employed 
contains  2  to  2  1/2  per  cent,  fluoroform 
dissolved  in  water.  Very  young  infants 
receive  two  teaspoonfuls  every  hour, 
while  older  children  may  take  as  much 
as  a  tablespoonful.  The  treatment 
should  be  continued  for  three  to  four 
weeks.  H.  Stepp  (Therapeutische 
M"iiatschrift,   November,   1901). 


188 


X-RAYS.     ZINC  CHLORIDE.     BOOK  REVIEWS. 


X-RAYS,  DANGERS  OF  THE. 

The  writer  has  made  use  of  the  fol- 
lowing expedients  to  avoid  the  injuries 
which  may  attend  x-ray  practice:  Every 
patient  is  placed  in  a  recumbent  position 
on  the  operating  table,  no  matter  where 
the  lesion  may  be  located,  and  is  pro- 
tected with  sheets  of  lead  foil.  A  sepa- 
rate mask  is  supplied  for  each  patient, 
with  an  aperture  which  permits  only  the 
exposure  of  the  lesion.  This  protects 
the  patient  from  injury  when  unavoid- 
able movements  are  made.  The  exposures 
are  of  a  definite  potency  in  accordance 
with  the  author's  method  of  radiometry. 
The  potency  is  small  at  the  beginning, 
and  is  gradually  increased  to  the  desired 
point.  With  regard  to  the  operator,  the 
added  aggravation  of  developing  solu- 
tions should  be  obviated  by  the  use  of 
rubber  gloves.  The  physiological  effects 
of  the  x-rays  are  now  so  reasonably  cer- 
tain that  untoward  effects  ought  not  to 
be  expected  in  the  hands  of  competent 
operators.  With  the  general  adoption  of 
the  radiometric  technics  described  by  the 
author  the  last  and  greatest  danger  of 


the  x-rays  will  have  been  eliminated. 
Milton  Franklin  (Archives  of  the  Roent- 
gen Ray,  January,  1905). 

ZINC   CHLORIDE,   CAUTERIZATION  BY. 

The  action  of  this  drug  on  wounds  as 
a  protective  against  infection  has  been 
studied  by  the  author.  His  experiments 
were  conducted  on  rabbits  and  on  the 
bacteria  themselves.  It  was  found  that 
even  in  concentrated  solutions  the  zinc 
chloride  was  devoid  of ,  antiseptic  prop- 
erties, but  that  the  eschar  which  resulted 
when  brought  into  contact  with  aseptic 
wound  surfaces  prevented  subsequent 
infection.  The  penetrating  powers  of 
this  substance  are  so  marked  that  it  pro- 
tects the  wound  even  when  applied  a  fuil 
minute  after  the  application  of  the  in- 
fectious agent.  The  slough  produced  is 
not  a  culture  medium,  for  bacteria  and 
other  pathogenic  organisms  cannot  be 
recovered  from  it  for  two  or  three  days 
after  they  have  been  applied.  L.  Brose 
(Deutsche  medicinische  Wochenschrift, 
December  22,  1904). 


ljook  Reviews. 


Lectures  to  General  Practitioners  on  Diseases  of  the  Stomach  and  Intestines.    By 
Boardman  Reed,  M.D.,  New  York:   E.  B.  Treat  &  Co.,   1904.     $5.00. 

Dr.  Reed  has  presented  an  exhaustive  book  of  over  1000  pages  upon  the  subject  of 
"Diseases  of  the  Stomach  and  Intestines,"  almost  encyclopaedic  in  character. 

The  volume  is  in  the  form  of  a  series  of  lectures  to  general  practitioners.  The  arrange- 
ment is  much  to  be  commended — a  systematic  presentation  of  elementary  subjects  and 
diseases  with  treatment.  Part  I  contains  anatomic,  physiologic,  chemic  and  diagnostic  feat- 
ures; Part  II,  methods  of  examination  in  which  little  is  omitted  now  recognized  as  being  of 
utility,  including  special  urinalyses,  the  examination  of  faeces  and  the  blood,  concluding  with 
a  systematic  guide  to  diagnosis. 

Part  III,  methods  of  treat  merit  are  most  carefully  presented.  In  glancing  over  this  most 
exhaustive  part  of  the  book  it  is  diflicult  to  see  how  anyone  can  escape  cure  with  such  an 
array  of  scientific  and  practical  measures  for  relief.  In  this  department  alone  there  are 
sixteen  lectures,  each  taking  up  a  different  form  of  treatment  in  exhaustive  outline. 

The  special  feature  of  the  book  is  Part  IV,  "The  Gastrointestinal  Clinic,"  beginning  with 
the  classification  of  diseases,  the  various  manifestations,  phenomena  of  derangement,  sympto- 
matology, disturbances  of  the  visceral  inter-relationships,  the  ptoses,  secretory  derangements, 
ulcers  and  erosions,  the  relationship  of  tuberculosis  and  malignancy;    their  differentiation, 


BOOK  REVIEWS.  189 

intestinal  obstruction,  appendicitis,  and  a  series  of  lectures  upon  functional  derangements, 
including  a  full  consideration  of  the  underlying  causes,  infectious,  neurotic,  secretory,  motor, 
and  psychic  defects,  and  diseases  of  the  rectum  and  anus;  bacteria,  animal  parasites  and  the 
relations  of  gastro-intestinal  conditions  to  other  diseases;  and  finally,  a  summary  of  the 
surgery  of  the  stomach  and  intestines. 

Dr.  Reed  forestalls  criticism  in  respect  to  completeness,  omitting  little  which  might  be 
needed  by  the  general  practitioner  or  specialist.  His  views  differ  little  from  those  current 
and  even  where  he  may  differ  in  his  conclusions  from  those  of  his  readers,  he  gives  good  ground 
for  the  faith  that  is  within  him  by  ample  references  to  authorities.  His  own  experience  is 
large  and  varied. 

Judging  the  book  from  the  standpoint  of  a  general  practitioner,  it  can  be  pronounced  one 
of  much  value  as  a  work  of  reference.  Practical  hints  appear  on  every  page.  It  would  take 
too  long  to  compare  Dr.  Reed's  views  on  certain  detail  points  with  those  of  others,  but  re- 
presents fairly  well  current  thought  and  opinion.  Of  especial  value  may  be  noted  chapter 
fifteen,  "A  Symptomatic  Guide  to  Diagnosis,"  and  "General  Consideration  on  Diet."  The  index 
is  ample  and  clear;    illustrations  are  good  and  helpful. 

The  book  can  be  safely  commended,  and  from  it  much  can  be  learned  necessary  to  a  full 
understanding  of  this  large  and  troublesome  class  of  derangements  and  diseases. — J.  M.  T. 

Saunders'  Question  Compends  :  Essentials  of  the  Practice  of  Medicine.  By  William 
R.  Williams,  M.D.  Philadelphia :     W.  B.  Saunders  &  Co.,  1905.     $1.75 

This  is  the  last  published  of  Saunders'  Question  Compend  Series,  designed  for  the  use  of 
the  medical  student.  The  practitioner  will  find  in  it  little  of  interest,  except  that  it  is  of 
distinct  value  now  and  again  for  anyone  to  systematize  his  mind  by  reading  a  condensed 
volume  such  as  this,  if  for  no  other  reason  than  to  get  a  perspective  upon  a  large  and  intricate 
subject. 

The  table  of  contents  shows  that  the  book  is  very  comprehensive,  including  most  of  the 
points  in  medical  practice  with  which  it  is  reasonable  to  expect  the  undergraduate  to  be 
familiar.  The  subjects  presented  are  so  extremely  condensed  as  to  be  almost  a  mere  catalogue 
of  salient  points.  This  renders  it  essential  that  it  be  accompanied  by  some  fuller  knowledge, 
such  as  previous  teaching,  or  the  use  of  an  ample  text-book.  The  arrangement  of  the  subjects 
lias  much  to  commend  it,  but  if  aboiit  twice  as  large,  it  would  be  more  useful  for  most  readers. 

The  reviewer  has  taken  pains  to  read  the  book  quite  extensively,  and  is  struck  with  the 
excellent  system  and  completeness  of  the  essential  points  touched  upon;  hence  it  will  prove 
of  much  practical  value  to  the  undergraduate,  as  others  of  this  series  are  known 
to  be.— J.  M.  T. 

Disease  and  Marriage:  The  Relationship  Between  Disturbances  of  Health  and 
The  Marriage  State.  Edited  by  Prof.  H.  Senator  and  S.  Kaminer,  in  association  with 
Drs.  G.  Abelsdorff,  L.  Blumreich,  E.  Eberstabt,  A.  Eulenburg,  C.  Ewald,  P.  Furbringer,  M. 
Gruber,  W.  Havelburg,  A.  Hoffa,  F.  Jolly.  E.  V.  Leyden,  A.  Moll,  A.  Neisser,  J.  Orth, 
S.  Plazzek,  C.  Posner,  P.  S.  Richter,  II.  Rosin,  W.  Wolff.  Part  III.  596  Pages.  New 
York:     Rebman  Company.     London:     Rebman,  Limited. 

With  the  exception  of  syphilis  and  gonorrhoea,,  comparatively  little  has  been  written  on 
the  influence  of  disease  of  the  genitalia  and  of  constitutional  diseases  upon  married  life.  It 
is  true  a  few  scattered  articles  have  appeared  in  literature.  These,  however,  have  been 
limited  mainly  to  the  diseases  purely  venereal.  Not  until  recent  years  has  any  systematic 
attempt  been  made  to  present  an  exhaustive  scientific  exposition  of  this  subject,  so  shame- 
fully neglected,  and  yet  of  greatest  importance  to  the  welfare  of  society.  The  publication 
of  "Disease  and  Marriage"  at  this  time  is  opportune,  the  more  enlightened  classes  are  beginning 
to  realize  that  excepting  alcoholism,  disease  causes  more  unhappiness  and  breeds  more  dis- 
content in  married  life  than  all  other  factors  taken  together.  In  America  a  few  attempts 
have  been  made  to  legislate  against  intermarriage  of  those  physically  unfit,  but  these  attempts 
have  been  too  rare  and  feeble  to  accomplish  much  result.  A  book  presenting  true  and 
accurate  information  may  become  a  powerful  factor  of  good,  by  forcing  upon  physicians  a 
realization  of  their  responsibility  to  humanity  and  posterity,  and  by  encouraging  the  passage 


190  BOOKS  AND  MONOGRAPHS  RECEIVED. 

of  laws  to  control  the  marriage  of  diseased  persons.     The  reviewer  believes  that  such  a  book 
is  now  supplied.     It  is  a  symposium  on  all  diseases  which  influence  the  marriage  state  before 
and  after.     It  includes  the  relation  of  marriage  to  gonorrhoea,  malignant  and  non-malignant 
disease  of  the  genitalia,  injuries  to  the  genital  organs,  gynwecologic  conditions,   alcoholism, 
morphinism,  nervous  diseases,  insanity,  the  influence  of  occupation  upon  conception,  sexual 
perversion,  psychical  impotence,  the  ethical  behavior  of  a  physician  toward  his  patients  being 
treated  for  venereal  diseases,  and  the  social  and  political  significance  of  marriage.    The  various 
sections  of  the  book  are  in  charge  of  twelve  sub-editors,  carefully  selected,  all  authorities  on 
their  respective   branches.     The  manner  of  presentation  is   satisfactory;    the  facts  are  given 
completely  and  concisely.     Some  of  the  minor  diseases,  like  the  less  important  skin  affections, 
are  mentioned  only  to  show  how  they  influence  marriage,  while  the  more  important  diseases, 
including  syphilis,  gonorrhoea,  malignant  growths,  insanity  and  nervous  affection,  are  treated 
in  greater  detail.     In  the  case  of  the  first  three  diseases  much  stress  is  laid  upon  the  im- 
portance of  a  proper  diagnois,  and  after  this  the  physician  should  insist  on  patients  following 
out  instructions  before  entering  matrimony.     Full  statistics  are  presented  to  corroborate  the 
conclusion  which    the   various   authors   formed   from   their   own   observation   and   experience. 
Much   valuable    information    may    be   gleaned    from    these    statistics.      For    instance,    in   the. 
chapter  on  the  "Influence  of  Carcinoma  .on  Marriage,"  six  cases  are  reported,  in  all  of  which 
cancer  was   contracted  during  cohabitation,   and   transmitted   from   the   male  to   the   female 
sexual   organs,   and  rice  versa.     Strong  arguments  for  the  infectiousness   of   cancer!      Each 
disease  is  treated  in  so  thorough  a   manner  that  it  is  difficult  in  so  short  a   space  to  give 
the  work  full  credit.    The  contagiousness  of  each  affection  is  discussed  at  length;    the  various 
forms  it  assumes,  the  prognosis  as  to  cure  and  as  to  the  advisability  of  marriage,  and  the 
probability  of  transmission  to  the  offspring.     The  relation  of  the  different  forms  of  insanity, 
including  the  discussion  of  the  advisability  of  marriage  when  other  members  of  the  family 
of  either  of  the  parties  are  insane,  and  the  laws  governing  divorce  where  insanity  develops 
in  the  wife  or  the  husband  are  given  in  chapter  xxii.     Sixty-two  pages  are  devoted  to  the 
relationship  of  sexual  perversion  and  psychical  impotence  to  marriage.     This  chapter  includes 
startling  information, , novel  to  all  who  have  not  made  the  subject  a  special  study,  including 
the  injurious  methods  resorted  to  by  both  sexes  while  gratifying  their  sexual  desires;    and 
also  includes  an  account  of  hermaphrodism  and  pseudo-hermaphrodism. 

In  chapter  xxiv,  the  influence  of  alcoholism  and  morphinism  upon  marriage,  and  the  evils 
resulting,  are  discussed  as  well  as  divorce  where  cases  are  incurable;  in  chapter  xxv,  disturb- 
ances of  marriage  and  conception  brought  about  by  occupation,  as  seen  in  factory  girls, 
workers  in  lead  and  phosphorus,  etc. ;  also  a  copy  of  the  German  laws  regulating  the  amount 
of  time  women  may  be  employed  at  unhealthy  occupations.  In  chapter  xxvi,  professional 
secrecy  and  medical  jurisprudance,  as  related  to  matrimony,  receive  attention.  Chapter  xxvii, 
deals  with  the  social  and  political  significance  of  marriage  under  sanitary  conditions.  Every 
physician  ought  to  become  thoroughly  acquainted  with  the  contents  of  this  book;  it  is  to  be 
regretted  that  they  have  not  accorded  this  subject  the  attention  it  deserves,  and  if  this  book 
can  convince  them  of  their  responsibility  in  urging  patients  contemplating  marriage  to 
postpone  doing  so  until  physically  sound,  it  will  do  much  for  the  alleviation  of  human  misery. 
This  book  is  printed  with  clear,  legible  type,  on  good  paper.  Notes  in  the  margin  of 
each  page  indicate  the  subject  under  discussion.  A  full  and  complete  index  is  appended,  and 
all  authors  referred  to  are  given  credit.— W.  E.  R. 

f}ool<s  and  /Vlonographs  Received. 

The   editor   begs   to   acknowledge,   with    thanks,   the   receipt   of   the    following   books   and 

monographs:  — 

Lectures  to  General  Practitioners  Oil  Diseases  of  the  Stomach  and  Intestines.  By  Board- 
man  Reed.  M.D..  Philadelphia.  E.  B.  Treat  &  Co.,  New  York.  1904.  Price  $5.00.— Saunders' 
Question  Compends:     Essentials  of  the  Practice  of  Medicine.     By  Willianj  R.  Williams,  M.D. 

W.    15.    Saunders   &   Co.,   Philadelphia.      1905.     Price   $1.75. Disease    and   Marriage:      The 

Relationship  between  Disturbances  of  Health  and  the  Marriage  State.    Part  III.    596  pages. 


BOOKS  AND  MONOGRAPHS  RECEIVED.  191 

Rebman    Company,    New    York. Conservative    Gynaecology    and    Electrotherapeutics.      A 

Practical  Treatise  on  the  Diseases  of  Women  and  Their  Treatment  by  Electricity.  By  G. 
Betton  Massey,  M.D..,  Philadelphia.  Fourth  Edition,  Revised,  Rewritten,  and  Greatly  Enlarged. 
Illustrated  with  Twelve  (12)  Original,  Full-Page  Chromodithographic  Plates;  Twelve  (12) 
Full  Page  Half-tone  Plates  of  Photographs  taken  from  Nature,  and  157  Half-tone  and  Photo- 
engravings in  the  Text.    Pages  XVI-468.     RoyaJ  Octavo.    Extra  Cloth,  Beveled  Edges.     Price, 

$4.00,  net.     F.  A.   Davis   Company,   Publishers,    1914-16   Cherry   Street,   Philadelphia. Eye, 

Ear,  Nose,  and  Throat  Nursing.  By  A.  Edward  Davis,  A.M.,  M.D.,  New  York,  and  Beainan 
Douglass,  M.D.,  New  York.  With  32  Illustrations.  Pages  XVI-318.  Size,  5  '/,  x  7  78  inches. 
Extra   Cloth.      Price,   $1.25,   net.      F.   A.   Davis   Company,   Publishers,    1014-10    Cherry    Street, 

Philadelphia. Studies  in  the  Psychology  of  Sex— Sexual  Selection  in  Man.     I,  Touch;    II, 

Smell;  III,  Hearing;  I\\  Vision.  By  Havelock  Ellis.  6  78  x  8  7A  inches.  Pages  XII-270. 
Extra  Cloth,  $2.00,  net.     Sold  only  by  Subscription  to  Physicians,  Lawyers,  and   Scientists. 

F.  A.  Davis  Company,  Publishers,  1914-10  Cherry  Street,  Philadelphia, Annual  Reports  of 

the  Department  of  Agriculture  for  the  Fiscal  Year  ended  June  30,  1904.  Washington,  D.  C, 
1904. Ostitis  Deformans.  By  DeForest  Willard,  M.D.,  and  W.  H.  Andrus,  M.D.,  Philadel- 
phia, 1904. Empyema.     By  DeForest  Willard,  M.D.,  Philadelphia,   1904. Old  Unreduced 

Dislocations.      By   DeForest   Willard,    Philadephia,    1904. Knee    Ankylosis.      By    DeForest 

Willard,  Philadelphia,  1905. Some  Aspects  of  Medical  Education.  John  H.  Musser,  Phila- 
delphia, 1904. Abdominal  Pain.  By  J.  H.  Musser,  Philadelphia,  1904. DeWeckers  Cap- 
sular Advancement  Operation.  By  William  Campbell  Posey,  Philadelphia,  1899. Asso- 
ciated Movements  of  Head  and  Eyes.  By  William  Campbell  Posey,  Philadelphia,  1902.— 
Vernal  Conjunctivitis.  By  William  Campbell  Posey,  Philadelphia,  1903. Unilateral  Ex- 
ophthalmos in  Exophthalmic  Goiter,  with  Report  of  a  Case.  By  William  Campbell  Posey 
and  W.  C.  Swindells,  Philadelphia,  1904. A  Case  of  Intense  Phlegmon  of  the  Orbit,  Sec- 
ondary to  Empyema  of  the  Ethmoidal  Cells.    By  William  Campbell  Posey,  Philadelphia,  1903. 

Prosthetic  Surgery,  with  Report  of  a  Case,  Illustrative.     Flavel  B.  Tiffany,  Kansas  City, 

.  Mo.,  1905. Middle  Ear  Disease  in  Tuberculosis.     By  Robert  Levy,  Denver,  Colo.,  1903. 

The  Prognosis   of  Laryngeal  Tuberculosis.     By  Robert  Levy,  Denver,  Colo.,   1904. Report 

of  a  Case  of  the  Invasion  of  a  Fibromyoma  of  the  Uterus  by  an  Adenocarcinoma,  Which  by 
Metaplasia  Had  Assumed   the  Appearance   of  a   Squamous   Cell   Carcinoma.     By   Charles  P. 

Noble,  Philadelphia,  1904. The  Nature  of  the  Indications  for  Operation  for  Fibroid  Tumors 

of  the  Uterus.     By  Charles  P.   Noble,  Philadelphia,   1904. Fourth  Annual   Report   of   the 

Committee  of  Inspection  Appointed  by  the  Executive  Committee  of  the  Post-Graduate  Med- 
ical  School  to  Review  the  Work  of  Dr.  John  F.  Russell  in  the  Treatment  of  Pulmonary  Tu- 
berculosis at  the  Post-Graduate  Hospital,  for  the  year   1904-1905. Beneficial  Bacteria  for 

Leguminous  Crops.  By  George  T.  Moore  and  T.  R.  Robinson,  United  States  Department  of 
Agriculture,  Washington,  D.  G,  1905.— The  Prickly  Pear  and  Oilier  Cacti  as  Food  for 
Stock.      By   David    Griffiths,    United    States   Department    of   Agriculture,    Washington,   D.    C, 

1905. Injury  to  Vegetation  by  Smelter  Fumes.     By  J.  K.  Haywood,  United  States  Depart 

ment  of  Agriculture,  Washington,  D.  C,  1905. The  Development  of  Single-Germ  Meet   Seed. 

By  O.  O.  Townsend  and  E.  C.  Rittue,  United  States  Department  of  Agriculture,  Washington. 

1).    ('.,    1905. Raspberries.      By   L.    C.    Corbett,    United    States    Department   of   Agriculture, 

Washington,  I).  C,  1905. Essential  Steps  in  Securing  an  Early  Crop  of  Cotton.     Bj    R.  J. 

Redding,  United  States  Department  of  Agriculture,  Washington,  I).  C,  1905. —  The  Control 
of  the   l'.oll   Weevil,  Including   Results   of   Recent   Investigations.     By  W.  D.   Hunter.   United 

States  Department    ,,f  Agriculture,  Washington,   1).  C,  1905. The  Greenhouse  White  Fly. 

By  A.  W.  Morrill,  United  Stales   Departmenl    of  Agriculture,  Washington,  D.  C,   1905. 

What    Forestry    Means   to    Representative    Men.     United  States  Departmenl   of  Agriculture, 

Washington,  D.  C,  1905. Report  of  the  Editor  for  1901.     By  George  William   Hill.     United 

States  Departmenl  of  Agriculure,  Washington,  D.  C  1904.-  The  Cotton  Boll  Worm:  Some 
Observations  and  Results  of  Field  Experiments  in  1904.  By  A.  L.  Quaintance  and  F.  C. 
Bishop]).      United    States    Department    of    Agriculture,    Washington,    D.    ('.,    19(1."..  Standard 

of  Purity  for  Food  Products.  United  states  Department  of  Agriculture,  Washington,  D.  C, 
1904. 


EDITORIAL  STAFF. 

Sajous's  Analytical  Cyclopaedia  of   Practical  Medicine. 


J.  GEORGE  ADAMI,  M.D., 

MONTREAL,  P.  «. 

LEWIS  H.  ADLER,  M.D., 
PHILADELPHIA. 

JAMES  M.  ANDERS,  M.D.,  LL.D., 
PHILADELPHIA. 

THOMAS  G.  ASHTON,  M.D., 

PHILADELPHIA. 

A.  D.  BLACKADER,  M.D., 

MONTREAL,  P.  Q. 

E.  D.  BONDURANT,  M.D., 

MOBILE,  ALA. 

DAVID  BOVAIRD,  M.D., 

NEW  YORK  CITT. 

WILLIAM  BROWNING,  M.D., 

BROOKLYN,  N.  Y. 

WILLIAM  T.  BULL,  M.D., 
HEW  YORK  CITY. 

CHARLES  W.  BURR,  M.D., 

PHILADELPHIA. 

HENRY  T.  BYFORD,  M.D., 
CHICAGO,  ILL. 

HENRY  W.  CATTELL,  M.D., 

PHILADELPHIA. 

WILLIAM  B   COLEY.  M.D., 
NEW  YORK  CITY. 

FLOYD  M.  CRANDALL,  M.D., 

NEW  YORK  CITY. 

ANDREW  F.  CURRIER,  M.D., 

NEW  YORK  CITY. 

ERNEST  W.  CUSHING,  M.D., 
BOSTON,  MASS. 

GWILYM  G.  DAVIS,  M.D., 

PHILADELPHIA. 

N.  8.  DAVIS,  M.D., 
CHICAGO,  ILL. 

AUGUSTUS  A.  ESHNER,  M.D., 

PHILADELPHIA. 

8IM0N  FLEXNER,  M.D., 

PHILADELPHIA. 

LEONARD  FREEMAN,  M.D„ 
DENVER,  COL. 

6.  O.  GANT,  M.D., 
NEW  YORK  CITY. 

J.  MoFADDEN  GASTON,  Sr.,  M.D., 

ATLANTA,  GA. 

J.  McFADDEN  GASTON,  Jr.,  M.D., 

ATLANTA,  GA. 

E.  B.  GLEASON,  M.D., 

PHILADELPHIA. 

EGBERT  H.  GRAN  DIN,  M.D., 
NEW  YORK  CITY. 


ASSOCIATE,  EDITORS. 

J.  P.  CROZER  GRIFFITH,  M.D., 

PHILADELPHIA. 


C.  M.  HAY,  M.D., 
PHILADELPHIA. 

FREDERICK  P.  HENRY,  M.D., 

PHILADELPHIA. 

L.  EMMETT  HOLT,  M.D., 

NEW  YORK  CITY. 

EDWARD  JACKSON,  M.D., 
DENVER,  COL. 

W.  W.  KEEN,  M.D., 

PHILADELPHIA. 

EDWARD  L.  KEYES,  Jr.,  M.D., 
NEW  YORK  CITY. 

ELWOOD  R.  KIRBY,  M.D., 

PHILADELPHIA. 

L.  E.  La  FETRA.  M.D., 

NEW  YORK  CITY. 

ERNEST  LAPLACE,  M.D.,  LL.D., 

PHILADELPHIA. 

R.  LEPINE,  M.D.,      . 
LYONS,  FRANCE. 

F.  LEVISON,  M.D., 

COPENHAGEN,  DENMARK. 

A.  LUTAUD,  M.D., 
PARIS,  FRANCE. 

G.  FRANK  LYDSTON,  M.D., 
CHICAGO,  ILL. 

F.  W.  MARLOW,  M.D.. 

SYRACUSE,  N.  Y. 

SIMON  MARX,  M.D., 
NEW  YORK  CITY. 

ALEXANDER  McPUEDRAN,  M.D., 
TORONTO,  ONT. 

E.  E.  MONTGOMERY,  M.D., 

PHILADELPHIA. 

HOLGER  MYGIND,  M.D., 

Copenhagen,  Denmark. 

W.  P.  NORTHRUP,  M.D., 
NEW  YORK  CITY. 

BUPERT  NORTON,  M.D., 
WASHINGTON,  D.  0. 

H.  OBERSTEINER,  M.D., 

VIENNA,  AUSTRIA. 

CHARLES  A.  OLIVER,  M.D., 

PHILADELPHIA. 

WILLIAM  OSLER.  M.D., 
BALTIMORE,  SID. 

LEWIS  S.  PILCHER.  M.D.,      " 

BROOKLYN, N.   Y 

WILLIAM  CAMPBELL  POSEY.  M.D., 

PHILADELPHIA. 


W.  B.  PRITCHARD.  M.D., 
NEW  YORK  CITY. 


JAMES  J.  PUTNAM,  M.D., 
BOSTON. 

B.  ALEXANDER  RANDALL,  M.D., 

PHILADELPHIA. 

CLARENCE  C.  RICE,  M.D., 
NEW  YORK  CITY. 

ALFRED  RUBINO,  M.D., 

NAPLES,  ITALY. 

REGINALD  H.  SAYRE,  M.D., 

NEW  YORK  CITY. 

JACOB  E.  SCHADLE,  M.D., 

ST.  PAUL,  MINN. 

JOHN  B.  SHOBER,  M.D., 

PHILADELPHIA. 

J.  SOLIS-COHEN,  M.D., 

PHILADELPHIA. 

SOLOMON  SOLIS-COHEN,  M.D., 

PHILADELPHIA. 

H.  W.  STELWAGON,  M.D., 
PHILADELPHIA. 

D.  D.  STEWART,  M.D., 
PHILADELPHIA. 

LEWIS  A.  STIMSON,  M.D., 
NEW  YORK  CITY. 

J.  EDWARD  STUBBERT,  M.D., 

LIBERTY,  N.  Y. 

A.  E.  TAYLOR,  M.D., 

SAN  FRANCISCO,  CAL. 

J.  MADISON  TAYLOR,  M.D, 
PHILADELPHIA. 

M.  B.  TINKER,  M.D., 

PHILADELPHIA. 

CHARLES  S.  TURNBULL,  M.D., 
PHILADELPHIA. 

HERMAN  F.  VICKERY,  M.D., 

BOSTON,  MASS. 

F.  E.  WAXHAM,  M.D., 

DENVER,    COL. 

J.  WILLIAM  WHITE,  M.D., 
PHILADELPHIA. 

JAMES  C.  WILSON,  M.D„ 
PHILADELPHIA. 

C.  SUMNER  WITHERSTINE,  M.D, 

PHILADELPHIA. 


ALFRED  C.  WOOD,  M.D., 

PHILADELPHIA. 


WALTER  WYMAN,  M.D, 

WASHINGTON,  D.  C. 


[End  of  the  Editorial  Department  of  the; Monthly  Cyclopaedia  for  April  1905.] 


THE    MONTHLY   CYCLOPEDIA 

OF 

PRACTICAL   MEDICINE 


(Published  the  Last  of  Each  Month) 


Vol.  XVIII. 
Old  Series. 


PHILADELPHIA,  MAY,  1905. 


Vol.  VIII,  No.  5. 
New  Series. 


TABLE  OF  CONTENTS. 


PAGE 

EDITORIALS 

PSYCHOLOGICAL  MEDICINE. 
Joseph  Jastrow 193 

THE  SIGNIFICANCE  OF  SO-CALLED 
"OCCULT  HEMORRHAGES  ' 
IN  DIAGNOSIS  OF  CERTAIN 
GASTRIC  AFFECTIONS.  Julius 
Friedenwald 199 

SUDDEN  DEATH.  William  S.  Wads- 
worth  201 

REMARKS  ON  THE  TREATMENT  OF 
PARALYSIS  AGITANS  AND 
CERTAIN  FORMS  OF  CHRONIC 
ACQUIRED  TREMOR.  J.  Madi- 
son Taylor 205 

CYCLOPEDIA    OF    CURRENT 
LITERATURE 

AGGLUTINATION  TESTS,  SOME 

FALLACIES  IN.     Oskar  Klotz....  208 
AIR  IN  VEINS  DURING    SURGICAL 

OPERATIONS.    Deloreaud  Duteil  209 
ALCOHOL:    LOCAL    THERAPY. 

K.  Walko 210 

APPENDICITIS,  METHOD  OP  OPEN- 
ING ABDOMEN  IN.  F.B.Har- 
rington    210 

APPENDICITIS,      MORTALITY      OF. 

C.  W.  Barrett 211 

ISEPTIO    OPERATING,    POINTS    IN 

THE    TECHNIQUE    OF.       H.    T. 

Byford 211 

BILE  DUCT  DISEA8E.     J.G.Mumford  212 
CACHEXIAL    FEVER,     THE    LEUCO- 

PENIA  OF.     Leonard  Rogers 2I3 

CANCER      IN      AND      ABOUT      THE 

MOUTH.     II.  A.  Lothrop  and  D. 

D   Scannell 213 

CANCER,    NATURAL    HISTORY   OF. 

W.  A.  Freund 214 

CANCER,   THE    GROWTH   OF.     E.  F. 

Bashford 215 


PAGE 

CEREBR0-8PINAL    FEVER.      C.  G. 

Stockton 215 

CEREBROSPINAL  MENINGITIS.    G. 

G.  Speer 216 

CHEST,    NEW   PHYSICAL   SIGNS   IN 

DISEA8E8    OF.     A.  Grober 216 

DERMATOLOGY,  SOME  NEW  THER- 
APEUTIC MEA8URES  IN.  Mal- 
colm Morris 217 

DIABETES,   ETIOLOGY    OF.     J.  II.  J. 

Upham 217 

DIPSOMANIAC  PHASES.    T.H.Evans  218 

EPILEP8Y,    PROGNOSIS    OF.      W.  A. 

Turner 219 

GALL-STONE    DISEASE.      W.  J.  and 

C.  H.  Mayo 220 

GASTRIC  HEMORRHAGE,  TREAT- 
MENT OF.     F.  G.  Connell 221 

GASTRIC  SECRETION,  INFLUENCE 
OF  SODIUM  CHLORIDE  SOLU- 
TIONS ON.     P.  Caseiani 222 

HJEM0PTY8IS,  TREATMENT  OF.    H. 

Hochhaus 222 

HEMORRHOIDS.  SURGICAL  TREAT- 
MENT OF.     Charles  McBurney...  223 

HERNIA,  RADICAL  CURE  OF.    Polya  223 

INTESTINAL  AMEBIASIS,  TROPI- 
CAL.    W.  E.  Musgrave 224 

INTESTINAL      BUTTON;     SOLUBLE. 

P.  Paterson 224 

INTESTINAL  OBSTRUCTION  AFTER 
SUPPURATIVE  APPENDICITIS. 
Fe'lermann 225 

INTUSSUSCEPTION    IN    CHILDREN. 

Fagge 225 

LEPROSY,  PATHOLOGY  AND  TREAT- 
MENT OF.     E.  R.  Rost 226 

OESOPHAGUS,    NEW    SUTURE    FOR. 

D.  v.  Navratil 227 

OPTIC     NEURITIS    AND     FACIAL 

PARALYSIS.     E.  A.  Shumway...  227 


PAGE 

PANCREAS,  EFFECTS  OF  EXTIRPA- 
TION   OF.    T   Silvestri 227 

PEPTIC    ULCER,     TREATMENT     OF. 

G   G.  Sears 228 

PERNICIOUS  ANEMIA,  THE  THE- 
ORY OF.     Litten  and  Michaelis...  229 

POSTPARTUM    HEMORRHAGE,      H. 

II.  Loveland 229 

POTAS81UM  IODIDE,  ADMINIS- 
TRATION OF.     M.  Hiihner 229 

PROSTATIC  HYPERTROPHY,  OB- 
STRUCTIVE, PATHOLOGY  OF. 
P.  M.  Pilcher 230 

PUERPERAL     FEVKR,     THE     BLOOD     » 
IN.     W.  D'Este  Emery 230 

PYELITIS,  TREATMENT  OF.    Howard 

A.  Kelly :31 

RENAL    DECAPSULATION.      J.    H. 

Zaaijer 231 

SPEECH,  RETARDED  DEVELOPMENT 
OF,  IN  YOUNG  CHILDREN. 
G.  Hudson-Makuen 232 

SPRUE,    USE    OF    CYLLIN    IN.      W. 

Hartigan 232 

8TOVAINE.     C.  G.  Coakley 233 

STREPTOCOCCI,        DISSEMINATION 

OF.     Alice  Hamilton 233 

STRYCHNINE  AS  A  HEART  STIMU- 
LANT.    Carlo  Gennari 234 

SURGICAL  SHOCK  AND  COLLAPSE. 

J.  P.  Lockhart  Mummery 234 

TUBERCULOSIS,  RELATION  OF  HU- 
MAN AND  BOVINE.  David 
Bovaird,  Jr 236 

URINE     EXAMINATION.        I.    R.    C. 

Cabot... 236 

UTERUS,    RETR0DISPLACEMENT8 

OF  THE.     Hayd 237 

BOOK   REVIEWS 2.  7 

BOOKS  AND  MONOGRAPHS  RE- 
CEIVED   239 

8TAFF   LIST 240 


Editorials. 


DEPARTMENT    IN   CHARGE   OF 

J.  MADISON  TAYLOR,  A.M.,  M.D. 


PSYCHOLOGICAL  MEDICINE. 

It  is  in  a  measure  regrettable  that  the  term,  psychological  medicine,  which 
would  be  so  apt  in  present-day  discussions,  should  have  been  put  out  of  service 
by  reason  of  its  professional  application  to  the  general  field  of  mental  disease.    Dr. 

(193) 


194  PSYCHOLOGICAL  MEDICINE. 

Tuke's  "Dictionary  of  Psychological  Medicine"  does  not,  as  its  title  might  legiti- 
mately imply,  consider  the  replacement  or  supplementing  of  the  ordinary  materia 
medica  by  psychological  doses,  but  is  a  general  cyclopaedia  of  mental  disturbances 
and  matters  allied  therewith.  For  the  past  two  or  three  decades  particularly  have 
the  psychologist  and  the  physician  been  called  upon  to  consider  the  status  and  the 
value  of  the  treatment  of  disease  by  mental  methods,  and  to  consider  in  a  compre- 
hensive manner  the  place  of  the  mental  factor  in  health  and  disease  alike.  The 
exclusive  advocate  of  "mental  healing"  has,  as  a  rule,  been  of  another  kidney ;  you 
may  find  him  appealing  directly  to  religious  faith  and  to  systematized  prayer ;  you 
may  find  him  with  emphatic  logic  glorifying  the  denial  of  material  ills;  you  may 
find  him  devising  peculiar  and  original  methods  of  spiriting  away  disease,  or,  at 
least,  the  symptoms  thereof.  Almost  all  of  these  "systems,"  even  the  attenuated  and 
telepathic  "absent  treatment,"  maintain  some  slight  connection  with  material  pro- 
cedures, even  if  it  be  nothing  more  than  the  laying  on  of  hands,  or  chronometric 
allowance  for  differences  of  longitude,  or  careful  attention  to  the  successive  stages 
of  the  parting  ills,  or  the  calling  in  of  supporting  friends  to  participate  in  the 
annihilation  of  the  too  solid  and  disturbing  flesh. ' 

In  view  of  all  this  interest  in  the  theory  and  practice  of  the  treatment  of  dis- 
ease by  mental  procedures,  it  is  a  matter  of  consequence  that  the  psychologist  and  the 
'  interested  members  of  the  medical  fraternity  should  co-operate,  the  one  to  aid  in 
the  expression  of  the  status  of  this  mental  factor  in  intelligible  terms,  and  the  other 
in  the  application  thereof  to  reputable  and  rational  forms  of  the  treatment  of  dis- 
ease. There  is  certainly  no  reason  in  the  fact  that  a  considerable  portion  of  "mental 
healers"  adopt  methods  and  profess  views  which  to  the  intelligent  physician  are 
suggestive  (to  put  it  mildly)  of  ignorance  and  imposition,  why  the  physician  him- 
self should  not  take  advantage  in  a  scientific  way  of  the  same  actual  influences  which 
are  thus  abused  by  his  less  reputable  rivals. 

In  a  confidential  after-dinner  mood,  the  psychologist  may  be  willing  to  confess, 
in  the  words  of  a  gifted  member  of  the  craft,  that  "psychology  is  but  a  string  of  raw 
facts,  a  little  gossip  and  wrangle  about  opinions,  a  little  classification  and  general- 
ization on  the  mere  descriptive  level,  a  strong  prejudice  that  we  have  states  of  mind, 
and  that  our  brain  conditions  them;"  but  in  so  doing  he  expects  an  equally  frank 
baring  of  the  soul  on  the  part  of  his  medical  hearers,  with  the  understanding,  of 
course,  that  both  confessions  are  for  home  consumption  only.  It  is,  then,  unfortu- 
nately true  that  with  regard  to  many  a  problem  of  neurology  and  psychology  we 
can,  at  present,  record  only  the  outward  workings  of  obscure  causes,  and  have  not  as 
yet  succeeded  in  presenting  in  a  consistent  and  illuminating  manner  the  fundamental 
relations  which  give  rise  to  the  phenomena  that  are  observed.  Such  type  of  knowl- 
edge is  familiarly  known  as  empirical,  and  awaits  justification  by  reference  back  to 


PSYCHOLOGICAL  MEDICINE.  195 

a  group  of  illuminating,  basal,  comprehensive  principles.  To  this  class  belongs  our 
knowledge  in  regard  to  the  influence  of  mental  processes  and  attitudes  upon  the 
physical  welfare  of  the  body.  . 

There  is,  however,  no  justification  in  this  lack  of  precision  of  our  knowledge 
for  any  less  careful  attention  to  the  practical  value  of  the  empirical  relations  estab- 
lished by  judicious  observation.  Briefly,  then,  we  may  not  know  why  and  how  men- 
tal attitudes  contribute  so  strikingly  to  make  or  mar  physical  conditions,  but  we  may 
utilize  the  fact  of  these  relations  and  study  the  less  obvious  and  more  complete  mani- 
festations, feeling  confident  that  in  this  study,  as  well  as  in  the  practical  application 
thereof,  will  be  found  many  a  hint  as  to  the  real  nature  of  the  actual  underlying" 
connections.  It  is  for  this  reason  that  the  psychologist  looks  to  the  careful  physician 
for  an  accumulation  of  such  observations  as  will  contribute  to  a  more  familiar  under- 
standing, even  if  only  on  a  descriptive  level,  of  this  interesting'  and  important 
psycho-medical  topic. 

As  a  general  background  to  the  more  distinctive  and  striking  examples  of  mental 
influence  in  disease,  we  recognize  the  general  changes  which  any  sort  of  being  out- 
of-health  is  likely  to  bring  about  in  the  mental  attitude.  We  notice  the  fluctuations 
of  exaltation  and  depression,  of  genial  excitement  and  groundless  despair,  of  vague 
but  real  mental  pain,  which  the  different  periods  of  day  and  night,  the  larger 
rhythms  of  the  seasons,  and  the  fluctuating  welfare  of  the  minor  concerns  of  life 
bring  about.  And  we  notice,  too,  how  differently  these  several  things  affect  or  fail 
to  affect  different  temperaments.  To  some  a  trifling  illness  is  actually  transformed 
into  a  joyous  holiday  in  bed,  while  with  others  the  reflex  of  a  slight  ailment  upon 
the  "nerves"  is  such  as  to  produce  a  distressing  mental  condition  in  which  restless- 
ness, worry,  irritability,  depression,  and  other  disturbances  of  the  mental  poise  are 
busily  at  work.  While  each  one  must  accept  his  status  between  these  two  extremes 
on  the  basis  of  his  own  heredity  and  the  acquired  control  of  his  mental  and  moral 
traits,  it  is  clear  enough  that  the  average  man  and  the  large  group  of  individuals 
who  fall  within  the  normal  variations  in  this  respect,  may  be  decidedly  helped  by 
such  appeals  to  their  temperament  as  will  for  each  be  most  effective  in  removing  these 
mental  obstacles  and  in  establishing  a  condition  most  favorable  to  nature's  healing 
processes.  With  this  as  the  ordinary  status,  it  becomes  more  intelligible  why,  in 
extraordinary  cases,  the  same  relation  should  be  exhibited  but  magnified  n-fold. 
These  develop  into  the  "show"  cases,  often  susceptible  of  brilliant  and  mystifying 
cure,  in  which  the  disease  itself  seems  to  consist  in  a  lapse  or  fault  of  the  normal 
flow  and  interchange  of  influences  between  mental  and  physical  conditions.  When 
the  dam  breaks,  and  the  natural  state  of  affairs  is  restored,  he  who  happens  to  be 
momentarily  on  duty  may,  if  he  be  of  that  ilk,  take  the  credit  of  the  whole,  slowly 
maturing,  complex,  partly  fortuitous,  issue. 


196  PSYCHOLOGICAL  MEDICINE. 

What  is  most  desirable  at  present  is  to  bind  together  the  various  types  of 
observation,  normal  and  abnormal,  trivial  and  momentous,  in  health  and  in  disease, 
so  that  there  may  result  from  the  whole  a  consistent  body  of  evidence  which,  how- 
ever empirical,  shall  furnish  a  rational  guide  alike  to  principle  and  to  practice.  The 
tendency  to  confine  attention  to  the  most  extraordinary  instances  of  bodily  effects 
due  to  mental  agencies  is  not  likely  to  lead  to  greater  insight;  such  cases  remain 
sporadic  and  meaningless  until  associated  with  a  much  larger  range  of  comparable 
instances,  in  themselves  not  sensational  and  doubtless  less  interesting,  but  suggesting 
in  their  entirety  some  efficient  modes  of  approach  to  the  underlying  problems.  Psy- 
chologically, the  connection  between  the  mental  and  the  bodily  faetor  in  conduct 
must  be  expressible  and  observable  in  ordinary  normal  relations;  for  this  connection 
is  not  one  that  comes  into  being  in  disease  or  in  "freaks,"  but  pervade  the  every- 
day working  of  mental  and  bodily  processes.  The  sensational  cases  serve  their  pur- 
pose in  that  being  written  so  large  they  command  attention  and  stimulate  inter*  -t  ; 
but  they  should  not  distract  from  the  more  intrinsically  valuable  service  of  the 
minor,  normal  illustrations  of  psycho-physical  interdependence. 

It  is  not  possible  in  the  present  connection  to  set  forth  the  range  and   import 
of  these  normal  relations;  but  it  is  possible  to  emphasize  their  directive  value  in  any 
study  of  the  topic.    It  may  also  be  possible  to  suggesl  the  trend  of  the  psychologist's 
mode  of  approach.    He  recognizes  a  wide  distribution  in  regard  to  the  directive  or 
controllable  factor  in  bodily  action,  as  well  as  in  the  normal  amount  of  awareness 
that  accompanies  various  activities;   and  he  recognizes  that  the  connections  betweeii 
these  are  complex,  variable,  and  yet  conforming  to  types  with  natural  limitations; 
and  he  recognizes  that  there  is  a  natural  division  of  labor  between  these  several 
ranges  of  activity,  the  observance  of  which   is  a  symbol  of  normality  and   health. 
Beginning  with  such  simple  observations  as' that  the  more  automatic  functions  are 
better  performed  when  the  will  keeps  its  hands  oil'  and  becomes  only  an  interested 
but  refraining  spectator,  he  passes  to  the  more  complex  cases  in  which  these  relations 
are  more  subtle  and  elusive,  and  finally  reaches  incidents  in  which  the  same  system 
of  procedure  accomplishes  results  that  are  noteworthy  in  themselves  and  valuable 
to  the  practitioner.    He  notes,  for  example,  that  the  swallowing  operation  is  a  very 
simple  performance  until  it  is  done  too  consciously  and  intentionally,  in  which  case 
the  pill  sticks  in  the  throat  and  will  not  go  down.     He  observes  the  difficulty  of  a 
patients  coming  under  the  influence  of  ether  because  of  a.  curious  resistance  to  the 
action  which  is  not  inconsistent  with  an  underlying  willingness  to  assist  the  desired 
result.     He  observes  how  difficult  it  is  to  throw  off  worry  or  despondency  in  Bpite 
of  an  underlying  desire  to  get  rid  of  these  important  interferences  with  convales- 
cence.    The  same  type  of  influence  affects  sensation  and  brings  it  about  that  the 
toothache  disappears  when  the  dentist's  door-bell  is  rung,  or  fliat  contact  with  a 


PSYCHOLOGICAL  MEDICINE.  197 

wooden  magnet  produces  instant  release  from  pain,  or  that  the  violent  excitement 
of  a  fire,  or  a  joyful  bit  of  news  restores  movement  to  an  apparently  long-suffering 
paralytic,  or  cures  hay  fever  by  brutally  revealing  that  the  rose,  the  presence  of  which 
was  so  irritating,  was  made  of  gauze  and  wire. 

It  thus  becomes  clear  on  the  one  side  that  the  comprehension,  in  terms  of 
psychology  and  physiology,  of  what  takes  place  in  these  and  similar  instances,  is 
not  an  impossible  goal,  and  it  is  equally  clear  that  our  present  partial  comprehension 
of  these  relations  does  not  interfere  with  a  considerable  and  elaborate  utilization 
thereof  in  practice.  The  procedures  of  such  practice  depend  upon  the  discovery  of 
means  to  influence  in  more  effective  ways  the  relations  between  voluntary  and  invol- 
untary, between  conscious  and  subconscious  processes.  Of  all  such  procedures  none 
is  more  definite  and  has  a  more  interesting  history  than  hypnotism.  This  too,  like  so 
many  other  procedures  in  this  field,  has  a  record  of  long  historical  associations  with 
ignorance  and  quackery,  with  the  propounding  of  false  issues  and  the  demand  for 
miracles.  It  can  also  point  to  a  systematic  study  which  began  with  the  simplest 
types  of  observations  and  led  to  a  system  of  therapeutics,  dependent  upon  the  under- 
lying principle  of  suggestion,  which  such  research  showed  to  be  the  keynote  of 
hypnotic  action.  Inadequate  as  may  be  the  psychology  of  suggestion,  it  is  sufficiently 
established  to  indicate  that  the  efficient  working  influence  is  the  throwing  out  of  gear 
of  the  inhibitory,  higher,  more  voluntary,  and  more  conscious  processes  which  serve 
alike  to  direct  and  to  check  normal  activity.  The  hypnotic  condition  thus  differs 
strikingly  from  the  normal  in  that  by  the  removal  of  these  psychic  inhibitions,  com- 
mands issued  by  outside  suggestion  find  a  more  direct  and  unimpeded  channel  to  the 
centers  of  motion  and  sensation,  especially  in  cases  in  which  they  have  been  too 
strongly  dependent  upon  complex,  and  it  may  be,  morbid  interferences  of  an  im- 
paired or  badly  regulated  will.  It  is  not  because  the  hypnotic  process  is  in  itself 
illuminating  or  explanatory,  but  rather  because  it  is  precise,  definite,  and  experi- 
mental that  it  has  become  a  recognized  form  of  treatment  in  such  a  large  range  of 
minor  disturbances.  What  in  one  case  is  most  effectively  accomplished  through 
hypnotic  suggestion,  may  in  another  be  similarly  brought  about  by  suggestion  in 
which  faith  or  confidence  or  hopefulness  or  good  cheer  or  distraction  of  new  sur- 
roundings furnishes  the  "leit-motif."  The  motive  of  all  these  procedures  is  to 
diminish  the  inefficiency  of  an  attitude  that  is  lacking  in  spontaneity,  common  in 
natural  vigor,  by  reason  of  being  too  much  distorted  by  the  pale  cast  of  thought. 
And,  moreover,  is  it  necessary  to  appreciate  that  such  conditions  have  a  peculiar 
relation  to  consciousness,  that  they  may  exist  without  the  subject's  awareness,  or 
even  in  spite  of  a  half-hearted  desire  to  antagonize  their  growth.  It  is  in  these 
3 


198  PSYCHOLOGICAL  MEDICINE. 

subtle  operations  that  the  physician  recognizes  many  of  the  permanent  and  tantaliz- 
ing symptoms  of  hysteria  and  neurasthenia. 

On  the  practical  side,  the  physician's  problem  is  thus  the  common  one  of  judg- 
ment, tact,  and  ingenuity  in  determining  what  influences  in  any  special  cases  are 
likely  to  be  most  efficacious.  The  same  tact  and  insight  must  also  be  used  in  discov- 
ering the  hidden  sources  of  irritation,  which  are  so  various,  so  unrecognized,  or  it 
may  be  so  deceitfully  withheld,  and  which  none  the  less  stand  as  the  real  obstacle 
between  the  actual  condition  and  such  approximation  to  the  normal  as  may  really 
be  brought  about.  Forcible  removal  from  such  disturbing  surroundings,  it  may  be 
from  family  and  friends,  in  another  case  a  direct  appeal  to  dormant  motives,  and 
in  a  third,  reliance  upon  change  of  scene  and  the  charm  of  new  interests — all  of 
these  are  obviously  pertinent  examples  of  psychological  medicine,  the  prescription  in 
each  case  being  successful  in  proportion  to  the  psychological  insight  of  the  physician. 
That  in  combination  with  such  treatment  the  reinforcement  of  the  physical  health 
and  the  usual  allaying  of  symptoms  and  building  up  of  tissue,  act  as  a  means  of 
supplying  favorable  conditions  for  the  psychological  medicine  to  work,  least  needs 
emphasis. 

In  this  presentation  decided  emphasis  has  been  placed  upon  the  more  ordinary 
and  usual  forms  of  the  mental  factor  in  disease,  because  of  the  conviction  that  herein 
lies  the  secret  of  the  understanding  of  the  entire  range  of  the  phenomena.  It  is  in 
these  rather  than  in  extreme  cases  of  similar  activity  that  illumination  is  to  be  found. 
None  the  less  the  extreme  instances  are  in  themselves  interesting  and  contribute  a 
type  of  evidence  at  once  important  and  worthy  of  record.  The  marvels  of  hypnotism 
on  the  one  hand  and  the  equally  remarkable  cures  by  effective  methods  of  suggestion 
or  mental  treatment,  are  sufficiently  well  authenticated,  in  spite  of  a  greater  mass 
of  fraudulent  and  misleading  observations,  to  impress  the  physician  and  the  psy- 
chologist alike.  They  hold  out  possibilities  of  the  extension  of  the  psychophysical 
principle  alike  alluring  and  deceptive.  In  view  of  the  status  of  present-day  psycho- 
logical medicine,  it  seems  almost  inevitable  that  the  future  practitioner  will  appre- 
ciate and  utilize  these  influences  for  the  treatment  of  disease  far  more  generally, 
intelligently,  and  successfully  than  has  yet  been  done;  will  appreciate  how  often  it 
"is  not  the  body,  but  the  man  is  ill."  Instead  of  the  old  age  adage  which  cast  reflec- 
tions upon  the  physician's  calling,  and  said  that  "where  there  are  three  physicians 
there  will  be  two  atheists,"  the  proverb  is  likely  to  receive  a  complimentary  turn, 
and  read  "that  where  there  are  three  physicians  there  are  two  psychologists." 

Joseph  Jastrow.* 
"Professor  of  Psychology   in   the   University   of  Wisconsin. 


OCCULT  HEMORRHAGES  IN  GASTRIC  AFFECTIONS.  199 

i 


THE  SIGNIFICANCE  OF  THE  SO-CALLED  "OCCULT  HEMORRHAGES" 
IN  THE   DIAGNOSIS  OF  CERTAIN   GASTRIC   AFFECTIONS. 

Advancements  in  our  methods  of  diagnosis  arc  always  welcomed  by  the 
profession,  especially  if  we  are  thus  enabled  by  means  of  some  simple  test  to  clear 
up  an  obscure  point  in  diagnosis.  It  is  my  desire  to  call  attention  to  a  very  simple 
test  the  significance  of  which  was  first  pointed  out  by  Boas  as  a  means  of  detecting 
minute  quantities  of  blood  in  the  gastric  contents  and  faeces.  This  investigator 
showed,  that  by  aid  of  the  well-known  Weber  test,  as  well  as  by  Klunge's  aloin  test, 
it  is  a  simple  matter  to  detect  a  minute  quantity  of  blood  having  its  origin  in  the 
stomach  too  insignificant  to  be  seen  by  the  naked  eye,  and  yet  which,  by  its  con- 
tinued persistence,  may  prove  a  serious  menace  to  life. 

Boas  advises  the  Weber  test  to  be  made  in  the  following  way :  "About  20 
cubic  centimeters  of  ether  are  added  to  15  cubic  centimeters  of  gastric  contents 
or  to  5'  to  10  grams  of  soft  or  softened  stools.  This  removes  the  fats  and  prevents 
disturbing  emulsions  later.  About  3  to  5  cubic  centimeters  of  glacial  acetic  acid 
are  then  added  to  the  gastric  contents  or  faeces  and  the  whole  is  poured  into  a  test- 
tube  and  extracted  again- with  ether.  There  must  be  no  admixture  of  alcohol,  as 
this  disturbs  the  test.  As  guaiac  dissolves  readily  in  ether  it  is  not  necessary  to  use 
the  tincture.  A  few  grains  of  finely  pulverized  guaiac  resin  are  added  to  the  ether 
extract,  the  whole  is  carefully  shaken,  and  then  20  to  30  drops  of  oil  of  turpentine 
are  added.  The  whole  is  shaken  up  again  and  then  set  aside.  The  color  gradually 
changes  to  a  violet  or  blue,  rendered  still  more  intense  by  addition  of  chloroform. 
This  blue  tint  is  sometimes  masked  by  the  brownish  color  of  the  fluid  and  the 
findings  of  the  test  can  be  controlled  by  repeating  it  with  Klunge's  aloin  (est.  As 
much  aloin  as  can  be  taken  up  on  the  tip  of  a  small  spatula  is  placed  in  a  test-tube 
and  lightly  shaken  up  with  3  to  5  cubic  centimeters  of  GO  to  70  per  cent,  alcohol. 
The  acetic  acid  and  ether  extract  of  the  faeces  or  stomach  content,  prepared  as 
above  described,  is  treated  with  20  to  30  drops  of  turpentine  and  then  immediately 
afterward  with  10  to  15  drops  of  the  freshly  prepared  aloin  solution.  In  the 
presence  of  blood  the  lluid  rapidly  assumes  a  bright  red  color,  which  turns  to  a 
fairly  durable  cherry  red  as  it  stands.  If  there  is  do  blood  the  fluid  remains  yellow 
for  an  hour  or  so  and  then  becomes  a  light  pink.  The  color  changes  may  he 
hastened  by  adding  a  irw  drops  of  chloroform.  Boas  makes  a  practice  of  con- 
ducting the  two  tests  as  controls,  and  believes  thai  the  aloin  is  superior  in  several 
points  to  the  guaiacum.  It  is  not  influenced  by  the  presence  of  fats  or  fatty  acids 
and   is  sometimes  positive  when   the  guaiac   findings  are  dubious/' 


200  OCCULT  HEMORRHAGES  IN  GASTRIC  AFFECTIONS. 

In  his  first  communication  Boas  pointed  out  the  fact  that  that  form  of  bleed- 
ing which  was  too  insignificant  to  be  detected  by  the  naked  eye,  and  which  he 
termed  "occult  haemorrhage,"  occurred  only  in  certain  gastric  conditions.  He 
never  found  it  in  the  gastric  contents  in  chronic  gastritis,  hyperacidity,  or  hyper- 
secretion; it  occurred  occasionally  in  gastric  ulcer  with  or  without  consecutive 
stenosis;  it  always  occurred  in  cancer  of  the  stomach,  as  was  shown  by  an  examina- 
tion in  20  cases. 

In  a  further  communication  Boas  showed  that  errors  due  to  slight  bleedings 
induced  by  introducing  the  stomach  tube,  causing  minute  erosions,  could  be  avoided 
by  investigating  the  fasces  rather  than  the  gastric  contents;  however,  in  the  exam- 
ination of  the  stools  for  these  haemorrhages  certain  precautions  must  be  taken, 
namely,  to  exclude  food  containing  fresh  unboiled  or  medium  done  meats  and 
sausage  from  the  diet  for  two  days  before  the  test  is  undertaken,  as  well  as  to 
ensure  soft  movements  by  means  of  Carlsbad  salts.  Menstrual  as  well  as  haemor- 
rhoidal  blood  must  also  be  excluded,  and  haemorrhages  from  the  teeth,  mouth, 
throat,  nose,  lungs,  and  intestines  must  be  guarded  against.  Koziczkowski  has 
recently  advised  a  restriction  in  diet  to  milk,  flour,  bread,  eggs,  fruit,  and  not  too 
much  fat  previously  to  applying  this  test. 

Boas  and  his  pupils,  as  well  as  others,  have  confirmed  the  original  conclusions 
concerning  the  significance  of  the  so-called  "occult  haemorrhages"  in  the  faeces  as 
a  most  important  diagnostic  test.  In  a  series  of  257  cases  of  patients  suffering 
with  gastric  disturbances  in  which  this  examination  was  made,  Boas  was  unable 
to  note  the  slightest  indication  of  the  presence  of  blood  in  the  faeces  in  any  form 
of  gastritis,  hyperacidity,  or  hypersecretion.  Schloss  examined  20  cases  of.  acylia 
gastrica  and  gastritis  anacida,  and  could  not  observe  any  trace  of  blood  at  any 
time.  Bleeding  is  present  at  times  in  ulcer  of  the  stomach  and  duodenum  with  or 
without  dilatation.  Joachim  found  it  in  83  per  cent,  of  28  cases  of  ulcer;  it  was 
always  present  in  all  cases  of  cancer  of  the  stomach — 18  cases  in  all. 

My  own  observations  agree  in  every  respect  with  the  conclusion  arrived  at  by 
Boas  regarding  the  significance  of  the  so-called  "occult"  bleeding.  Occult  blood 
has  never  been  found  by  me  in  any  form  of  gastritis,  either  acid  or  anacid;  in 
hypersecretion  or  hyperacidity  without  the  presence  of  ulcer  or  in  any  form  of 
gastric  neurosis.  So  significant  is  this  fact,  that  I  have  frequently  been  enabled  to 
rely  on  the  constant  absence  of  this  sign  as  evidence  sufficient  to  exclude  the  pres- 
ence of  ulcer  and  cancer,  and  on  the  other  hand  as  evidence  in  favor  of  the  presence 
of  either  a  gastritis  or  some  form  of  gastric  neurosis. 

In  cancer  of  the  stomach  or  intestines  this  form  of  bleeding  is  constantly 
present;  in  but  a  very  few  examinations  was  its  absence  noted  by  me;  so  constant 
is  this  finding,  that  it  serves  to  differentiate  cancerous  processes  of  the  stomach 


SUDDEN  DEATH.  201 

and  intestines  from  ordinary  inflammations  and  ulcer.  It  is  found  early  in  the 
course  of  this  disease,  and  gives  evidence  of  this  condition  long  before  the  physical 
signs  of  a  tumor  become  manifest. 

In  ulcer  of  the  stomach  blood  is  found  irregularly  in  the  stools.  It  is  most 
frequently  noted  when  the  patient  has  been  complaining  of  pain,  especially  before 
the  so-called  ulcer  cure  (rest  in  bed  and  a  diet  mainly  of  milk)  has  been  under- 
taken. After  this  treatment  has  been  instituted  for  a  period  of  days,  the  "occult" 
bleeding  disappears.  Inasmuch  as  these  findings  vary  so  greatly  in  ulcer  of  the 
stomach,  it  is  necessary  to  make  repeated  investigations  to  determine  the  exact 
conditions.  We  have  found  this  sign  a  most  valuable  aid  in  the  diagnosis  of  this 
disease,  especially  in  those  cases  in  which  the  symptoms  are  not  decisive  and  in 
which  the  diagnosis  varied  between  gastralgia  and  ulcer.  In  every  instance  in 
which  the  ulcer  treatment  was  undertaken,  the  improvement  in  the  patient's  con- 
dition indicated  the  correctness  of  the  diagnosis  and  the  value  of  this  sign.  Occult 
bleeding  has  often  as  much  significance  as  pronounced  haemorrhage  and  will  fre- 
quently indicate  the  presence  of  ulcer  long  before  visible  haemorrhage  is  present. 

The  presence  of  this  sign  alone,  however,  has  no  significance;  but  in  addition 
to  other  clinical  evidence,  I  have  found  it  of  such  practical  value  that  I  should  urge 
a  careful  investigation  for  occult  bleeding  in  all  obscure  forms  of  gastric  disease. 

Julius  Friedenwald,* 

Baltimore. 


SUDDEN  DEATH. 

From  the  earliest  times  the  subject  of  sudden  death  has  held  a  subtle  fascina- 
tion for  laymen  and  physicians.  The  possibility  of  sudden  death  overtaking  a 
healthy  person  has  given  rise  to  a  fear  of  impending  dissolution  that  is  very  gen- 
eral. This  fear  is  so  powerful  a  motive  in  human  affairs  that  it  has  been  used  as 
a  lever  by  moralists  and  quacks  in  all  ages.  The  specialists  of  ancient  days  used 
it  to  heighten  the  effects  of  their  celebrations.  Many  good  and  great  deeds  would 
never  have  been  performed  but  for  the  fear  of  impending  death.  To  the  physician 
it  is  always  one  of  the  great  impelling  forces  that  keeps  him  from  becoming  care- 
less and  lax.  How  often  has  the  life  of  a  patient  been  saved  by  a  physician  who  was 
keenly  alive  to  this  anxiety  for  his  patient's  life?  Among  the  thousands  of  cases 
of  sudden  death  I  have  been  called  on  to  investigate  not  a  few  could  have  been 
averted  had  the  physician  been  properly  on  the  alert.  It  is  the  duty  of  every 
physician  to  be  watchful  for  all  forms  of  sudden  death  and  not  a  little  thought  is 


*  Clinical   Professor   of   Diseases   of   the   Stomach,   College  of   Physicians   and   Surgeons 
of  Baltimore,  Md. 


202  SUDDEN  DEATH. 

needed,  after  the  physiological  facts  have  been  learned,  before  the  mind  is  ready 
to  grasp  quickly  and  surely  the  significance  of  those  symptoms  and  conditions  that 
lead  to  what  is  so  often  spoken  of  as  "sudden  death." 

A  large  number  of  cases  of  so-called  sudden  death  should  not  be  so  classed; 
tbey  are  merely  unexpected.  In  many  cases  the  dying  is  quickly  accomplished  at 
the  last  stage,  but  not  infrequently  there  has  been  a  noticeable  delay  or  arrest  of 
the  morbid  process,  so  that  if  we  were  familiar  with  the  case  in  detail  we  would  won- 
der at  the  slowness  of  the  lethal  process  and  use  some  other  term  rather  than  call 
the  dissolution  itself  sudden.  Not  a  few  cases,  where  details  are  previously  known, 
are  given  a  most  unfavorable  prognosis,  and  we  often  meet  those  persons  who  have 
years  before  been  consigned  to  an  early  and  sudden  death  by  some  over-susceptible 
diagnostician. 

The  double  lesson  of  caution  from  fear  of  a  sudden  death  and  realization  of 
the  remarkable  tenacity  of  vital  action  of  the  tissues  on  which  life  depends,  is  one 
that  is  not  easy  to  learn  and  the  importance  of  which  we  too  often  forget. 

The  principal  groups  into  which  sudden  deaths  naturally  fall  are: — 

(a)  Those  occurring  in  newly  presented  and  unstudied  cases  to  which  the 
practitioner  is  called  for  the  first  time  just  as  the  last  phase  of  death  is  passing 
under  review. 

(b)  Those  occurring  suddenly  in  old  cases  where  new  symptoms  have  un- 
expectedly developed. 

(c)  Those  occurring  in  familiar  cases  where  old  symptoms  have  assumed  an 
undue  gravity. 

(d)  A  large  group  where  previous  study  would  have  been  of  little  aid  in  meet- 
ing the  emergency ;    which  group  may  in  time  be  divided  into : — 

1.  Cases  of  violence,  such  as  heat  stroke,  burning,  freezing,  electric  shock, 
drowning,  or  mechanical  injury. 

2.  Cases  of  poison  where  a  fatal  dose  has  been  taken,  either  through  the  skin 
or  orifices  or  by  injection. 

3.  Cases  of  internal  accidents,  such  as  concealed  haemorrhages,  perforations, 
or  rupture. 

Certain  physiological  conceptions  will  be  of  use  to  us  in  handling  those  cases, 
when  seen  in  the  critical  period,  which  would,  if  left  alone,  terminate  in  death. 
I  find  deaths  occurring  in  these  cases  from  changes  in  four  great  physiologic  groups 
of  factors,  and  these  are  often  interdependent  to  such  a  degree  that  it  is  more  than 
difficult  to  determine  which  of  the  four  was  the  chief  agent  in  the  result,  and 
oftener  still  is  it  difficult  to  decide  which  of  the  four  was  most  efficient,  because 
the  lesions  we  find  may  have  been  caused  by  a  debility  in  other  organs. 

Nutrition  stands  first  in  my  mind  as  a  most  forceful  physiologic  factor,  for 


SUDDEN  DEATH.  203 

no  organ  can  work  long  if  its  food  supply  is  cut  off  or  changed  seriously.  A 
digestive  disturbance,  a  cardiac  depression,  or  a  vasomotor  storm  would,  any  or  all, 
give  rise  to  tissue  starvation  that  might  prove  rapidly  fatal,  and  a  hemorrhage 
usually  does  kill  by  inducing  a  swift  tissue  starvation. 

Nerve  supply  stands  second  as  important  for  the  quickest  deaths  which  result 
from  insults  to  the  nervous  system,  and  mo-re  old  hearts  and  kidneys  give  out  as  a 
result  of  faulty  or  morbid  conditions  of  innervation  than  many  of  the  books  would 
lead  us  to  believe. 

Excretion  is  a  tremendously  potent  factor  which  opens  up  the  largest  studies 
of  the  future,  not  to  be  measured  by  albumin  percentages,  but  by  all  the  phenomena 
of  tissue  life  in  the  body;  just  as  the  condition  of  a  plant  reveals  the  qualities  of 
the  soil,  so  do  the  tissues  show  those  of  the  blood.  There  must  be  assumed  a  grasp 
of  these  vital  indices  if  medicine  is  to  be  regarded  as  an  art.  There  must  be  clear 
standards,  measures  of  these  forces,  if  it  is  to  approach  the  limits  of  science. 

Respiration,  while  in  some  respects  including  the  functions  of  both  nutrition 
and  excretion,  is  so  important  in  its  resultants  that  it  deserves  a  special  place  in 
our  thoughts,  provided  always  we  are  to  be  something  greater  than  mechanics,  and 
regard  the  processes  simply  as  the  air-moving  devices  of  the  thorax.  It  means  that 
air  is  supplied  to  the  tissues,  giving  full  value  to  the  lymph  and  blood  as  ultimate 
oxygen  carriers,  and  to  the  heart  as  the  main  mechanical  factor,  in  addition  to  the 
usual  concepts  of  the  function  of  the  air  passages  and  thorax. 

Under  a  subsidiary  heading  we  may  group  the  organs  which  are  affected  by 
the  four  noble  forces.  They  may  by  themselves  cause  a  marring  of  that  symphony 
of  functions  we  call  health,  or,  if  we  must  be  technical,  we  may  call  it  a  serial 
svmptom  complex,  first  of  those  organs  usually  affected;  or,  again,  it  may  be  that 
the  primary  cause  is  a  weakening  of  the  heart.  Generally  the  heart  is  damaged  by 
digestive  toxics;  frequently  it  is  lashed  to  an  ungovernable  energy  by  an  excited 
nervous  system,  and  occasionally  it  gives  out  for  mechanical  reasons. 

A  heart  muscle  which  is  getting  a  supply  of  good,  clean  blood,  shows  often 
a  wonderful  vitality  even  after  accidents  to  the  valves  unless  some  ignorant  meddler 
lias  been  overburdening  it  with  harmful  drugs.  Next  come  the  lungs.  As  a  cause 
of  sudden  death  they  are  usually  secondary  in  importance  to  derangements  of  the 
central  nervous  system,  the  heart  or  the  kidneys,  which  one  or  all  combined  give 
rise  to  oedema  and  congestion. 

The  simplest  form  of  respiratory  arrest  is  of  course  wholly  id'  nervous  causa- 
tion. The  kidneys  are  responsible  for  happenings  Unit  often  seem  strange  to  the  un- 
initiated, and  the  "kidney  face"  is  just  as  truly  a  type  as  was  the  "bicycle  face;" 
and  when  a  kidney  grows  rebellious  after  having  been  imposed  upon  for  years  by 
a  much  abused  digestive  apparatus,  strange   things  are  apt    to  happen,  which  go 


204  SUDDEN  DEATH. 

down  in  the  records  of  vital  statistics  as  apoplexy  and  heart  disease,  because 
some  one  has  forgotten  to  use  his  scanty  store  of  physiologic  knowlege.  These 
physiologic  principles  are  needed  at  the  beginning  of  an  analysis  of  the  problem 
presenting. 

Let  us  suppose  a  man  has  fallen  unconscious  in  front  of  our  office;  what  is 
it?  and  what  shall  we  do?  Send  him  to  a  hospital?  possibly;  but  if  we  are  not 
too  heavily  burdened  already  to  take  cognizance  of  the  normal  actions  in  the  case 
if  will  be  well  to  study  him  closely,  thoroughly,  and  at  ouce.  We  should  apply  to 
him  the  key  supplied  by  the  four  dominant  physiologic  spheres.  Test  his  motor  and 
sensory  impulses  so  that  we  can  be  able  to  tell  in  five  minutes  whether  his  nervous 
system  is  supplying  normal  or  abnormal  stimuli  to  the  voluntary  and  involuntary 
muscles,  including  heart  and  lungs  and  reflexes.  Observe  the  respiration,  its  quali- 
ties and  rate  so  as  to  determine  surely  whether  alcohol,  opium,  or  other  toxic  agents 
are  at  work.  The  pulse  should  be  constantly  observed  so  that  we  may  know  what 
effect  our  tests  are  having  on  the  cardiac  action,  and  be  not  in  our  haste  confused 
by  pressure  of  clothing  on  the  vessels  above  to  mislead  our  estimate.  Observation 
of  skin  and  mucous  membranes  will  reveal  something  of  positive  value  not  to  be 
found  out  by  any  other  method.  The  glands  of  the  skin  will  help  us  to  estimate 
the  responsiveness  of  the  nervous  system. 

Temperature  observed  by  the  hand  will  often  tell  the  whole  story.  The  points 
of  observation  and  test  can  be  gone  over  in  three  minutes,  and  then  we  can  begin 
to  build  up  the  symptom  complex  of  the  case  and  return  to  our  examination  for 
confirmation  or  correction. 

True,  we  may  have  spent  five  minutes  on  a  typical  case,  but  the  results  will 
not  be  so  terrible  as  they  would  have  been  if  we  had  made  a  snap  diagnosis  and 
instituted  harmful  procedures. 

Suppose  a  case  (I  have  records  of  such)  where  a  pallor  and  a  feeble  pulse  were 
thought  to  be  an  indication  for  salt  solution  and  the  operator  with  swiftness  pumped 
a  quart  of  water  or  saline  solution  into  the  body,  and  was  surprised  when  I  pointed 
out  marked  oedema  of  the  legs,  possibly  even  of  the  face.  We  can  even  conceive  of 
his  expressing  indignation  that  such  a  line  of  action  could  be  held  questionable. 
I  have  seen  a  case  where  a  quart  of  salt  solution  was  thrown  in  while  the  man  was 
dying  of  oedema  of  the  lungs,  notwithstanding  the  fact  that  the  oedema  had  been 
recognized !     Such  inconsistencies  are  little  short  of  homicide. 

Again,  I  have  seen  a  case  of  internal  haemorrhage  treated  with  large  injections 
of  digitalis,  with  the  result  that  the  last  drops  of  blood  were  pumped  out  most  thor- 
oughly by  an  over-supported  heart  and  there  was  a  smile  of  satisfaction  on  the 
physician's  face  because  he  had  treated  the  case  "symptomatically." 

How  many  sins  have  been  committed  in  the  name  of  therapeutics  that  might 


PARALYSIS  AGITANS  AND  CHRONIC  ACQUIRED  TREMOR.  205 

have  been  avoided  had  the  practitioner  but  learned  to  accept  physiology  as  a  guide, 
and  applied  judgment  at  the  bedside. 

Again,  another  type  of  error  occurs.  A  woman  whose  face  and  lips  and  nails 
told  me  at  a  glance  that  she  had  bled  to  death,  had  been  given  a  vaginal  douche  and 
turpentine  application  to  the  bowels  by  her  attendant,  who  had  not  noticed  the 
extreme  air-hunger  and  growing  yellow  pallor.  The  woman  could  have  been  saved 
had  the  attendant  but  seen  all  that  was  obvious  before  he  commenced  to  use  measures 
which  obscured  the  significant  symptoms. 

There  must  be  an  intelligent  grasp  of  the  relationships  of  the  physiological 
phenomena,  and  how  they  may  vary;  of  the  normal  acts  and  what  these  variations 
mean,  and  the  reading  of  symptoms.  A  diagnosis  with  some  of  the  symptoms  left 
out,  because  they  are  not  obtrusive  or  insistent,  is  apt  to  add  to  the  list  of  sudden 
death  in  the  vicinity. 

Too  great  stress  can  hardly  be  laid  on  the  value  of  a  fair  concept  of  the  four 
factors — nutrition,  innervation,  excretion,  respiration — and  the  clinical  study  of 
cases  with  these  in  mind.  These  will  give  a  power  to  think  physiologically  which 
will  alone  enable  one  to  treat  judiciously  the  existing  conditions.  The  habit  of 
giving  a  speculative  estimate  of  the  values  of  this  quadrate  group  and  of  the  func- 
tions of  the  organs,  the  heart,  lungs,  and  kidneys,  which  will  give  a  power  of  deter- 
termining  the  forces  to  be  relied  on  for  recovery,  without  which  medicine  is  but  the 
most  miserable  quackery. 

In  cases  of  violence  or  poison  we  have  new  factors  to  add  to  those  already 
touched  on,  but  each  type  would  be  a  large  subject  in  itself. 

Occasionally  one  encounters  the  case  too  late  to  be  of  any  use,  and  the  usual 
observations  should  be  made  as  far  as  possible  and  of  course  supplemented  by  all 
available  evidence,  though  the  greatest  caution  should  be  used — accepting  state- 
ments cautiously,  for  they  are  apt  to  be  misleading.  Where  there  has  been  evidence 
of  crime  or  negligence,  or  even  a  suspicion  of  them,  the  authorities  must  be  con- 
sulted and  there  exists  a  moral  and  loyal  obligation  to  assist  such  authorities,  and 
the  simple  rule  is  best  to  treat  them  as  you  would  like  to  be  treated  in  their  position. 

William  S.  Wadsavorth,* 

Philadelphia. 


REMARKS  ON  THE  TREATMENT  OF  PARALYSIS  AGITANS  AND 
CERTAIN  FORMS   OF  CHRONIC  ACQUIRED  TREMOR. 

The  relief  of  the  phenomenon  tremor  has  proven  to  be  a  difficult  task. 
Medicines  directed  to  the  symptom  are  proverbially  unsatisfactory.  For  the  toxic 
tremors  eliminants  have  some  utility.     Where  hysteria  is  the  basis  of  a  tremor 


Physician  to  the  Coroner  of  Philadelphia. 


206  PARALYSIS  AGITANS  AND  CHRONIC  ACQUIRED  TREMOR. 

associated  causes  must  be  reckoned  with;  but,  however  complex,  it  yields  best  to 
suggestion,  rational  auxiliary  measures  also  proving  helpful.  Some  forms  of 
tremor  are  incurable,  particularly  those  of  disseminated  sclerosis;  but  even  these 
can  often  be  mitigated  by  rightly  directed  efforts.  Hygienic  measures  accomplish 
most,  and  in  proportion  as  they  are  rationally  and  persistently  applied;  also,  in 
respect  to  the  degree  of  intelligent  cooperation  afforded  by  the  patient.  The 
etiologic  conditions  in  most  chronic  acquired  tremors  are  analogous;  perhaps  more 
closely  so  than  is  generally  admitted.  We  look  for  some  central  defects,  but  the 
major  lesions  arc  probably  degenerative  changes,  beginning  or  progressing,  and 
chiefly  in  the  periphery.  The  one  disorder  frequently  met  in  which  tremor  is  the 
most  conspicuous  phenomenon,  is  paralysis  agitans — Parkinson's  disease.  The 
practical  conditions  we  have  to  meet  here  are  (1)  progressive  weakness,  (2)  ex- 
hausting continuous  tremor,  and  (3)  disabling  rigidities.  Along  with  these  there 
appears  in  most  cases  increasing  apathy  or  disinclination  to  effort  of  any  kind. 

The  disease  usually  occurs  in  persons  of  late  middle  life  in  whom  degenerative 
changes  are  to  be  inferred,  though  autopsy  findings  are  not  marked  or  not  definite. 
They  are  analogous  to  senile  tissue  alterations,  sclerotic  vascular  processes  in  the 
smaller  vessel,  the  glia,  and  connective  tissue.  Nutrition  is  usually  good;  organic 
derangements  are  seldom  obvious;  longevity  is  often  little  interfered  with  if  fairly 
comfortable  conditions  can  be  maintained.  We  may  also  have  the  disease  without 
the  tremor. 

It  was  my  privilege  some  years  ago  to  meet  a  large  number  of  cases  of  paralysis 
agitans,  and  I  made  them  the  subject  of  two  papers — clinical  communications. 
Some  of  my  cases  improved  pronouncedly  and  permanently;  they  would  probably 
have  resulted  more  satisfactorily  had  it  been  possible  to  have  continued  super- 
vision; the  gains  certainly  would  have  been  more  marked  could  I  have  elicited  a 
larger  measure  of  personal  cooperation.  What  usually  defeated  progress  was  the 
apathy,  the  weakness,  and  the  advanced  age. 

Further  experience  _since  the  last  paper  was  written  has  induced  the  conviction 
that  the  measures  I  then  advocated  are  valuable,  deserving  a  wider  application. 
Charles  L.  Dana  has  recently  contributed  a  paper  (Cornell  University  Medical 
College  Reports)  in  which  he  recommends  a  series  of  exercises  with  the  object  of 
overcoming  the  weakness  and  stiffness  in  the  muscles,  and  to  check  the  tendency 
to  tip  forward  while  walking.  A  reading  of  his  paper  leads  me  to  infer  that  he  has 
applied  some  part  of  my  recommendations,  but  not  the  most  important  ones; 
hence,  I  am  encouraged  to  rehearse  my  convictions  in  outline  and  express  the  hope 
that  clinicians  will  make  more  extensive  use  of  the  principles  I  emphasize  and 
report  their  experience  for  the  benefit  of  sufferers. 

(1)  The  circulation  of  those  suffering  from  chronic  acquired  tremor,  especially 


PARALYSIS  AGITANS  AND  CHRONIC  ACQUIRED  TREMOR.  207 

paralysis  agitans,  is  commonly  found  to  be  enfeebled;  the  heart  beats  are  weak, 
the  pulse  tension  low,  the  skin  leaky,  etc.  When  this  is  the  case  (most  of  my 
cases  showed  those  features)  tonics  are  indicated  to  increase  the  efficiency  of  the 
adrenal  system,  e.g.,  digitalin  (Merck)  in  full  doses,  strychnia,  quinia  hydro- 
chlorate,  etc.  These  or  some  of  them  should  be  administered  continuously  or  inter- 
mittently, especially  the  digitalin,  until  the  myocardium  has  recovered  nutrition 
and  competence,  and  the  blood  distribution  is  shown  to  have  improved  in  circu- 
latory tone  (Henry  Beates),  and  hence  oxygenation  (Sajous).  (2)  Not  until 
this  condition  is  satisfactory  can  we  expect  good  results  from  the  most  definite 
measure,  viz. :  passive  exercises,  whereby  the  nutrition  of  the  muscles,  the  motor 
nerves>  and  the  centers  as  well,  are  definitely  bettered,  followed  by  increasing  active 
use  of  the  limbs  and  truncal  muscles. 

Our  chief  object  in  overcoming  tremor  is  to  secure  muscular  competence,  free- 
dom from  contractures,  elasticity  of  the  machinery  of  motion.  Then,  and  then 
only,  can  the  nutrition  of  the  various  centers  and  subsidiary  centers  become 
amended,  the  normal  activities  be  gained,  and  the  tremor  overcome.  I  never  saw 
a  case  of  paralysis  agitans  where  the  disabilities  described  were  absent.  If  one 
should  be  found  then  the  central  lesion  probably  cannot  be  controlled.  It  is  prac- 
tically controllable  in  proportion  as  these  contractures  can  be  overcome. 

It  was  my  endeavor  to  show  (in  the  aforesaid  papers  and  elsewhere)  that  we 
can  achieve  the  highest  degree  of  muscular  efficiency  in  the  healthy  or  diseased  only 
after  securing  full  elasticity  of  the  enveloping  structures  and  ligamentous  attach- 
ments, and  by  overcoming  irregular  tensions.  Experience  teaches  that  where  this 
is  secured  the  balance,  the  strength,  the  accuracy  and  force  of  the  muscles  returns 
in  proportion  to  their  inherent  capabilities.  In  persons  past  middle  life  there  are 
always  more  or  less  recognizable  contractures. 

It  is  well  known  that  the  pursuit  of  mere  muscular  exercises,  such  as  the 
commoner  occupations  or  sports,  will  not  induce  this  elasticity  unless  there  is 
involved  that  kind  of  movement  which  makes  for  the  full,  accurate  stretching  of 
the  muscles  of  neck,  trunk,  and  limbs.  Automatic,  monotonous  repetitions  of  move- 
ment, as  labor  or  sports,  tend  to  induce  faulty  habits  limiting  the  range  of  action; 
the  full  excursus  is  rarely  attained  unless  the  importance  of  this  principle  of  fullest 
stretching  is  borne  in  mind.  The  patient  is  rarely  vigorous  enough  to  follow  those 
pursuits  or  sports  which  demand  this  action,  of  which  fencing  is  the  best,  and 
next  in  value  is  the  ancient  game  of  bean  hag,  squash,  racquets,  and  the  medicine 
hall.  The  use  of  dumb-bells  is  notoriously  had,  inducing  muscle  binding  or  stiffen- 
ing; hence  it  is  not  to  be  encouraged  unless  a  careful  teacher  compels  the  fullest 
tensions,  extensions,  and  accuracy  of  posturings.  The  constant  flexor  action,  the 
grip  of  the  hand  on  the  dumb-bell  is  harmful.     It  is,  moreover,  rather  exhausting; 


208  AGGLUTINATION  TESTS,  SOME  FALLACIES  IN. 

hence  not  to  be  recommended  in  comparison  with  the  systematic  training  suggested 
in  my  article  in  the  Therapeutic  Gazette.  This  consists,  in  brief,  of  first,  a  course 
in  passive  movements,  torsions,  forceful  tractions,  overtensions,  lengthenings,  fol- 
lowed by  accurate  outreachings,  elongations,  energetic  rotations,  to  the  limit  of 
elasticity  and  normal  joint  action. 

When  the  patient  has  thus  acquired  fair  control  of  the  long  impaired  normal 
actions  (which  are  due  partly  to  previous  disease  and  also  found  in  healthy  folk, 
and  partly  from  the  effects  of  the  possible  spinal  disease),  he  or  she  should  be 
trained  in  posturings,  using  particularly  fullest  extension  for  the  hands  and  arms, 
and  fullest  flexions  for  the  legs  and  feet.  To  avoid  aggravating  the  effects  of  weak- 
ness, usually  a  marked  and  disabling  feature,  many  of  these  are  best  executed  while 
lying  down. 

One  other  measure  I  have  found  of  great  additional  value.  This  is  to  manipu- 
late the  tissues  lying  adjacent  to  the  vertebrae  by  gentle  repeated  pressures.  By 
this  it  seems  we  can  aid  in  improving  the  circulation,  hence  the  nutrition  in  the 
cell  bodies  in  the  segments  of  the  cord.  It  is  best  done  by  the  physician  himself. 
General  massage  has  its  value,  but  less  for  mere  muscle  kneading  than  the  passive 
movements  of  the  joints,  the  elasticizing  of  the  ligaments,  etc. 

When  the  mobility  of  the  thorax  admits  of  it,  systematic  respiratory  education 
will  valuably  supplement  the  oxygen  intake  and  distribution.  As  soon  as  strength 
and  elasticity  permit,  open  air  employments,  such  as  gardening  and  light  farm 
work,  are  most  salutory.  Always  encouragement  and  cheerfulness  is  to  be  insisted 
on.  The  simplest  active  sports  should  be  pursued  with  what  enthusiasm  is  pos- 
sible. 

J.  Madison  Taylor,* 

Philadelphia. 


Cyclopaedia  of  Current  literature. 


AGGLUTINATION    TESTS,    SOME    FALLA-  comparisons  of  the  results  obtained  by 

CIES  IN.  different  observers. 
Without  entering  into  the  discussion  The  susceptibility  of  an  organism  to 

as  to  the  chemical  or  physico-chemical  agglutinins    increases    for    the    first   six 

nature  of  agglutination  and  the  bearing  months  from  the  time  it  has  been  iso- 

this  has  on  the  differences  in  the  agglu-  lated  from  the  animal  body  and  grown 

tination    reaction    and    vice    versa,    the  on  artificial  media.    Inoculations  of  ani- 

writer  wishes  to  point  out  that  in  carry-  mals  with  broth  culture  will  produce  in 

ing  out  these  tests,  a  greater  uniformity  their  sera,  beside  the  agglutinins,  pre- 

in   the   technique   is    required    to    allow  cipitins  whose  reaction^  in  broth  culture 

*  Formerly  neurologist  to  the  Howard  Hospital. 


AIR  IN  VEINS  DURING  SURGICAL  OPERATIONS. 


209 


cannot  be  distinguished  from  true  ag- 
glutination, as  the  organisms  are  me- 
chanically deposited  in  the  precipitate. 
Pseudo-clumping  may  be  obtained  by 
using  emulsions  of  bacteria  in  undiluted 
broth  and  testing  against  the  above 
serum.  The  agglutination  of  a  micro- 
organism varies  with  the  medium  in 
which  it  is  grown,  the  reaction  of  that 
medium,  the  temperature  of  incubation, 
and  the  number  of  organisms  present  in 
the  emulsion.  Pseudo-clumping  may  be 
produced  by  sudden  changes  in  the  tem- 
perature and  by  the  addition  of  certain 
chemicals.  The  addition  of  carbolic  acid 
or  of  chloroform  as  preservatives  in  an 
immune  serum  does  not  interfere  with 
the  agglutination  reaction.  In  using  the 
dried  blood  test,  paper  having  a  soluble 
gloss  should  be  avoided  for  collecting 
the  blood.  In  the  author's  hands  the 
macroscopic  method  for  determining  ag- 
glutination has  proved  the  most  useful 
and  rapid.  Oskar  Klotz  (Journal  of 
the  American  Medical  Association,  April 
23,  1905). 

AIR    IN    VEINS    DURING    SURGICAL    OP- 
ERATIONS. 

Basing  their  conclusions  on  recent 
clinical  operations,  and  on  the  results  of 
the  careful  experiments  of  Begouin  made 
in  1898,  the  authors  throw  some  fresh 
light  on  the  mechanism  and  the  treat- 
ment of  the  surgical  disaster  known  as 
air  in  veins.  This  rare  accident,  though 
as  a  rule  rapidly  fatal,  may  in  some  in- 
stances present  a  prolonged  and  less 
fulminating  series  of  symptoms,  and, 
indeed,  may  result  in  recovery.  Cases 
have  been  recorded  in  which  death, 
which  usually  occurs  within  ten  min- 
utes from  the  first  appearance  of  the 
symptoms,  has  been  retarded  for  inter- 
vals   varying    from    three    to,  thirteen 


hours,  and  the  authors  assert  surgeons, 
in  the  course  of  operations  on  the  neck, 
have  observed  the  characteristic  symp- 
toms of  the  entrance  of  air  into  veins, 
after  having  heard  the  distinct  hissing 
sound,  and  yet  have  seen  their  patients 
recover  after  an  interval  of  a  few  hours. 

In  discussing  the  cause  of  death  in 
cases  of  air  in  veins,  the  authors  hold 
that  it  exists  not  simply  in  obstruction 
of  the  pulmonary  capillaries,  but  in  an 
association  of  pulmonary  embolism  with 
weakening  of  the  heart's  action,  due  to 
distension  of  the  cavities  on  the  right 
side.  The  introduction  of  "air  into  a  vein 
in  the  course  of  a  surgical  operation  is 
held  to  be  the  consequence  of  venous  gap- 
ing, the  result  either  of  a  normal  an- 
atomical condition  as  is  presented  in  the 
neck  and  axilla,  or  of  a  pathological 
modification  consisting  in  induration  of 
the  venous  coats  or  of  the  perivenous  tis- 
sues. The  part  played  by  this  venous 
patency  in  the  aspiration  of  air  may  be 
supported  by  a  diminution  of  venous 
tension  resulting  from  repeated  or  pro- 
fuse hemorrhage.  The  severity  of  the 
symptoms  bears  a  relation  to  the  amount 
of  air  introduced  into  the  veins,  and  the 
rapidity  of  this  introduction.  It  has 
been  shown  by  experiments  on  dogs  that 
while  the  sudden  and  forcible  injection 
of  from  40  to  60  cubic  centimeters  of  air 
will  cause  death  in  one  or  two  minutes, 
a  gentle  injection  of  from  8  to  10  cubic 
centimeters  will  in  most  instances  be 
followed  by  recovery.  These  results  ex- 
plain why  the  entrance  of  air  into  veins 
is  not  always  fatal.  The  air  slowly  in- 
troduced becomes  partly  dissolved,  and 
if  the  quantity  be  not  excessive,  the 
heart  may  continue  its  contractile  action. 

In  their  remarks  on  the  prevention 
and  treatment  of  this  accident,  the  au- 
thors insist  on  the  importance  in  the 


210 


ALCOHOL. 


APPENDICITIS,  OPENING  ABDOMEN  IN. 


removal  of  a  large  tumor  from  a  vascular 
region  of  securing  all  visible  vessels,  and 
especially  dilated  veins,  before  these  are 
divided.  As  a  scientific  and  promising 
method  of  dealing  with  the  serious  con- 
dition caused  by  the  entrance  of  air,  they 
suggest  aspiratory  puncture  of  the  heart. 
The  most  suitable  part  of  this  organ  to 
be  attacked  in  such  treatment  would, 
they  state,  be  the  right  ventricle,  as  this, 
in  consequence  of  the  thinness  of  its 
walls,  is  apt  to  be  especially  affected  by 
over-distension,  and,  moreover,  aspira- 
tion of  this  cavity  may  act  more  directly 
on  the  large  venous  trunks,  and  possibly 
remove  some  of  the  air.  The  right  au- 
ricle, it  is  asserted,  may  be  readily 
reached  by  introducing  the  needle  in  the 
third  intercostal  space  on  the  left  side 
at  a  distance  of  1  1/2  cubic  centimeters 
from  the  border  of  the  sternum,  and, 
after  the  wall  of  the  chest  has  been 
traversed,  of  passing  its  point  toward  the 
mecho-sternal  line.  This  minor  opera- 
tion is  regarded  as  quite  free  from  risk, 
and  likely,  if  practiced  without  delay, 
to  be  as  beneficial  on  the  human  sub- 
ject as  it  has  proved  to  be  on  animals. 
Delore  and  Duteil  (Rev.  de  Chir.,  No. 
3,  1905 ;  British  Medical  Journal,  April 
8,  1905). 

ALCOHOL:     LOCAL  THERAPY. 

The  author  reports  the  results  of  his 
tests  with  local  application  of  alcohol  in 
a  large  series  of  cases  of  which  the  his- 
tories are  given.  For  the  alcohol  com- 
presses he  employed  50  per  cent,  of  alco- 
hol in  some  cases  and  9G  per  cent,  in 
other  cases,  poured  on  a  piece  of  hydro- 
philous gauze,  folded  into  eight  layers. 
Most  of  the  patients  suffered  from  ery- 
sipelas, while  the  remainder  included 
tuberculous  peritonitis  and  appendicitis. 
In    erysipelas    excellent    results    are    re- 


ported. The  swelling  of  the  eyelids,  the 
lips  and  cheeks  were  favorably  and  rap- 
idly influenced,  and  in  none  of  his  pa- 
tients did  severe  complications  set  in. 
In  the  case  of  erysipelas  a  50  per  cent, 
solution  of  alcohol  should  be  used,  for 
the  more  concentrated  solutions  harden 
the  superficial  layers  of  the  skin  and 
prevent  its  absorption.  The  author 
states  that  in  tuberculous  peritonitis  the 
alcohol  treatment  is  especially  indicated 
when  the  disease  is  accompanied  by 
other  forms  of  tuberculosis,  or  when  an 
operation  is  impossible  for  any  reason. 
The  results  obtained  in  appendicitis  are 
most  favorable.  The  author  agrees  with 
Filatow  as  to  the  therapeutic  value  of 
alcohol  in  this  condition,  and  concludes 
that  in  many  cases  which  fail  to  respond 
to  opium  and  ice,  alcoholic  compresses 
may  lead  to  rapid  recovery  and  assist  in 
preserving  the  strength  of  the  patient. 
A  compress  of  96  per  cent,  alcohol  is 
well  borne  by  the  skin,  but  only  when  it 
is  covered  with  flannel  instead  of  wax 
paper,  for  the  latter  excludes  the  air.  An 
ice-bag  should  be  laid  upon  the  flannel. 
When  the  skin  is  tender,  as  in  young 
children,  a  thin  compress  of  two  layers 
should  be  employed,  and  in  every  case 
the  flannel  should  be  covered  with  an 
ice-bag.  It  was  observed  that  the  appli- 
cation of  alcohol,  aside  from  its  pain- 
alleviating  and  resorptive  action,  suc- 
ceeded in  many  cases  in  aborting  abscess 
formation.  K.  Walko  (Berliner  klin- 
ische  Wochenschrift,  February  13,  1905 ; 
American  Medicine,  April  15,  1905). 

APPENDICITIS,      METHOD      OF      OPENING 
ABDOMEN    IN. 

The  writer  considers  McBurney's 
gridiron  incision  ideal  for  a  large  ma- 
jority of  the  interval  operations  of  ap- 
pendicitis.    If  more  room  is  needed  the 


APPENDICITIS,  MORTALITY  OF. 


ASEPTIC  OPERATING, 


211 


incision  may  be  enlarged,  the  so-called 
extended  McBurney  incision.  In  nearly 
every  case  of  appendicitis  the  writer 
makes  it  a  rule  to  enter  the  free  abdominal 
cavity  beyond  the  appendix  and  the  in- 
flammatory mass  in  order  to  examine 
for  secondary  abscesses  and  to  determine 
the  condition  of  the  rest  of  the  abdomen. 
If  the  appendix  mass  extends  beyond 
the  semilunar  line  it  is  better  to  open 
the  abdomen  by  a  vertical  incision 
through  the  rectus  sheath  and  separate 
the  rectus  muscle  or  to  retract  it.  If 
it  extends  to  the  middle  line  or  be}'ond, 
the  author  opens  in  the  middle  line. 
The  rectus  incision  for  the  interval  op- 
eration is  a  good  one,  but  has  the  ob- 
jection that  if  drainage  is  found  to  be 
necessary,  the  oblique,  and  transversalis 
muscles,  when  they  contract,  tend  to 
spread  the  opening  in  the  rectus  muscle 
and  sheath.  P.  B.  Harrington  (Boston 
Medical  and  Surgical  Journal,  March 
23,  1905). 

APPENDICITIS,   MORTALITY   OF. 

To  decrease  the  mortality  of  appen- 
dicitis an  early  diagnosis  is  of  the  first 
consideration.  All  troublesome  appen- 
dices should  be  removed  without  wait- 
ing for  an  acute  attack.  All  acute 
cases  should  be  dealt  with  surgically  in 
the  interval  between  the  onset  of  appen- 
dicitis and  the  dangerous  rupture,  with- 
out waiting  for  pus  outside  the  appendix, 
for  peritonitis,  for  adhesions,  or  for  a 
possible  but  remote  interval. 

Cases  of  perforation  or  gangrene,  with 
localized  abscess,  should  be  operated  on 
with  drainage  or  removal  of  the  appen- 
dix, according  to  the  judgment  of  the 
operator.  Cases  with  perforation  or 
gangrene  without  a  wall  or  adhesion  are 
in  still  greater  need  of  an  outlet  for  the 
infection,  to  lessen   tin1  tendency  of  in- 


fection to  travel  inward.  Price,  Murphy, 
Hawkes,  and  others  have  shown  a  better 
percentage  of  recovery  by  the  operative 
treatment  of  acute  perforative  perito- 
nitis. 

A  case  of  appendicitis  should  be  op- 
erated on  at  any  time  if  the  patient's 
condition  will  admit  of  an  operation,  un- 
less the  case  is  rapidly  and  beyond  a  ques- 
tion of  doubt  convalescing.  And  in  this 
latter  case  we  should  wait  until  all  acute 
symptoms  have  passed.  Healthy  appen- 
dices should  be  let  alone. 

The  proper  treatment,  as  indicated 
above,  does  not  contraindicate  the  use 
of  stomach  lavage  or  the  withholding  of 
food,  and  when  proper,  these  things 
should  be  employed,  with  or  without  op- 
eration. 

Lastly,  life  is  not  the  only  considera- 
tion. Time  of  cure  and  after-conditions 
are  important.  A  patient  going  through 
an  acute  attack  without  operation  is 
saved  by  the  adhesions.  Adhesions  are 
life-saving  for  the  time,  but  they  may 
be  death-dealing  afterward.  The  wait- 
ing treatment  favors  adhesions.  The 
early  operation  avoids  .them.  An  early 
operation  sends  the  patient  home  in  from 
ten  days  to  three  weeks.  »  Twelve  cases 
treated  by  the  rest  treatment  show  an 
average  of  60.5  days  from  the  onset  of 
the  disease  to  the  discharge  from  the 
hospital.  C.  W.  Barrett  (Journal  of  the 
American  Medical  Association.  April  15, 
1905). 

ASEPTIC  OPERATING,  POINTS  IN  THE 
TECHNIQUE  OF. 
The  author  does  not  regard  rubber 
gloves  as  an  ideal  coating,  since  they  not 
only  interfere  with  delicacy  of  manipu- 
lation, but  they  excite  pcrspi rat  ion. 
which  may  at  any  moment,  through  a 
tear  or  puncture  in  the  glove,  convey  in- 


212 


BILE  DUCT  DISEASE. 


fection  to  the  patient.  Coating  the 
hands  with  gutta-percha  is  open  to  the 
same  objection — a  scratch  would  liberate 
an  accumulation  of  infectious  material. 
The  old  way  of  thoroughly  cleansing  the 
the  hands  and  then  applying  a  germicide 
that  will  harden  the  surface  and  check 
perspiration,  and  that  can  be  removed 
from  time  to  time  during  a  long  opera- 
tion, seems  to  be  very  nearly  the  ideal 
method  of  treating  a  surface  that  can- 
not be  sterilized  except  in  the  most  su- 
perficial manner. 

Since  the  bristles  of  the  brush  cannot 
enter  the  pores  of  the  skin,  in  addition 
to  scrubbing  the  hands,  a  certain  amount 
of  soaking  is  necessary  to  loosen  the  dirt 
that  cannot  be  reached.  Twenty  min- 
utes of  soaking  in  soapy,  frequently 
changed  water  in  a  basin  is  better  than 
washing  under  running  water.  After 
cleansing  with  green  soap,  matter  that 
may  be  insoluble  in  the  alkali  is  to  be 
removed  by  brief  soaking  in  dilute  acetic, 
citric,  or  oxalic  acid  solution.  A  fur- 
ther scrubbing  with  90  or  95  per  cent, 
alcohol  will  penetrate  deeper,  harden  the 
cuticle,  and  tend  to  imprison  the  un- 
reachable staphylococci. 

This  preparation  should  be  sufficient 
for  a  short  operation,  but  for  a  long  one 
a  further  scrubbing  and  soaking  for  five 
minutes  in  a  1  to  2000  aqueous  solution 
of  mercuric  chloride  is  recommended. 
The  hardened  film  is  probably  worked 
off  during  a  protracted  operation,  but  it 
can  be  renewed  by  dipping  the  hands  and 
arms  in  the  mercuric  chloride  solution 
every  ten  or  fifteen  minutes.  The  prac- 
tice of  covering  the  arms  with  sterile 
sleeves  is  open  to  the  objection  that  the 
more  or  less  loose  folds  are  apt  to  catch 
up  dirt  and  carry  it  into  the  field  of 
operation  without  being  noticed,  while 
in  the  case  of  the  bare  arms  contact  with 


unsterilized  articles  is  felt  by  the  op- 
erator. 

With  the  ordinary  preparations  for 
operations  it  is  true  that  there  is  danger 
of  the  antiseptic  solution  in  use  during 
the  operation  being  brought  into  con- 
tact with  and  irritating  the  peritoneum. 
To  exercise  due  care  in  this  matter  the 
operator  should  have  three  basins  within 
easy  reach,  two  filled  with  warm,  sterile 
water,  and  one  with  a  warm  1/2000  mer- 
curic chloride  solution.  The  hands 
should  be  dipped  first  into  a  basin  of 
warm  water  to  remove  the  blood,  then 
into  the  solution,  and  lastly  into  the 
other  basin  of  water  to  remove  the  ex- 
cess of  mercuric  chloride. 

In  the  matter  of  dressings  also  there 
is  danger  from  such  as  do  not  insure 
perfect  dryness  of  the  skin,  for  germs 
require  moisture  for  their  development. 
Dry  dressings  over  peritoneal  sutures 
should  be  changed  every  four  hours,  and 
oftener,  if  they  become  saturated.  H.  T. 
Byford  (Journal  of  the  American  Med- 
ical Association,  March  11,  1905). 

BILE  DUCT  DISEASE. 

Stones  should  be  removed,  for  if  left 
behind  they  are  very  sure  to  cause  sub- 
sequent disturbance,  and  it  is  known, 
conversely,  that  after  the  thorough  re- 
moval of  stones  their  recurrence  is  al- 
most unknown.  So  far  as  possible,  all 
disorganized,  degenerated,  and  perma- 
nently crippled  tissue  should  be  re- 
moved; such  tissue,  when  left  behind, 
may  become  the  nidus  for  subsequent  in- 
flammation, stone  formation,  and  a  re- 
turn to  the  invalid  condition.  Drainage 
should  be  resorted  to,  for  without  drain- 
age there  is  no  certainty  of  the  removal 
of  infectious  material.  J.  G.  Mumford 
(Boston  Medical  and  Surgical  Journal, 
March  2,  1905). 


CACHEXIAL  FEVER,  LEUCOPENIA  OF. 


CANCER  OF  MOUTH. 


213 


CACHEXIAL    FEVER,     THE    LEUCOPENIA 

or. 

A  very  marked  decrease  in  the  leuco- 
cytes is  always  found  in  uncomplicated 
cases  of  cachexial  fever,  and  when  they 
number  below  2000  cubic  centimeters 
this  is  almost  diagnostic  of  the  disease, 
but  may  rarely  occur  in  true  malarial 
cachexia. 

In  cachexial  fever  the  white  corpuscles 
are  reduced  to  a  greater  degree  than  the 
red,  so  that  the  ratio  falls  below  1  to 
1000  in  all  uncomplicated  progressive 
cases.  This  is  rarely  so  in  true  malarial 
cachexia,  while  a  reduction  in  the  ratio 
to  below  1  to  1500  appears  to  be  quite 
diagnostic  of  cachexial  from  other  In- 
dian fevers. 

The  most  marked  degrees  of  reduc- 
tion of  the  leucocytes,  and  especially  of 
the  polynuclears,  is  of  bad  prognostic 
import,  and  vice  versa. 

Red  marrow  tabloids  are  of  great  value 
in  increasing  the  leucocytes,  and  this  in- 
crease may  take  place  during  the  con- 
tinuance for  months  of  intermittent 
fever,  and  be  then  followed  by  cessation 
of  the  fever  and  complete  recovery. 

High  remittent  fever  is  accompanied 
by  progressive  deterioration  of  the  blood 
and  general  condition,  but  it  may  be 
often  to  a  large  extent  reduced  to  the 
less  injurious  intermittent  form  by  con- 
tinued large  doses  of  quinine,  combined 
with  red  marrow.  The  best  results  yet 
reported  have  been  obtained  by  those  who 
carry  out  vigorous  quinine  treatment. 
Leonard  Rogers  (British  Medical  Jour- 
nal, April   1,  1905). 

CANCER  IN  AND  ABOUT  THE  MOUTH.  * 

The  mortality  of  cases  suffering  from 
carcinoma  in  and  about  the  buccal  cav- 
ity (based  on  the  statistics  presented  in 
the  authors'  report)    is  extremely  high, 


at  least  90  per  cent.  All  unoperated 
cases  die  sooner  or  later  of  the  disease, 
barring  intercurrent  affections.  The 
duration  of  life  of  operated  cases  as  com- 
pared with  those  not  operated  is  in  favor 
of  the  former  by  an  average  of  about 
three  and  one-half  months.  The  com- 
fort of  the  individual  is  distinctly  added 
to  (even  if  it  be  only  temporary)  by 
some  sort  of  surgical  intervention ;  such 
relief  may  be  either  mental  or  physical. 
An  early  diagnosis  of  malignant  dis- 
ease about  the  buccal  cavity  is  of  the 
greatest  importance,  and  a  moderately 
radical  excision  of  parts  offers  the  great- 
est hope  of  a  radical  cure,  commensurate 
with  the  comfort  of  the  patient  and  the 
immediate  risk  to  life.  The  importance 
of  a  most  radical  excision  of  parts  in 
and  about  the  seat  of  malignant  disease 
is  realized.  In  general,  such  extremely 
radical  measures  offer  the  greatest  hope 
of  permanent  cure.  The  surgical  treat- 
ment of  malignant  disease  situated  in 
very  many  parts  of  the  body  should  con- 
sist of  most  radical  excision.  On  the 
other  hand,  malignant  disease  may  be 
situated  in  and  about  certain  parts  where 
extreme  radical  excision  is  attended 
either  with  great  immediate  risk  to  life 
or  may  so  interfere  with  the  function  of 
the  parts  that  the  subsequent  suffering 
and  discomfort  of  the  patient,  provided 
he  survive  the  operation,  does  not  war- 
rant such  radical  treatment,  in  view  of 
the  great  probability  of  recurrence. 
There  are  instances  where  the  patient 
wishes  extreme  measures  to  be  taken  for 
the  purpose  of  avoiding  recurrence,  and 
under  such  circumstances  there  is  no  ob- 
jection to  employing  the  most  radical 
measures.  Tbe  risk  and  discomfort, 
however,  together  with  the  inability  to 
offer  much  hope  of  non-recurrence,  fol- 
lowing   the    complete    removal    of    the 


214 


CANCER,  NATURAL  HISTORY  OF. 


tongue,  the  inferior  maxilla  or  more  or 
less  of  the  pharynx  and  larynx,  should 
be  weighed  and  carefully  presented  to 
the  patient  before  such  radical  treat- 
ment is  undertaken. 

When  there  is  extensive  invasion  of 
the  parts,  excision  (if  done  at  all)  should 
be  undertaken  solely  with  the  idea  of 
palliation,  without  too  serious  interfer- 
ence with  physiological  function  and 
without  too  great  immediate  risk.  H.  A. 
Lothrop  and  D.  D.  Scannell  (Boston 
Medical  and  Surgical  Journal,  April 
13,  1905). 

CANCER.    NATURAL   HISTORY   OF. 

The  author  remarks  that  his  clinical 
experience  is  confirming  him  more  and 
more  in  the  belief  that  senilism,  in  the 
widest  application  of  the  term,  is  the 
primal  etiologic  factor  in  cancer.  The 
senile  changes  may  be  premature  or  at 
the  normal  period;  they  may  be  local- 
ized in  skin,  mucosa,  or  glands,  or  they 
may  be  generalized,  and  they  may  occur 
spontaneously  and  normally  or  abnor- 
mally in  these  parts  of  the  body.  He 
is  further  convinced  that  a  local,  slow, 
and  torpid  affection,  with  mild  and  in- 
significant symptoms,  may  pass  into  an 
acutely  malignant  phase  under  the  in- 
fluence of  depressing  circumstances.  A 
number  of  instances  are  cited  in  which 
an  old,  mild  gastric  trouble  developed 
into  a  rapidly  fatal  cancer  after  ex- 
cessive overwork  or  ovcrworry.  In  re- 
gard to  the  curability  of  cancer,  the  au- 
thor thinks  that  permanent  cures  can  be 
counted  on  after  early  removal  of  pri- 
mary carcinomata  in  certain  regions  of 
the  skin,  especially  on  the  face,  and  in 
case  of  tumors  that  have  developed  from 
warts  or  novi.  He  also  believes  that  the 
prospects    are   better    in    case    of    spare 


elderly  patients  than  for  younger  per- 
sons, especially  pregnant  women,  and 
that  metastases,  as  a  rule,  obscure  the 
prognosis.  It  is  remarkable,  however, 
that  the  metastatic  tumors  are  so  much 
more  amenable  to  curative  measures  than 
the  primary  growth. 

The  importance  of  hygiene,  of  regular 
habits  of  life  and  of  avoidance  of  con- 
tact with  cancer  subjects,  which  may  be 
dangerous  for  the  predisposed,  is  em- 
phasized. Spontaneous  retrogression  of 
metastatic  tumors  after  removal  of  the 
primary  focus  is  also  liable  to  occur. 
The  author  calls  attention  again  to  a 
method  of  treating  cancer  which  he  pub- 
lished some  years  ago.  It  is  based  on 
the  observation  that  the  individual  can- 
cer cells  are  very  short  lived.  He  ex- 
cludes temporarily  the  affected  limb  or 
organ  from  the  circulation  and  then  tries 
to  flush  it  through  one  of  its  main  ar- 
teries with  an  alkaline  fluid,  washing  out 
the  residual  blood  by  a  counter  opening 
in  one  of  the  main  veins.  His  descrip- 
tion of  a  cancer  of  the  uterus  thus  treated 
in  1892  was  published  in  Hegar's  Beit- 
rage,  vol.  i,  No.  3.  He  adds  that  a 
promising  field  for  cancer  research  is  in 
the  study  of  the  parts  most  frequently 
affected  with  cancer  before  such  -growth 
occurs.  Further  important  results  may 
be  obtained  from  study  of  the  vitality  of 
the  cells  of  various  adjacent  tissues  sepa- 
rated from  their  environment.  Went- 
scher  has  already  reported  research  in 
this  line  on  the  persisting  vitality  of  the 
.  cells  of  the  rete  malpighii  in  detached 
scraps  of  skin.  Study  of  such  cells 
within  twenty-four  hour?  after  death 
might  also  afford  interesting  results.  It 
is  important  to  study  the  favorite  locat- 
ing points  of  cancer  in  the  lymph  and 
blood-vessels,  as  Kroemer  and  R.  Freund 
have  been  doing  for  tire  uterus.     W.  A. 


CANCER,  GROWTH  OF. 

Freund  (Zeitschrift  f.  Krebsforschunf, 
vol.  ii,  No.  1 ;  Journal  of  the  American 
Medical  Association,  April  8,  1905). 

CANCER,   THE   GROWTH   OF. 

Cancer  is  identical  in  all  vertebrates 
and  in  growing  accommodates  itself  in 
a  striking  manner  to  the  time  limitations 
imposed  by  the  compass  of  life  in  dif- 
ferent animals.  Under  favorable  experi- 
mental conditions  the  growth  of  cancer 
is  undefined,  of  enormous  and,  so  far  as 
can  be  judged,  limitless  amount.  Arti- 
ficially propagated  cancer  displays  all 
the  characteristic  features  of  the  growth 
of  sporadic  tumors,  and  is  due  to  the  con- 
tinued proliferation  of  the  parenchyma 
cells.  The  author  has  confirmed  this 
conclusion,  originally  advanced  by  Jen- 
sen, on  his  own  tumor  and  on  four  other 
different  carcinomata. 

The  artificially  propagated  parenchyma 
makes  the  reaction  of  the  host  subserve 
its  own  needs.  Artificially  propagated 
tumors  cause  no  symptoms  in  the  organ- 
ism to  which  they  have  been  added.  The 
power  of  differentiation  is  definitely  in 
one  direction  only,  even  three  and  a  half 
years  after  separation  from  the  original 
host.  The  number  of  chromosomes  con- 
stant for  the  healthy  body  tissues  is  re- 
tained, notwithstanding  the  recurring 
reduction  of  this  number  to  the  exact 
half.  The  balance  of  evidence  is  in 
favor  of  the  growth  being  interrupted 
and  not  uniform  and  continuous. 

From  the  standpoint  of  therapeutics 
the  investigations  of  the  Imperial  Can- 
cer Research  Fund  thus  far  establish  the 
early  surgical  treatment  of  cancer  and 
of  the  conditions  suspicions  of  cancer 
upon  that  experimental  and  rational 
basis  which  has  hitherto  failed.  Arti- 
ficially propagated  tumors  produce 
metastases,  as  do  sporadic  tumors.     Suf- 


CEREBRO-SPINAL  FEVER. 


215 


ficiently  early  removal  of  the  local  trans- 
planted tumor  removes  metastasis  from 
the  region  of  possibility  and  the  imme- 
diate practical  outcome  of  the  whole  in- 
vestigation is  a  strong  experimental 
justification  of  early  operation  in  can- 
cer. Many  attempts  have  been  made  to 
modify  the  growth  of  propagated  tu- 
mors; they  have  been,  however,  purely 
empirical  and  must  continue  so  until 
the  fundamental  problem  which  has 
been  outlined  has  been  solved.  E.  F. 
Bashford  (British  Medical  Journal, 
April  1,  1905). 

CEREBRO-SPINAL   FEVER. 

The  author  concludes  that  when  the 
difference  in  virulence  in  different  epi- 
demics is  taken  into  consideration,  it  is 
easy  to  understand  how  faulty  notions 
of  the  effects  of  treatment  may  gain 
credence.  A  review  of  the  subject  seems 
to  warrant  the  conclusion  that  benefit 
does  follow  certain  measures  and  that 
the  most  useful  procedure  is  to  bring 
about  the  best  hygienic  condition  for  the 
patient,  that  is:  (1)  Absolute  quiet  in 
well-ventilated,  darkened  rooms,  with  the 
absence  of  all  excitement  and  irritation. 
(2)  Giving  the  greatest  attention  to  se- 
cure the  proper  performance  of  the  vari- 
ous functions  of  the  body.  (3)  The 
trial  of  the  hot  baths  after  the  method 
of  Aufrecht  in  all  cases  in  which  they 
seem  to  do  good.  (4)  The  practice  of 
intraspinal  puncture,  with  drainage 
when  necessary  to  relieve  severe  pressure 
symptoms,  to  be  repeated,  if  necessary. 
provided  benefit  follows  the  first  punc- 
ture. (5)  The  use  of  antipyrine  in  cases 
in  which  the  temperature  is  raised,  not 
only  for  the  relief  of  this  symptom,  but 
for  the  mitigation  of  headache  and  hy- 
persesthesia.  This  drug  is  also  useful  in 
improving  the  mental  state,  and  it  is  not 


216         CEREBROSPINAL  MENINGITIS.  CHEST,  SIGNS  IN  DISEASES  OF. 


followed  by  depression.  (6)  The  use  of 
opium  or  the  bromides  alone,  or  in  con- 
nection with  antipyrine  for  the  relief  of 
convulsions,  pain,  hyperesthesia,  and 
pressure  symptoms  generally,  which  are 
not  relieved  by  the  foregoing  methods  of 
treatment.  (7)  The  use  of  mercury 
when  needed  for  its  laxative  effect,  or  to 
assist  elimination.  C.  G.  Stockton 
(American  Medicine,  April  1,  1905). 

CEREBRO-SPINAL   MENINGITIS. 

Cerebro-spinal  meningitis  when  first 
recognized  was  purely  epidemic  in  char- 
acter, and  is  now  endemic  in  large  cities. 
Its  method  of  transmission  from  place 
to  place  and  person  to  person  is  un- 
known. According  to  the  latest  and 
best  investigators,  the  exciting  cause  of 
the  epidemic  form  is  the  diplococcus  in- 
tracellularis  meningitidis.  And  no  evi- 
dence has  been  produced  to  prove  that 
the  cause  of  epidemic  and  sporadic  cases 
is  not  the  same.  The  probable  entrance 
of  the  pathogenic  germ  into  the  system  is 
through  the  respiratory  tract,  especially 
that  portion  covered  by  the  Schneiderian 
membrane.  And  its  point  of  attacks  and 
usual  seat  of  greatest  activity  is  the  base 
of  the  brain,  from  which  it  involves  other 
portions  of  the  meninges  of  the  brain 
and  spinal  cord.  Its  action  is  that  of  a 
septic  invasion,  and  its  symptoms  a  com- 
bination of  toxin  poisoning,  nerve  irri- 
tation, and  pressure. 

The  rate  of  mortality  in  late  epidemics 
has  been  about  50  per  cent.,  which  may 
be  lowered  by  a  better  agreement  among 
the  profession  regarding  methods  of  care 
and  treatment.  Spinal  puncture  is  a 
requisite  of  exact  diagnosis,  but  as  a 
method  of  treatment  it  is  still  in  the 
experimental  stage  and  leaves  much  to 
be  desired.  Old  methods  of  treatment 
may  be  made  effective  and  reliable  if  used 


with  decision  and  pushed  to  the  limit  of 
therapeutic  effect.  Cerebro-spinal  men- 
ingitis in  its  worst  form  is  amenable  to 
treatment.  G.  G.  Speer  (Medical  Kec- 
ord,  April  15,  1905). 

CHEST,    NEW    PHYSICAL    SIGNS    IN    DIS- 
EASES  OF. 

A  number  of  new  physical  signs  de- 
scribed by  the  writer  are  considered  by 
him  as  far  more  valuable  in  the  diag- 
nosis of  intrathoracic  disease  than  dias- 
copy.    It  is  but  little  known  that  differ- 
ence in  the  size  of  the  pupils  is  a  com- 
mon symptom  of  apex  tuberculosis.    The 
pupils  of  the  affected  side  is  generally 
wider,   since   the   sympathetic  nerve   is 
irritated  by  the  inflamed  pleura.     An- 
other  valuable  sign  is  the  behavior  of 
the  veins  of  the  chest  if  an  expiratory 
effort  is  made  with  closed  glottis,  as  in 
Valsalva's  method.     Normally  the  ves- 
sels on  both  sides  swell  equally,  but  with 
tumors,  aneurisms,  etc.,  the  veins  which 
are  affected  by  the  compression,  will  be 
more  prominent.     Normally,  the  pupils 
will   contract  somewhat   during  expira- 
tion and  dilate  slightly  with  inspiration; 
with  Valsalva's  method,  there  will  be  a 
gradual,  slight  dilatation  during  the  deep 
inspiration  preceding  the  expiratory  ef- 
fort  and   a   gradual,   slight   contraction 
during  the  latter:    The  following  varia- 
tions occur:     Only  one  pupil  will  show 
the  normal  contraction;    the  other  will 
dilate.     On  the  side  of  the  latter,  patho- 
logical   lesions    of    definite    localization 
will  be  found   in  the  thorax.     If  both 
pupils  dilate  instead  of  contracting  dur- 
ing forced  expiration,  the  disease  is  bi- 
lateral.    If  there  is  a  difference  in  the 
size  of  the  pupils  during  normal  respira- 
tion and  the  dilated  pupil  widens  still 
more     during     Valsalva's     experiment, 
while   the   contracted   one   will   become 


DERMATOLOGY. 


DIABETES,  ETIOLOGY  OF. 


217 


normal,  intrathoracic  disease  of  the  wide 
pupil  is  probable.  If  the  pupils  differ  in 
size  with  quiet  respiration,  but  dilate 
with  Valsalva's  method,  bilateral  intra- 
thoracic affection  is  probable.  If  the 
smaller  pupil  becomes  equal  in  size  or 
larger  than  the  second  one,  the  disease 
probably  also  affects  both  sides,  if  local 
disease  or  organic  disease  of  the  nervous 
system  can  be  excluded. 

Absence  of  all  these  phenomena  does 
not  argue  against  intrathoracic  disease. 
The  percussion  note  obtained  over  the 
manubrium  sterni  is  also  of  the  greatest 
value.  In  real  or  inflammatory  tumors 
of  the  mediastinum  there  will  often  be 
dullness  with  closed  mouth  and  dull 
tympany  with  open  mouth,  or  dull  tym- 
pany with  closed  mouth  and  Wintrich's 
change  of  percussion  with  open  mouth. 
If  the  posterior  mediastinum  is  chiefly 
affected,  the  note  will  be  purely  tym- 
panitic with  closed  mouth,  with  distinct 
Wintrich's  change  on  opening  the  mouth. 
A.  Grober  (Deutsch.  Arch.  f.  klinische 
Medicin,  vol.  lxxxii,  Nos.  3  and  I ;  Med- 
ical News,  March  18,  1905). 

DERMATOLOGY,    SOME    NEW    THERAPEU- 
TIC MEASURES  IN. 

As  a  general  rule,  in  the  treatment  of 
chronic  and  obstinate  affections  of  the 
skin,  the  object  to  be  aimed  at  is  the 
production  of  reaction.  So  far  from  its 
being  an  accident  to  be  avoided,  the  au- 
thor thinks  that  it  is  a  most  important 
part  of  the  curative  process.  Of  course. 
there  must  not  be  any  excess  of  zeal,  or 
the  overwhelming  force  called  into  play 
may  be  as  destructive  as  a  too  powerful 
ally  brought  in  to  suppress  a  rebellion. 
The  means  must  in  all  cases  be  precisely 
adapted  to  the  end  that  is  aimed  at.  It 
would,  for  instance,  be  unjustifiably  rash 
to  run  the  risk  of  poisoning  a  patient 


with  chrysarobin  to  cure  a  small  patch 
of  psoriasis  on  the  elbow.  Caution  is 
particularly  necessary  in  the  use  of  the 
x-rays,  which,  as  every  one  knows,  may, 
if  used  without  strict  precautions,  cause 
necrosis  of  tissues,  even  extending 
through  the  thickness  of  a  limb. 

It  is  better  as  a  general  principle  to 
produce  reaction  by  a  local  application, 
but  where  this  is  found  to  be  impossible 
an  attempt  should  be  made  to  excite  it 
by  means  of  agents  within  the  body. 

The  author  does  not  wish  to  be  under- 
stood as  holding  that  the  whole  or  even 
the  essential  part  of  the  curative  process 
consists  in  reaction  alone.  There  may 
be  other  factors  which  stimulate  the  vital 
processes  into  healthier  activity,  produce 
chemical  changes,  destroy  parasites,  or 
render  the  soil  unsuitable  for  their 
growth,  or  make  an  environment  in 
which  they  cannot  live,  or  act  in  some 
way  at  present  totally  unknown. 

The  active  principle  in  the  cure  may 
be  generated  or  brought  into  operation 
by  the  reaction,  and  different  kinds  of 
reaction  may  have  special  functions. 
Much,  too,  must  depend  on  the  manner 
in  which  the  reaction  is  excited ;  it  is 
probable  that  a  certain  kind  of  reaction 
is  adapted  to  a  particular  disease.  This 
field  of  clinical  and  pathological  re- 
search is  as  yet  almost  virgin  soil,  which 
will  repay  cultivation.  Malcolm  Morris 
(British  Medical  Journal,  April  1, 
1905). 

DIABETES,    ETIOLOGY    OF. 

The  pancreatic  theory  of  the  origin  of 
diabetes  rests  upon  a  hypothetical  inter- 
nal secretion  having  its  origin  in  the 
islands  of  Langerhans  of  the  pancreas, 
and  which  may  act  in  one  of  two  ways. 
either  first,  by  acting  on  the  sugar  in  the 
blood  so  as  to  convert  it  into  some  new 


218 


DIPSOMANIAC  PHASES. 


substance  for  final  assimilation  by  the 
tissue  cells,  or  second,  by  antagonizing  or 
neutralizing  some  substance  present  in 
the  body,  probably  toxic  in  nature,  which 
tends  to  prevent  this  change  in  the 
blood-sugar.  In  either  instance  this  in- 
ternal secretion  is  absolutely  essential  to 
carbohydrate  metabolism,  and  its  ab- 
sence brings  about  that  chain  of  symp- 
toms which  is  denominated  as  diabetes. 
The  islands  of  Langerhans  may  be  con- 
genially lessened  in  number,  so  that 
there  may  be  all  gradations  from  an  idio- 
syncrasy to  alimentary  glycosuria  or  to 
a  diabetes  developing  in  very  early  life. 

Chronic  pancreatitis,  analogous  to  in- 
terstitial nephritis  or  hepatic  cirrhosis, 
and  often  associated  with  either  or  both, 
is  not  always  accompanied  by  diabetes; 
when  it  is,  the  latter  is  usually  a  late 
product  following  the  final  invasion  of 
the  islands  by  the  progressive  growth  of 
the  connective  tissue;  not  infrequently 
the  greater  part  of  the  acini  being  al- 
most completely  atrophied  before  this 
takes  place.  Chronic  pancreatitis  of  the 
intra-acinar  type  is  much  more  apt  to 
be  accompanied  by  diabetes  because  of 
the  much  earlier  invasion  of  the  islands. 
Other  changes  affecting  the  islands, 
such  as  an  apparent  hyaline  degenera- 
tion of  the  cells,  obscure  in  origin  or 
atrophy,  the  result  of  pressure  from  neo- 
plasms within  or  without  the  pancreas, 
are  not  infrequently  associated  with  dia- 
betes. 

Lastly,  alcohol,  syphilis,  etc.,  may  be 
etiological  factors  indirectly  by  produc- 
ing one  or  the  other  forms  of  pancreati- 
tis, but  possibly  some  other  toxic  sub- 
stances may  act  directly  by  inhibiting 
activity  of  the  island  cells  or  by  antagon- 
izing their  secretion. 

Unfortunately,  there  remains  a  cer- 
tain per  cent,  of  cases  in  which  one  may 


find  no  sufficient  lesion  whatever  of  the 
pancreas  or  elsewhere,  and  therefore  we 
must  confess  the  possibility  of  other  fac- 
tors in  such  as  nervous  hepatic,  etc.,  un- 
less, indeed,  in  these  the  absence  of  le- 
sion may  be  explained  by  the  discovery 
of  the  presence  of  a  toxin  acting  in  the 
manner  just  stated  above.  J.  H.  J.  Up- 
ham  (Columbus  Medical  Journal,  April, 
1905). 

DIPSOMANIAC    PHASES. 

A  change  of  scene  is  necessary  in  the 
treatment  of  dipsomania.  The  patient 
comes  to  associate  certain  changes  of  his 
physical  and  intellectual  breakdown  with 
his  ordinary  occupations..  This  vicious 
circle  must  be  broken  up  by  outside  in- 
fluences. In  most  cases  of  nervous  dis- 
ease some  changes  in  the  state  of  nerve 
conductivity  are  appreciable.  As  a  rule, 
hypertonic  conditions  precede  attacks ; 
these  are  to  be  taken  as  part  of  a  neuras- 
thenic process.  Later  on  this  feverish 
activity  brings  about  exhaustion,  which 
is  more  or  less  a  matter  of  systemic  con- 
cern. In  any  event,  the  plus  condition  is 
factitious  and  not  a  positive  gain. 

In  the  cerebral  organism  undoubtedly 
certain  psychic  circuits  become  estab- 
lished— those  of  the  moral  and  higher 
intellectual  values.  Alcohol  and  other 
narcotics  tend  to  break  down  this  evo- 
lution. On  the  other  hand,  it  is  conceiv- 
able that  an  inordinate  associative  power 
may  create  an  overplus  of  such  higher 
intellectual  values.  The  continuity  of 
protoplasmic  organism  makes  for  tissue; 
psychic  continuity  is  thought.  In  cer- 
tain morbid  processes  excessive  and  im- 
proper" tissue  organization  occurs.  In 
neurotic  individuals,  instead  of  a  dimin- 
ished psychic  activity,  an  actual  excess 
of  ideation  may  be  noticed.     This  may 


EPILEPSY,  PROGNOSIS  OF. 


219 


be  along  lines  of  ordinary  or  extraordi- 
nary correlation. 

But,  while  certain  extremes  of  envi- 
ronment are  prejudicial  to  tissue  con- 
tinuity, so  certain  adventitious  elements 
or  excessive  psychic  activity  may  not 
make  for  the  clearest  consciousness.  It 
may  be  asserted  safely  that  attention  and 
apperception  are  elements  of  the  higher 
consciousness  and  are  the  result  of  more 
or  less  perfect  balance  and  superior  co- 
ordination of  psychic  circuits.  In  neu- 
rotic individuals  —  epileptics,  neuras- 
thenics, dipsomaniacs,  and  the  alienated 
in  general — we  might  expect  to  find 
pathological  circuits  established  in  the 
intellect  whereby  certain  reflex  currents 
may  be  set  in  action,  appreciable  to  the 
self  or  reflective  consciousness,  but  out 
of  its  ordinary  control.  Dreams  and  the 
subconscious  mental  activity  may  be  bor- 
derland effects  of  a  similar  exhibition. 

In  looking  about  for  the  reasons  of 
these  changes,  cither  vasomotor  and 
vascular  modifications  or  essential  nerv- 
ous pathological  processes  must  be  laid 
hold  of.  In  protoplasm  there  are  four 
facultative  aspects,  namely,  contractil- 
ity, irritability,  nutrition,  and  reproduc- 
tion. In  all  the  higher  organized  tissues 
these  four  are  fundamental.  Essential 
changes  must  be  due  to  modifications  of 
these  factors.  A  great  many  causes,  in- 
trinsic and  extrinsic,  are  to  be  looked  for 
as  modifying  influences.  The  effect  on 
the  individual  of  the  four  fundamental 
protoplasmic  faculties  may  be  summed 
up  throughout  bis  tissues  as  (a)  the 
initiative  reflex,  (h)  the  temperamental 
reflex,  (c)  the  nutritive  reflex,  and  (d) 
the  sexual  reflex,  respectively.  These 
work  out  their  influences  according  to 
the  special  nature  of  the  tissues  involved. 
It  may  be  just  as  well  when  our  knowl- 
edge of  the  influence  of  nutritive   and 


therapeutic  values  can  be  extended  to 
include  their  effects  on  the  primitive 
protoplasmic  powers  and  the  organic  re- 
flexes therefrom. 

It  is  the  duty  of  the  physician,  in  the 
matter  of  dipsomaniacs,  as  well  as  of 
other  borderland  cases  of  alienation,  to 
educate  public  sentiment  and  to  secure 
for  them  adequate  places  of  treatment 
and  opportunities  of  protected  environ- 
ment. Seclusion  in  a  lunatic  asylum  is 
not  the  thing.  The  dipsomaniac  has  to 
sustain  enough  loss  of  self-respect  with- 
out having  that  pressure  added  too. 
Cases  of  transient  mental  affection  ought 
by  no  means  to  be  associated  with  chronic 
or  disagreeable  manifestations  of  intel- 
lectual or  nervous  disease.  The  author 
believes  that  relapses  in  melancholic 
cases  may  justly  be  attributed  to  the 
regimen  or  associations  with  which  they 
have  been  made  to  feel  the  disgrace  of 
such  sickness.  A  certain  attitude  toward 
mental  cases  is  very  keenly  appreciated 
by  them,  even  if  they  are  "insane." 

The  dipsomaniac  may  be,  and  usually 
is,  of  enough  intelligence  to  feel  his 
situation  deeply,  and  the  open  disgrace 
of  alcoholism,  and  his  belief  in  the  im- 
possibility of  taking  it  from  the  memory 
of  others,  let  alone  himself,  increases  the 
chance  of  recidivism. 

In  treatment  nothing  equals  the  ex- 
pulsive power  of  a  new  affection.  The 
patient  should  be  found  something  safe, 
honorable,  and  interesting  to  do — some- 
thing that  is  suitable  for  a  patient  of 
intelligence,  but  of  neurasthenic  trend. 
T.  II.  Evans  ("New  York  Medical  Jour- 
nal and  Philadelphia  Medical  Journal, 
April  1,  1905). 

EPILEPSY,  PROGNOSIS  OF. 

The  author  reports  his  observations  on 
51G  cases  of  epilepsy.     All  cases  which 


220 


GALL-STONE  DISEASE. 


showed  any  coexistent  complication,  such 
as  organic  cerebral  disease,  and  all  cases 
of  idiocy  and  pronounced  imbecility 
were  eliminated,  and  any  transitory  ame- 
lioration resulting  from  medicinal  or 
other  treatment  was  checked  by  fixing 
the  minimum  period  of  observation  at 
two  years. 

Sex  plays   little  part   in  the  general 
prognosis  of  epilepsy.    Rather  more  males 
than  females  show  arrest  of  the  seizures, 
but  at  the  same  time  the  former  sex 
gives  a  greater  percentage  of  confirmed 
cases.     As  to  the  influence  of  a  heredi- 
tary  disposition,   it  would   appear   that 
there  is  as  great  a  chance  of  arrest  of 
epileptic  fits  in  those  who  have,  as  in 
those  who  have  not,  a  known  family  his- 
tory of  epilepsy.     In  those  who  have  a 
hereditary    history    the    chances    as    to 
whether  the   fits   become   arrested,   im- 
proved, or  confirmed  are  in  any  given 
case  about  equal.    As  regards  general  im- 
provement, more  is  to  be  expected  in 
those  who  have  no  hereditary  disposition, 
while  a  considerably  smaller  percentage 
of  confirmed   epileptics  is  to  be  found 
among  those  who  have  no  family  pre- 
disposition   to    the    disease.      Epilepsy 
commencing  under   10  years  of  age  is 
least  favorable   for   arrest   or   improve- 
ment, and  most  favorable  for  the  pro- 
duction of  confirmed  cases.     In  those  in 
whom  the  disease  commenced  during  the 
period  of  puberty  is  to  be  found  the 
greatest  percentage  of  confirmed  cases. 
Between    the    twenty-first    and    twenty- 
fifth  year  of  age  there  is  a  steady  dim- 
inution   in    the    percentage    of    arrests 
and  a  progressive  increase  in  the  per- 
centage of  confirmed  cases.     After  the 
latter  age  there  is  again  a  diminution  in 
the  number  of   confirmed   cases,   while 
senile  epilepsy  is  essentially  a  tractable 
disorder.    The  earlier  a  case  is  brought 


under  systematic  treatment,  the  more 
hopeful  the  prognosis  and  the  greater  the 
probability  of  improvement.  The  longer 
the  interval  between  the  attacks,  the 
greater  the  prospect  of  arrest  or  im- 
provement. 

The  greatest  percentage  of  arrest  oc- 
curred in  cases  of  grand  mal.  Then  fol- 
lowed the  cases  of  the  combined  grand 
and  petit  mal,  while  the  least  favorable 
were  the  cases  of  petit  mal  occurring 
alone.  Long  periods  of  arrest,  though 
as  a  rule  indicating  a  favorable  progno- 
sis, are  not  synonymous  with  the  cure  of 
the  disease,  long  remissions  may  occur 
under  bromide  administration,  to  be  fol- 
lowed by  a  relapse  when  the  administra- 
tion of  the  drug  is  discontinued.  On  the 
other  hand,  a  remission  of  long  duration 
may  be  broken  by  an  accidental  circum- 
stance, such  as  a  blow  on  the  head,  a  fall, 
childbirth,  or  an  acute  inflammatory 
disorder.  In  order  to  obtain  the  per- 
centage of  cures  the  writer  took  only 
those  cases  which  were  under  observa- 
tion for  a  period  of  at  least  nine  years. 
They  form  a  total  of  147,  of  which  15 
were  arrested  for  nine  or  more  years, 
giving  a  percentage  of  10.2  cures.  Of 
the  series  of  cases  in  which  the  disease 
was  arrested,  somewhat  over  50  per  cent, 
showed  arrest  within  one  year  of  treat- 
ment. W.  A.  Turner  (Boston  Medical 
and  Surgical  Journal,  February  16, 
1905). 

GALL-STONE    DISEASE. 

In  a  series  of  1000  operations  for  gall- 
stone disease,  extending  from  1891  to 
1904,  the  entire  mortality  (including  all 
patients  who  failed  to  leave  the  hospital 
alive,  no  matter  after  how  long  a  pe- 
riod) was  5  per  cent.  In  the  benign 
series,  960  cases,  4.27  per  cent,  died; 
of  the  40  malignant  cases,  22  per  cent. 


GASTRIC  HEMORRHAGE,  TREATMENT  OF. 


221 


succumbed.  Where  the  disease  was 
limited  to  the  gall-bladder  the  mortality 
was  2.4  per  cent.  Of  the  benign  com- 
mon duct  operations  11.7  per  cent,  died 
in  137  cases;  the  malignant  were  dis- 
couraging, as  few  were  really  benefited. 
In  two  cases  of  cholecystectomy  malig-) 
nant  disease  was  found  by  microscop- 
ical examination;  both  have  remained 
well  (over  2  years).  Next  to  malig- 
nancy and  acute  perforative  infection 
of  the  gall-bladder  and  pancreas,  the 
most  serious  thing  that  can  happen  is 
involvement  of  the  common  duct  of  the 
liver — mortality  of  2.4  per  cent,  (in  820 
cases)  versus  11.7  per  cent,  (in  137 
cases). 

Cholecystostomy  is  a  safe  operation, 
a  removal  of  the  viscus  only  being  per- 
formed under  certain  conditions.  Cys- 
tectomy should  be  done  when  the  blad- 
der is  cystic  or  when  a  stone  is  impacted 
in  the  cystic  duct  (danger  of  stricture), 
if  the  duct  is  injured  during  removal  of 
a  calculus,  if  the  bladder  is  thickened. 
If  bile  is  found  at  time  of  operation 
drainage  may  be  practiced.  The  au- 
thors look  upon  cholecystitis  without 
stones  with  suspicion  and  palpate  duo- 
denum, stomach,  pancreas,  right  kidney, 
and  appendix.  The  gall-bladder  should 
be  thickened,  the  neighboring  lymph 
glands  enlarged,  the  bile  tarry,  and  the 
mucosa  covered  with  fibrous  specks  be- 
fore the  diagnosis  is  allowed. 

In  jaundiced  patients  with  symptoms 
of  liver  infection,  drainage  of  the  blad- 
der is  indicated.  Only  2  out  of  every 
5  cases  have  shown  necessity  for  per- 
forming a  cholecystectomy  and  then  for 
the  conditions  mentioned  above.  The 
seriousness  and  high  mortality  of  com- 
mon duct  surgery  docs  not  depend  upon 
the  difficulty  or  long  duration  of  the 
operation,  but  upon   the  jaundice  and 


the  infection  which  may  extend  to  the 
minutest  ramifications  of  the  bile  ducts. 
When  the  stone  passes  into  the  duct, 
infection  and  jaundice  are  well  marked, 
but  during  the  interval  the  mortality 
was  no  more  than  2  per  cent.  Most  of 
these  patients  have,  however,  before 
they  are  seen,  either  passed  the  stage  of 
intermission  or  never  have  it.  The 
ague  symptoms,  with  increasing  jaun- 
dice, decline,  moderate  pain  and  nausea, 
are  pathognomonic.  Extreme  bile 
stasis  invites  post-operative  infection, 
while  petechia  are  usually  followed  by 
death  "from  capillary  oozing.  Calcium 
chloride  before  operation  was  regularly 
used,  but  its  effect  is  doubtful. 

Those  patients  with  extreme  obstruc- 
tive jaundice,  without  bile  in  the  pas- 
sages, the  common  and  hepatic  duct  con- 
taining clear  fluid,  all  died — the  liver 
seems  put  out  of  action.  In  earlier 
stages  of  this  condition  the  ducts  con- 
tained a  thick  flocculent  bile  of  greenish 
color ;  half  of  these  recovered. 

No  stones  reformed  in  the  gall-blad- 
der after  cholecystostomy,  but  in  two 
cases  common  duct  stones  were  found, 
once  after  gall-bladder  stone  removal, 
once  after  common  duct.  Liver  duct 
stones  were  always  due  to  blocking  of 
the  papilla  by  a  gall-bladder  stone.  In 
the  1000  operations  the  common  duct 
was  involved  in  14.6  per  cent.  W.  -1. 
and  C.  H.  Mayo  (American  Journal 
Medical  Sciences,  March,  1905). 

GASTRIC      HEMORRHAGE,      TREATMENT 
OF. 

From  a  survey  of  the  different  meth- 
ods of  treatment  for  gastric  haemor- 
rhage, it  would  seem  that  after  pallia- 
tive treatment  has  failed  to  effect  a  cure 
in  a,  reasonable  time,  and  in  all  eases 
in  which  three  or  more  profuse  acute 


222 


GASTRIC  SECRETION. 


HEMOPTYSIS,  TREATMENT  OF. 


haemorrhages  have  occurred,  that  surgi- 
cal treatment  is  demanded.  Of  the 
various  methods  of  surgical  interven- 
tion, unless  distinctly  counterindicated, 
the  direct  method  should  he  preferred. 
The  indirect  method  is  indicated  when 
the  direct  cannot  he  carried  out,  and 
sometimes  as  a  supplementary  operation 
after  the  direct  procedure.  Of  the  di- 
rect methods,  the  choice  will  lie  between 
ligation  of  the  mucous  membrane,  ex- 
cision of  the  ulcer,  or  pylorectomy  and 
Andrews's  operation.  Of  the  indirect 
methods,  gastroenterostomy  will  be  the 
operation  performed. 

The  mortality  rate  to  he  expected 
after  radical  operation  will  depend  upon 
various  conditions,  such  as  the  previous 
history  and  the  present  condition  of  the 
patient,  the  number  and  character  of 
the  ha-'inorrhages,  and  whether  the  oper- 
ation is  being  undertaken  as  a  prophy- 
lactic or  a  life-saving  measure.  F.  G. 
Council  (American  Medicine,  April  15, 
1905). 

GASTRIC  SECRETION,  INFLUENCE  OF 
SODIUM  CHLORIDE  SOLUTIONS  ON. 
The  author  experimented  on  dogs 
with  gastric  fistulae,  according  to  Paw- 
low's  method,  with  a  view  of  determin- 
ing the  influence  of  mineral  waters  con- 
taining varying  percentages  of  sodium 
chloride  upon  the  gastric  secretion.  He 
found  that  hypotonic  sodium  chloride 
waters  increase  the  secretion  of  hydro- 
chloric acid,  and  of  the  gastric  juice. 
Hypotonic  mineral  waters  containing 
calcium  bicarbonate,  on  the  other  hand, 
have  no  appreciable  effect  on  the  gastric 
secretion  or  the  excretion  of  hydro- 
chloric acid  in  the  stomach.  The 
first  class  of  waters  mentioned  are, 
therefore,  indicated  in  diseases  with  di- 
minished   gastric    secretion,    while    the 


last  named  class  are  suitable  for  cases 
with  an  increased  secretion  of  hydro- 
chloric acid,  merely  as  mild  stimulants 
to  the  stomach.  One  of  the  author's 
students,  Coleschi,  experimented  clinic- 
ally in  patients  with  the  same  results 
as  were  obtained  on  dogs.  The  results 
obtained  by  Coleschi  showed  that  hypo- 
tonic sodium  chloride  waters  were  more 
efficient  as  regards  the  increase  of  gas- 
tric secretion  than  hypertonic  waters  of 
the  same  class.  Therefore,  waters  con- 
taining sodium  chloride  and  hypotonic 
to  the  blood  serum  of  normal  man  are 
especially  adapted  to  the  treatment  of 
gastric  diseases  associated  with  a  lack 
of"  gastric  secretion  or  of  hydrochloric 
acid  secretion.  P.  Casciani  (Riforma 
Medica,  March  1,  1905;  New  York 
Medical  Journal  and  Philadelphia  Medi- 
cal Journal,  April  15,  1905). 

HEMOPTYSIS,  TREATMENT  OF. 

Besides  the  usual  rest  for  both  body 
and  mind,  no  food  except  cool  drinks  or 
soups,  and  small  scraps  of  ice  during  the 
first  few  hours,  with  an  ice-bag  to  the 
lung  or  a  compressing  bandage,  the 
writer  advocates  subcutaneous  injection 
of  gelatine.  His  experience  has  shown 
it  to  be  very  valuable.  He  warns 
against  morphine  or  anything  of  the 
kind,  unless  to  relieve  a  distressing  de- 
sire to  cough.  Another  valuable  adju- 
vant is  constriction  of  the  limbs.  The 
constriction  is  applied  loosely  enough  to 
permit  the  influx  of  arterial  blood,  but 
not  the  efflux  of  the  venous  blood.  This 
holds  the  blood  in  the  limbs  and  thus 
reduces  the  blood  pressure  in  the  lungs. 
Operative  treatment  should  be  consid- 
ered as  a  last  resource  when  all  other 
measures  fail.  H.  Hochhaus  (Deutsche 
mcdicinische  Wochenschrift,  January 
31,  1905). 


HEMORRHOIDS,  SURGICAL  TREATMENT.  HERNIA,  CURE  OF. 


223 


HEMORRHOIDS,    SURGICAL    TREATMENT 
OF. 

Great  care  should  be  used  in  the  prep- 
aration of  the  patient  and  in  securing 
asepsis.    The  hemorrhoid  to  be  operated 
upon  is  grasped  with  a  tight  clamp  from 
side  to  side,  lifted  gently  from  its  at- 
tached aspect  by  an  assistant,  while  the 
operator  with  a  knife  makes  an  incision 
on  either  side  of  the  tumor,  parallel  with 
its  long  axis,  through  the  mucous  mem- 
brane above,  and  the  skin  below.     The 
two  incisions  should  meet  at  a  very  acute 
angle  below,  and  should  invade  the  skin 
only    enough    to    make    this    angle    and 
avoid  producing  an  awkward  fold  or  tag. 
The  tumor  with  the  surface  included  by 
the  incision  is  now  to  be  dissected  up 
with   the  knife   or  with  straight  sharp 
scissors.     This   dissection  must   include 
the  vessels  of  the  hemorrhoid,  but  no 
more  surrounding  tissue  than  is  neces- 
sary.     The   incisions   can   now   be   con- 
tinued   upward    on    either    side,    always 
converging   to    a   point   just   above   the 
hemorrhoid.     The  small  pedicle  will  be 
found  to  contain  the  principal  artery  of 
supply  and  emergent  veins.    This  should 
be  tied  at  the  highest  point,  but  the  hem- 
orrhoid  should   not   yet   be    cut   away. 
Every    bleeding    vessel    in    the    wound 
should  be  tied  or  twisted,  and  the  wound 
closed  by  continuous  suture  up  to  the 
base  of  the  pedicle,  when  it  is  cut  away. 
A  second  or  third  hemorrhoid  may  be 
removed  in  a  similar  manner.     A  sup- 
pository containing  opium  should  be  in- 
troduced and  opium  given  internally  at 
intervals  so  as  not  to  allow  the  bowels  to 
move    until    the    sixth    or    seventh    day. 
The  dressing  is  very  important  if  oedema 
of  the  lower  angle  of  the  wounds,  pain, 
and  delay  in  healing  are  to  be  avoided. 
It  is  claimed   tor  this  operation  that  it 
is   absolutely   safe;    that   it   is   radical; 


that  neither  ulceration  nor  stenosis  ever 
result  from  it ;  that  convalescence  is 
painless,  and  that  cure  is  obtained  with 
a  minimum  loss  of  time.  Charles  Mc- 
Burney  (New  York  Medical  Journal  and 
Philadelphia  Medical  Journal,  March  4, 
1905). 

HERNIA,  RADICAL  CURE  OF. 

The  Bassini  operation,  though  the 
most  reliable  and  the  most  favored 
method  for  attaining  a  radical  cure  of 
inguinal  hernia,  is  apt  in  by  no  means  a 
small  proportion  of  cases  to  be  followed 
by  relapse.  Failure  of  the  operation  is 
attributed  in  some  cases  to  difficulty  in 
closing  the  gap  in  the  muscular  wall  of 
the  abdomen,  and  in  others  to  the  re- 
sults of  suppuration  and  of  accumula- 
tion of  blood  in  the  wound,  to  too  rapid 
absorption  of  the  suture  material  and 
to  tearing  away  of  the  muscular  tissue 
from  the  sutures  in  consequence  of  too 
much  tension,  or  of  a  too  brief  rest  of 
the  patient  in  bed  after  the  operation. 
Relapses  of  the  second  category  can  be 
prevented  by  strict  observance  of  gen- 
eral rules  in  practical  surgery;  such,  for 
instance,  as  rigorous  asepsis,  careful 
hemostasis,  a  right  selection  of  suture 
material,  prolonged  confinement  to  bed 
during  the  after-treatment,  and  a  care- 
ful administration  of  the  anesthetic  in 
regard  to  the  prevention  of  violent  mus- 
cular movements  in  the  course  of  the 
operation.  The  first-mentioned  cause 
of  relapse,  on  the  other  hand,  cannot  be 
overcome  except  by  a  thorough  and  suc- 
cessful endeavor  to  restore  the  normal 
anatomical  conditions,  and  by  an  effi- 
cient method  of  establishing  a  perma- 
nent closure  of  the  inguinal  canal  at  its 
weak  parts.  The  author  advocates  the 
method  recommended  by  Bassini,  but 
disregarded  by  many  surgeons,  of  stitch- 


224' 


INTESTINAL  AMEBIASIS,  TROPICAL. 


INTESTINAL  BUTTON. 


ing  to  the  back  of  Poupart's  ligament 
the  outer  margin  of  the  rectus  muscle 
exposed  by  division  of  its  facia.  The 
modification  devised  by  the  author  is  di- 
rected mainly  to  the  prevention  of  a  re- 
current hernial  protrusion  along  the  in- 
tramuscular portion  of  the  cord.  To 
attain  this  object  he  stitches  in  the  first 
place  the  upper  margin  of  the  divided 
aponeurosis  of  the  external  oblique  to 
the  posterior  surface  of  Poupart's  liga- 
ment, leaving  a  narrow  slit  for  the  tran- 
sit of  the  cord  well  to  the  outer  side  of 
the  internal  ring,  and  he  afterwards  in- 
closes the  cord  in  a  narrow  passage 
formed  by  bringing  over  it  the  lower  flap 
of  the  aponeurosis,  which  is  secured  in 
its  overlapping  position  by  sutures. 
Polya  (Zentralblatt  fiir  Chirurgie,  No. 
9,  1905;  British  Medical  Journal,  April 
8,  1905). 

INTESTINAL  AMEBIASIS,    TROPICAL. 

A  variety  of  pathological  conditions 
may  produce  symptoms  of  appendicitis 
in  intestinal  amebiasis,  and  it  is  difficult 
and  often  impossible  to  differentiate 
these  during  life.  They  are  produced 
most  frequently  by  lesions  in  the  caecum 
without  involvement  of  the  appendix 
where  surgical  intervention  is  contra- 
indicated.  Somewhat  less  often  such 
symptoms  follow  aggravation  of  an  ex- 
isting chronic  appendicitis  due  to  other 
causes,  by  the  continuation  of  inflamma- 
tion from  the  caecum,  and  nearly  always 
without  amebic  involvement  of  the  ap- 
pendix. Operation  is  rarely  found  to  be 
necessary,  provided  medical  treatment 
of  the  disease  is  rationally  administered. 

In  a  small  number  of  cases,  such 
symptoms  are  due  to  amebic  involve- 
ment of  the  appendix  as  a  continuation 
of  a  similar  process  from  the  caecum, 
and  early  operation  is  indicated.     In  a 


minority  of  these  appendectomy  may  be 
satisfactorily  performed,  but  more  often 
the  operator  will  find  a  gangrenous 
caecum  and  increase  his  mortality  rates. 
In  150  necropsies  there  were  two  cases 
where  operation  would  probably  have 
saved  or  prolonged  life.  One  of  these 
was  amebic  appendicitis  without  exten- 
sive ulceration  in  the  caecum,  and  the 
other  a  pericecal  amebic  abscess.  A 
surgeon  should  be  called  in  consultation 
in  all  cases  of  intestinal  amebiasis  with 
symptoms  suggesting  appendicitis,  and 
questions  of  operation  decided  only 
after  careful  consideration.  W.  E.  Mus- 
grave  (Journal  of  the  American  Medical 
Association,  April  8,  1905). 

INTESTINAL  BUTTON,  SOLUBLE. 

One  of  the  great  disadvantages  to  the 
use  of  mechanical  supports  in  perform- 
ing intestinal  anastomosis  is  the  uncer- 
tainty that  the  support  will  be  dis- 
charged after  it  has  fulfilled  its  func- 
tion, it  being  sometimes  necessary  to 
perform  a  second  operation  for  its  re- 
moval. If  a  button  could  be  obtained 
which  would  be  easy  to  manipulate  and 
which  would  remain  in  situ  for  the 
necessary  length  of  time  without?  in  the 
meantime,  injuring  the  intestine  and 
then  undergo  solution,  the  principal  ob- 
jection to  this  method  of  intestinal  union 
would  disappear.  After  many  experi- 
ments, the  author  concludes  that  gela- 
tine which  has  been  treated  with  chrome 
alum  meets  these  requirements.  It  can 
be  prepared  in  such  a  manner  as  to  be 
more  or  less  resistant  to  the  action  of 
the  digestive  secretions  according  to  the 
activity  of  these  in  the  part  operated 
upon,  or  to  suit  the  particular  purpose 
the  surgeon  may  have  in  view.  The 
method  officing  the  support  is  almost  the 
same  as  that  employed  in  using  Mur- 


INTESTINAL  OBSTRUCTION. 


INTUSSUSCEPTION. 


225 


phy's    button. 
April  1,  1905). 


P.    Paterson    (Lancet, 


INTESTINAL    OBSTRUCTION    AFTER    SUP- 
PURATIVE APPENDICITIS. 

The  author  publishes  a  table  of  six 
cases  treated  by  Sonnenburg,  of  intesti- 
nal   obstruction    from    adhesions    after 
suppurative  appendicitis.     This  form  of 
mechanical  obstruction  occurring  sooner 
or    later    after    appendicitis,    whether 
treated  or  not  by  operation,  is,  the  au- 
thor states,  a  rare  complication.      It  is 
usually  the  result  of  multiple  adhesions 
formed  by  chronic  peritonitis  set  up  by 
small  encapsuled  inflammatory  deposits, 
or  by  a  large  and  single  pelvic  abscess. 
The  symptoms  of  obstruction  are,  as  a 
rule,  so  well  marked  that  there  is  no 
difficulty  in  making  a  sure  diagnosis  at 
an  early  stage.     The  treatment  can  only 
be  a  surgical  one;    the  prognosis  being 
by  no  means  bad  and  the  prospects  of 
the  operation  being  the  more  favorable 
the  sooner  it  is  performed.     The  opera- 
tion of  election  consists  in  laparotomy, 
separation  of  all  adhesions,  closure  by 
suturing  of  any  serous  defects,  cleans- 
ing with  saline  solution,  and  complete 
closure   of   the   external  wound.       The 
median  incision  is  preferred,  as  it  af- 
fords the  most  ready  access  to  the  ad- 
hesions which  may  exist  in  any  region  of 
the  abdominal  cavity.     If  the  condition 
of  the  patient  at  the  time  of  operation 
be  unfavorable;    if  it  be  found  imprac- 
ticable to  divide  all  the  adhesions;    or 
if  a   purulent  deposit  be  found   in   the 
abdominal  cavity  the  opening  of  which 
would    probably    set   up    peritonitis,    it 
would  be  advisable,  the  author  holds,  to 
open  the  small  intestine  and  to  establish 
a  temporary  fistula  in  the  middle  line, 
with  the  view  of  undertaking  a  radical 
operation   and   closing  this   fistula  at   a 


later  and  more  favorable  period.  The 
formation  of  adhesions  after  suppura- 
tive appendicitis  may,  it  is  suggested,  be 
prevented  by  direct  and  early  surgical 
treatment  of  any  large  abscess.  Feder- 
mann  (Archiv  f .  klin.  Chir.,  bd.  76,  heft 
-1;  British  Medical  Journal,  March  25, 
1905). 

INTUSSUSCEPTION  IN  CHILDREN. 

The  author  has  operated  in  18  cases, 
and  the  advantages  of  operation  are  now 
generally  recognized.      Fourteen  of  the 
patients  were  under  1  year  of  age.      In 
16  a  tumor  was  felt  through  the  abdomi- 
nal wall  or  per  rectum.     Eoutine  exami- 
nation under  an  anaesthetic  is  always  de- 
sirable in  suspicious  cases.      All  those 
cases  in  which  the  lesion  had  persisted 
less  than  forty-eight  hours  were  reduci- 
ble, reduction  being  facilitated  by  very 
early  treatment.      Ten  of  the  intussus- 
ceptions were  single  and  ileocecal,  one 
was   single    and    enteric.       Seven   were 
double,  3  being  colic  ileocecal,  two  ileo- 
colic-colic,    two    enteric    ileocecal.      In 
one  case  there  was  probably  a  triple  in- 
tussusception.      In    17    cases    primary 
laparotomy  was  undertaken  as  quickly 
as  possible,  in  1  inflation  had  been  twice 
tried    without    success.       The    incision 
was,  as  a  rule,  on  the  right  of  the  middle 
line,  its  center  being  at  or  below   the 
level  of  the  umbilicus.      The  combina- 
tion of  inflation  with  laparotomy  is  not 
approved.        The     intussusception     can 
often  be  reduced  by  a  finger  in  the  rec- 
tum as  high  as  the  iliac  colon,  where  it 
c;m    be   easily   treated   through  the  ad- 
dominal  incision.      Until  the  reduction 
reaches   the  ascending  colon  it  is  per- 
formed partly  out  of  sight;  the  intussus- 
ception is  then  delivered    from   the  ab- 
domen.     The  escape  of   the  intestines 
from  the  abdomen  should  be  avoided  as 


226 


LEPROSY,  PATHOLOGY  AND  TREATMENT. 


far  as  possible.  When  eventration  has 
been  compulsory,  the  abdominal  wound 
should  be  widely  opened  and  the  intes- 
tines returned,  coil  by  coil. 

Six  patients  died  from  shock  and 
toxpeimia  within  twenty  hours  after 
the  operation;  a  seventh  died  on 
the  fourth  day,  2  more  died  on 
the  twenty-third  day,  but  only  in- 
directly from  intussusception.  A 
number  of  the  cases  were  gangrenous 
and  offered  no  chance  for  recovery. 
There  are  remote  as  well  as  immediate 
risks  from  intussusception,  and  recovery 
from,  the  acute  illness  may  be  more  ap- 
parent than  real.  When  the  intussus- 
ception is  irreducible,  gangrene  being 
present,  resection  is  preferable  to  the 
formation  of  an  artificial  anus.  Fagge 
(Annals  of  Surgery,  March,  1905). 

LEPROSY.   PATHOLOCrX"  AND  TREATMENT 
OF. 

The  antagonism  which  has  been 
shown  to  exist  between  certain  patho- 
genic organisms  having  been  pretty 
thoroughly  worked  out  and  classified,  is 
beginning  to  be  a  groundwork  for  most 
important  researches.  The  author  has 
observed  that  the  bacillus  of  tuberculo- 
sis can  be  made  to  grow  very  rapidly  by 
eliminating  the  salts  of  chlorine  from 
the  nutrient  media.  Chlorine,  however, 
is  so  universally  distributed,  that  the 
removal  of  these  salts  proves  by  no 
means  an  easy  matter.  Wereit  not  for 
the  fact  that  they  could  be  removed 
with  ease  by  chemical  processes,  except 
in  this  particular  instance,  where  such 
processes  would  ruin  the  nutrient 
media,  the  problem  would  not  be  so  diffi- 
enlt.  The  bacillus  tuberculosis  will 
grow  in  a  fluid  of  low  nutrient  value,  but 
one  prepared  by  a  distillation  of  extract 
of  beef,  and  containing  only  the  volatile 


substances  of  the  beef  by  passing  steam 
from  an  autoclave  through  the  extract, 
and  so  will  the  germs  of  leprosy  and  the 
bacillus  of  Lustgarten.  In  this  medium 
a  growth  of  tuberculosis  germs  can  be 
had  in  from  one  to  three  days  and  the 
leprosy  in  from  three  to  five  days.  It 
is,  however,  very  difficult  to  obtain  a 
solid  medium  on  which  to  grow  the 
bacillus,  as  agar  contains  a  large  quan- 
tity of  chlorine.  The  writer  succeeded 
in  preparing  a  satisfactory  medium  by 
dialyzing  nutrient  agar  in  frequently 
changed,  warmed,  distilled  agar.  The 
bacillus  of  leprosy  grows  at  first  as  a 
white  and  later  a  yellow  or  brick  red, 
curly  thick  growth  on  the  surface  of  the 
agar,  very  much  as  the  bacillus  of  tuber- 
culosis grows  on  the  surface  of  glycerin- 
ized  nutrient  agar.  From  these  cultures 
the  author  has  prepared  a  toxin  which 
he  calls  leprolin.  This  is  prepared  in 
similar  lines  with  tuberculin.  Leprolin 
prepared  in  this  way  will  produce  a  pow- 
erful reaction  in  case  of  leprosy,  which 
will  last  for  three  days  or  more.  The 
author  has  prepared  500  doses  of  lepro- 
lin and  has  injected  it  in  120  cases  of 
leprosy  and  in  each  case  there  has  been 
the  same  reaction.  Leprolin  is  now  be- 
ing used  in  30  different  places  in  India, 
but  owing  to  the  difficulty  of  prepara- 
tion, only  20  doses  per  diem  can  be  made 
with  the  present  outfit.  Eeaction  of 
leprolin  may  come  on  very  soon  after 
the  injection,  the  temperature  running 
up  to  101°  F.  The  dose  now  is  10  cubic 
centimeters  of  a  glycerinated  prepara- 
tion. The  most  remarkable  effect  of 
the  injection  is  the  suddenness  with 
which  sensation  returns  in  the  anaes- 
thetic patches.  It  further  relieves  the 
shooting  pains  of  the  limbs  and  joints 
and  causes  a  disappearance  of  the  feel- 
ing of  weight  in  the  legs.     It  makes  the 


(ESOPHAGUS,  NEW  SUTURE. 


PANCREAS,  EXTIRPATION. 


227 


rough  skin  smooth.  Areas  which  had 
been  anaesthetic  before  become  tender 
to  the  touch.  It  causes  ulcers  to  heal, 
sometimes  after  one  injection.  The 
same  leprolin  and  the  same  preparation 
of  the  same  culture  will  not  always  pro- 
duce the  same  reaction  in  all  cases  of 
leprosy.  As  the  results  of  treatment, 
it  seems  certain  that  four  cases  have 
been  permanently  cured.  The  number 
of  cases  now  under  treatment  in  Burmah 
is  about  100.  The  author  refutes  the 
theory  that  the  organism  can  enter  the 
body  through  the  consumption  of  badly 
'  cured  fish,  the  demonstrated  aversion  of 
the  bacillus  of  leprosy  to  salt  proving 
beyond  peradventure  that  it  could  not 
possibly  be  contained  in  the  fish  so  often 
referred  to.  E.  E.  Kost  (British  Medical 
Journal,  February  11,  1905). 

(ESOPHAGUS,  NEW  SUTURE  FOR. 

The  writer  relates  that  experiments 
on  dogs  and  on  the  cadaver  to  make  and 
then  to  cure  a  fistulous  opening  between 
the  oesophagus  and  the  trachea  have 
proved  successful.  The  arteries  in  the 
thyroid  gland  were  ligated  and  then  the 
gland  detached  to  render  it  movable. 
The  next  day  the  gland  was  drawn  to 
the  point  where  the  sutures  had  been 
applied  in  the  oesophagus  and  trachea, 
and  thus  reinforced  by  the  body  of  the 
thyroid  gland.  The  dog  thus  treated 
was  completely  cured  in  a  few  days,  the 
wound  of  the  (esophagus  having  rapidly 
healed  by  primary  intention.  By  this 
utilization  of  the  thyroid  even  large 
defects  in  the  oesophagus  might,  be  stop- 
ped. The  author  used  a  rubber  button 
to  keep  the  fistula  open.  The  thy- 
roid gland  was  fitted  in  between  the  su- 
tures in  the  trachea  and  oesophagus  and 
was  held  in  place  with  a  tampon  and  a 
few  sutures  in  the  skin.     Recovery  was 


rapid  and  complete  and  the  anatomic 
healing  and  conditions  were  found  ideal 
when  the  animal  was  killed  two  months 
later.  D.  v.  Navratil  (Deutsche  Zeits- 
chrift  fiir  Chirurgie,  vol.  lxxv,  No.  6; 
Journal  of  the  American  Medical  Asso- 
ciation, April  15,  1905). 

OPTIC    NEURITIS    AND    FACIAL    PARAL- 
YSIS. 

Optic  neuritis  is  occasionally  asso- 
ciated with  facial  paralysis,  either  alone 
or  as  part  of  a  multiple  neuritis;  the 
etiologic  factor  may  be  rheumatism,  but 
at  times  appears  to  be  an  infection,  the 
nature  of  which  is  as  yet  undetermined. 
The  optic  neuritis  is  usually  of  the  re- 
trobulbar type,  but  a  decided  papillitis 
may  be  present,  and  be  followed  by  more 
or  less  marked  atrophy.  In  cases  of  mul- 
tiple neuritis  of  the  cranial  nerves,  the 
eyegrounds  should  be  examined  for  pos- 
sible, optic  nerve  complication. 

In  facial  paralysis,  flattening  of  the 
face  and  enophthalmus  may  appear,  and 
are  to  be  considered  as  due  to  a  neuritis 
of  the  fifth  nerve,  and  not  to  involve- 
ment of  possible  sensory  fibers  in  the 
facial  nerve.  E.  A.  Shumway  (Journal 
of  the  American  .Medical  Association, 
February  11,  1905). 

PANCREAS,     EFFECTS     OF     EXTIRPATION 
OF. 

The  author's  experiments  were  made 
on  dogs.  Complete  removal  of  the  pan- 
creas always  entailed  transient  gly- 
cosuria for  twenty-four  to  thirty-six 
hours,  followed  by  very  slight  glycosuria 
proportional  to  tin-  nature  of  the  food 
taken.  All  glycosuria  vanished  in  forty- 
five  to  sixty  (lavs.  The  animals  also 
displayed  at  first  various  nutritional  and 
metabolic  disturbances,  with  excessive 
hunger  and  thirst.      These  disturbances 


228 


PEPTIC  ULCER,  TREATMENT  OF. 


gradually  subsided  and  the  animals  re- 
turned to  apparently  normal  conditions. 
In  1  of  the  7  animals  the  glycosuria  was 
more  pronounced,  and  the  animal  be- 
came sicker  and  sicker,  with  final  paresis 
of  the  hind  legs.     The  symptoms  corres- 
pond  in   every   respect  with  those   ob- 
served in  pancreatic  diabetes,  and  the 
liver  was  found  atrophied,  in  fatty  de- 
generation, with  vacuolization,  when  the 
animal  was  killed  in  about  a  month.     In 
this  case  there  had  evidently  been  infec- 
tion  and   intoxication  which  had  pre- 
vented the  development  of  the  compen- 
satory processes  which  alone  render  it 
possible  for  the  organism  to  resume  its 
functions  and  to  recuperate.      In  con- 
clusion, the  author  protests  against  the 
way  in  which  every  glycosuria  is  called 
diabetes.       There    are    many    diabetics 
who   thrive   with   large   proportions   of 
sugar  and  others  who  are  in  bad  condi- 
tion with  very  little  sugar.      He  does 
not  think  that  constitutional   diabetes 
is  the  effect  of  the  reduced  sugar  de- 
stroying capacity.     Its  essential  charac- 
teristic is  a  progressive  aggravation  of 
the  initial  changes.      The  voracious  ap- 
petite and  thirst  are  the  reaction,  the 
response  of  the  organism  to  abnormal 
or    excessive    decomposition    going    on 
within  it.     Diabetes  is,  therefore,  in  its 
essence  an  autolysis.      This  conception 
has  been  adopted  by  Ferrannina  for  dia- 
betes insipidus,  which  he  explains  as  an 
anomaly  in  metabolism  due  to  the  exces- 
sive instability  of  the  albuminoid  mole- 
cule.     Hence  the  relationship  between 
these  two  forms  of  diabetes  and  the  fre- 
quent transformation  of   one   into  the 
other.     The  discrepancies  in  the  results 
obtained  by  various  investigators  have 
probably  been  due  to  predisposing  con- 
ditions, to  the  age  of  the  animals  ex- 
perimented   on,    and    to    complications 


such  as  shock,  infections,  auto-intoxica- 
tions, etc.  T.  Silvestri  (Eiforma  Medica, 
vol.  xxi,  Nos.  6,  7;  Journal  of  the 
American  Medical  Association,  April  15, 
1905). 

PEPTIC  ULCER,  TREATMENT  OF. 

The  strongest  argument  so  far  pre- 
sented in  favor  of  the  surgical  over  the 
medical  treatment  of  peptic  ulcer  is  the 
failure  of  the  latter.  The  danger  to 
the  patient  from  operation  in  skilled 
hands  is  not  greatly  increased,  the  im- 
mediate results  of  both  medical  and 
surgical  treatment  being  about  the  same. 
The  future  interest  to  the  clinician 
lies,  not  in  hearing  of  the  prowess  of 
the  surgeon,  recorded  in  long  series  of 
successful  operations,  but  in  learning 
their  end  results.  Until  they  are  known 
conservatism  seems  the  proper  course, 
but  when  medical  treatment  has  failed, 
as  shown  by  the  recurrence  of  repeated 
small  haemorrhages,  or  the  persistence 
of  other  symptoms,  a  resort  to  operation 
is  legitimate  and  justifiable. 

The  surgical  treatment  of  haemor- 
rhage is  of  questionable  utility,  since  in 
many  cases  it  has  continued,  or  first  ap- 
peared, after  operation,  and  in  some,  at 
least,  of  the  successful  ones  it  is  doubt- 
ful if  operation  had  any  influence  for 
good. 

The  interests  of  the  patient  will  be 
best  served,  when  doubt  arises  as  to  the 
advisability  of  operation,  if  the  decision 
is  not  left  to  the  physician  or  surgeon 
alone.  Only  by  their  cooperation  will 
it  be  possible  to  avoid  either  the  sacri- 
fice of  life  from  unnecessary  delay,  or 
the  performance  of  useless  or  even 
harmful  operations.  G.  G.  Sears  (Bos- 
ton Medical  and  Surgical  Journal, 
March  30,  1905).     - 


PERNICIOUS  ANEMIA,  THEORY  OF. 


POTASSIUM  IODIDE. 


229 


PERNICIOUS  AN2EMIA,  THE  THEORY  OF. 

The  authors  have  deduced  the  follow- 
ing as  the  result  of  a  series  of  experi- 
ments which  they  performed :  The 
serum  of  pernicious  ansemia  has  neither 
an  agglutinating  nor  a  solvent  action 
upon  the  blood-corpuscles  of  the  patient, 
either  in  the  body  or  in  a  test  tube. 
Neither  does  the  serum  show  any  solvent 
action  upon  the  blood-corpuscles  when 
the  Landsteiner  method  is  employed. 
This  want  of  ability  to  dissolve  the 
blood-corpuscles  of  the  blood  of  which 
a  given  specimen  of  serum  forms  a  part 
does  not  depend  upon  the  absence  of  the 
so-called  complement.  The  serum  of 
pernicious  anaemia  also  fails  to  dissolve 
the  blood-corpuscles  in  other  specimens 
of  blood,  of  which  it  does  not  form  a 
part,  but  it  does  have  an  agglutinating 
effect  in  many  such  cases.  This  last- 
mentioned  peculiarity  is  not  entirely 
characteristic,  however,  of  the  blood  of 
pernicious  anaemia.  The  inability  of  the 
serum  to  dissolve  the  corpuscles  in  blood 
of  which  it  does  not  form  a  part  is  not 
due  to  a  want  of  complement. 

The  authors  conclude  that  it  has  not 
been  proved,  up  to  the  present  time,  that 
the  blood  poison  which  is  supposed  to  be 
present  in  pernicious  anaemia  is  a  com- 
plex haemolysin  in  the  sense  in  which  it 
has  been  described  by  Bordet  and  Ehr- 
lich.  Litten  and  Michaelis  (Fortschritte 
der  Medizin  ,  December  20,  1904). 

POSTPARTUM  HEMORRHAGE. 

Postpartum  haemorrhage  is  one  of  the 
most  serious  complications  found  in  ob- 
stetric practice.  It  is  not  always  pre- 
ventable by  careful  management  of  the 
third  stage  of  labor,  as  some  authors 
seem  to  believe.  The  first  step  in  the 
treatment  of  a  rapid  and  severe  case  is 
the  insertion  of  a  hand  in  the  uterus, 


the  other  meanwhile  manipulating  the 
fundus  through  the  abdominal  wall. 
Hot-water  douching  is  convenient, 
cleanly,  and  effective,  and  no  obstetri- 
cian's outfit  is  complete  without  appar- 
atus for  the  infusion  of  salt  solution  and 
for  intravenous  douching. 

The  benefit  to  be  gained  by  packing 
the  uterus  with  gauze  is  doubtful,  the 
danger  is  evident.  Later  experiences, 
not  only  in  postpartum  haemorrhage,  but 
in  other  conditions  in  which  uterine 
haemorrhage  is  feared,  as  after  curetting 
for  abortion,  or  miscarriage  in  the  early 
months  of  pregnancy,  have  firmly  con- 
vinced the  author  that  it  is  not  wise  to 
put  anything  into  the  uterus  that  is  not 
necessary,  nor  to  leave  anything  there 
that  can  be  avoided,  even  though  im- 
pregnated with  antiseptics.  H.  H.  Love- 
land  (American  Medicine,  April  15, 
1905). 

POTASSIUM      IODIDE,      ADMINISTRATION 
OF. 

The  method  of  administering  potas- 
sium iodide  should  differ  in  accordance 
with  the  purpose  for  which  it  is  given. 
For  therapeutic  purposes  potassium 
iodide  should  always  be  given  in  solu- 
tion, well  diluted,  and,  if  possible,  never 
on  an  empty  stomach.  Milk  is  the  best 
diluent,  but  compound  syrup  of  sarsa- 
parilla,  mineral  water,  or  ordinary  pure 
water  may  be  used.  The  drug  must  be 
pure.  Many  bad  effects  are  due  to  im- 
purities. By  observing  strict  cleanli- 
ness of  the  skin,  disagreeable  skin  erup- 
tions to  a  large  degree  may  be  prevented. 
Where  accurate  dosage  is  of  importance 
it  is  safer  to  prescribe  a  50  per  cent,  solu- 
tion, 2  drops  to  equal  1  grain  of  the 
drug.  Potassium  iodide  should  never 
be  given  in  phthisis,  or  when  there  is 
even  a  suspicion  or  tendency  to  phthisis. 


230 


PROSTATIC  HYPERTROPHY. 


PUERPERAL  FEVER,  BLOOD  IN. 


In  children  it  is  best  to  give  the  drug 
very  frequently  in  small  doses,  1/i  grain 
every  hour,  rather  than  infrequently  in 
large  doses.  A  very  convenient  way  is 
to  dissolve  the  daily  dose  to  be  taken  in 
twenty-four  teaspoonfuls  of  water  and 
have  the  child  take  one  teaspoonful 
every  hour  while  awake,  and  two  or  three 
teaspoonfuls  on  awakening  after  a  two 
or  three  hours'  sleep.  In  this  way  a  six- 
months-old  child  may  take  as  much  as 
15  or  30  grains  in  twenty-four  hours 
for  a  long  time  without  inconvenience. 
Special  plans  of  administration  are  de- 
scribed for  syphilis,  locomotor  ataxia, 
chronic  endarteritis,  asthma,  nephritis, 
lead  poisoning,  rheumatism,  gout,  and 
neuralgia.  M.  Hiihner  (Medical  Eec- 
ord,  April  1,  1905). 

PROSTATIC      HYPERTROPHY,      OBSTRUC- 
TIVE, PATHOLOGY  OF. 

Pathologically,  there  are  three  types 
of  prostates  causing  urinary  obstruc- 
tion: (a)  The  large,  soft  type;  (b)  the 
hard,  small,  contracted  type,  and  (c)  the 
mixed  type.  Infection  does  not  influ- 
ence the  variety  of  the  pathological 
change.  The  contracted  form  of  pros- 
tate is  not  a  secondary  stage  of  the 
large,  soft  type  of  hypertrophied  pros- 
tate, but  is  distinct  from  it.  In  many 
cases  of  hypertrophy  of  the  prostrate 
there  is  present  a  true  muscular  hyper- 
trophy. In  some  of  the  atrophic  cases 
the  glandular  elements  are  relatively  di- 
minished and  the  muscular  elements 
relatively  increased. 

Gonorrhoea  is  not  an  important  factor 
in  the  production  of  this  disease,  and 
there  is  no  necessity  for  assuming  it  to 
be.  The  theory  of  obstruction  to  the 
ducts  causing  passive  dilatation  of  the 
glandular  elements,  as  advanced  by  Cie- 


chanowski  and  Crandon,  does  not  satis- 
factorily explain  the  pathological  find- 
ings. Hypertrophy  of  the  prostate  re- 
sults from  glandular  overgrowth,  influ- 
enced by  the  degenerative  changes  of 
old  age,  and  other  agents  which  tend  to 
produce  the  formation  of  fibrous  connec- 
tive tissue  in  an  actively  functionating 
gland.  P.  M.  Pilcher  (Annals  of  Sur- 
gery, April,  1905). 

PUERPERAL  FEVER,  THE  BLOOD  IN. 

At  term  the  patient  may  or  may  not 
be  slightly  anaemic ;  if  anaemic  the  haem- 
oglobin is  affected  rather  more  than  the 
red  corpuscles,  leading  to  a  slight  reduc- 
tion of  the  color-index.  The  leucocytes 
are  increased  in  number,  especially  in 
first  pregnancies,  and  the  increase  mainly 
affects  the  poly nucl ears.  During  a  nor- 
mal puerperium  the  number  of  the  leu- 
cocytes commences  to  fall  soon  after  de- 
livery and  continues  to  do  so  for  about  a 
fortnight,  whereas  the  red  corpuscles 
and  haemoglobin  fall  slightly  for  a  day 
or  so  and  are  then  gradually  regenerated. 
When  the  process  is  arrested  by  a  general 
septic  infection  the  fall  in  the  leucocytes 
ceases,  and  is  replaced  by  a  gradual  rise, 
the  increase  being  due  mainly  to  an  in- 
creased number  of  polynuclears.  At  the 
same  time,  the  regeneration  of  the  reds 
ceases,  and  is  replaced  by  a  fall  in  the 
haemoglobin,  and  a  smaller  fall  in  the 
red  corpuscles.  The  iodine  reaction  is 
well  marked.  When  abscess  formation 
occurs  apart  from  a  general  septicaemia, 
the  rise  in  the  leucocytes  (due  to  this 
case  also  to  polynuclears)  is  more  sud- 
den, and  a-  higher  level  is  reached.  The 
The  haemoglobin  and  reds  are  affected 
slightly,  if  at  all;  and  the  leucocytes 
give  the  iodine  reaction.  W.  D'Este 
Emery  (Practitioner,- March,  1905). 


PYELITIS,  TREATMENT  OF. 


RENAL  DECAPSULATION. 


231 


PYELITIS,  TREATMENT  OF. 

The  author  emphasizes  the  fact  that 
mild  types  of  pyelitis  are  not  infrequent, 
and  that  if  they  are  unrecognized  or  im- 
properly treated  they  may  lead  to  very 
serious  consequences.  The  practical 
deductions  to  be  drawn  from  the  paper 
are :  It  is  important  to  take  cognizance 
of  a  pjrelitis  of  any  grade  whatever,  as  it 
may,  at  any  time,  become  a  menace  to 
the  functional  value  of  the  kidney,  or 
even  to  life  itself.  The  severer  grades 
of  the  affection  are  often  the  sequelae 
of  a  milder  pyelitis  of  long  standing. 
The  first  step  in  the  investigation  is  to 
determine  the  extent  of  the  affection  by 
estimating  the  amount  of  pus  in  the 
urine  and  the  relative  number  of  organ- 
isms. It  is  important  to  determine  the 
cause  of  the  infection,  which  is  often  of 
a  mechanical  nature,  and  therefore 
easily  relieved.  By  removing  the  cause, 
the  disease  may  either  be  cured,  or  be  so 
far  benefited  that  a  subsequent  complete 
relief  by  means  of  local  treatment  is 
easily  brought  about.  The  milder  forms 
are  best  treated  by  rest,  abundant  water, 
and  urotropin.  If  there  is  not  speedy 
improvement,  the  next  simplest  plan  of 
treatment  is  the  catheterization  of  the 
kidney  every  two  to  four  days  for  the 
purpose  of  evacuation,  distention  of  the 
pelvis,  irrigation,  and  instillation.  Boric 
acid  and  nitrate  of  silver  are  the  best 
drugs  in  this  connection. 

Improvement  should  be  measured  by 
the  disappearance  of  pus  from  the  urine 
and  the  diminution  in  the  organisms, 
taking,  say,  three  platinum  loops  as  the 
measure  in  conveying  the  infected  urine 
to  the  agar.  A  patient  improved,  but 
not  cured  (complete  absence  of  bac- 
teria), should  be  watched  in  the  inter- 
vals of  treatment,  and  guarded  with  es- 
pecial care  in  case  of  any  intercurrent 


disease.  Should  such  a  disease  super- 
vene, urotropin  is  a  good  prophylactic. 
The  severer  forms  of  the  disease  may  be 
treated  by  irrigation,  which  often  brings 
great  temporary  relief.  As  a  rule,  how- 
ever, the  kidney  must  be  opened  and 
drained;  if  it  has  been  extensively  dis- 
eased, it  should  be  removed.  Howard  A. 
Kelly  (Medical  Eecord,  April  8,  1905). 

RENAL  DECAPSULATION. 

As  regards  the  functional  value  of  the 
new-formed  capsule  after  decapsulation, 
the  conclusions  deduced  from  considera- 
ble experimental  work  on  rabbits  are  fa- 
vorable on  the  whole.      When  the  ani- 
mals were  killed  four  weeks  after  the 
decapsulation  the  anastomoses  between 
the  kidney  and  the  capsule  did  not  have 
the  total  capacity  of  the  normal  vascu- 
lar conditions,  but  at  some  parts  had 
locally    a   greater   capacity.      This    oc- 
curred especially  at  the  points  where  the 
kidney  had  been  more  injured.      Five 
series  of  experiments  were  made:    (a) 
ligation  of  the  renal  artery  with  kidney 
intact  and  removal  of  kidney  three  or 
five  days  later;   (b)  decapsulation  of  kid- 
ney and  its  removal  after  five  days;   (c) 
decapsulation  of  kidney  and  simultane- 
ous ligation  of  renal  artery;  removal  of 
kidney  after  two  or  five  days;    (d)  de- 
capsulation of  kidney  with  ligation  of 
renal  artery  four  weeks  later  and  then 
removal  of  kidney  after  five  days;    (e) 
half  decapsulation  of  kidney  with  liga- 
tion   of    renal    artery    four    weeks    or 
twenty-three  days  later,  and  removal  of 
kidney  after  five  days.      In  series  (c) 
little  influence  on  the  process  of  necrosis 
could  be  detected,  but  under  especially 
favorable  circumstances  a  new  capsule 
developed  so  rapidly  and  grew  so  inti- 
mately into  the  kidney  that  an  import- 
ant intermediary  zone  was  formed,  with 


232       SPEECH,  RETARDED  DEVELOPMENT. 


SPRUE,  USE  OF  CYLLTN  IN. 


a  zone  of  demarcation.  In  series  (d)  the 
fibrous  capsule  became  regenerated  al- 
most ad  integrum.  It  was  more  closely 
adherent  to  the  kidney  than  normally. 
Little  islands  of  living  parenchyma  were 
found  close  to  the  capsule,  the  tissues 
evidently  receiving  extra  nourishment 
from  the  capsule  at  these  points.  J.  H. 
Zaaijer  (Mitteilungcn  a.  d.  Grenzgebie- 
ten,  Jena,  vol.  xiv,  No.  3;  Journal  of 
the  American  Medical  Association,  April 
8,  1905). 

SPEECH,    RETARDED    DEVELOPMENT    OF, 
IN  YOUNG  CHILDREN. 

Retarded  development  of  speech  in 
young  children  may  be  the  result  of 
structural  irregularities  in  the  periph- 
eral organs,  impaired  respiration  due  to 
nasal,  postnasal,  and  pharyngeal  ob- 
structions, paresis  of  the  nerves  supply- 
ing the  organs  of  speech,  and  not  infre- 
quently to  some  disturbance  of  hearing 
not  necessarily  amounting  to  absolute 
deafness.  Eetarded  development  of 
speech  always  results  in  defective  men- 
tality. 

The  treatment  consists  in  the  removal 
of  any  obstruction  that  may  exist  in  the 
peripheral  organs  and  in  the  systematic 
t raining  of  the  auditory  and  speech  cen- 
ters by  the  use  of  specially  prepared 
vocal  exercises.  A  child  may  be  taught 
to  hear  it  in  exactly  the  same  way  as 
he  is  taught  to  read  and  write.  G.  Hud- 
son-Makuen  (New  York  Medical  Jour- 
nal and  Philadelphia  Medical  Journal. 
March  4,  1905). 

SPRUE,  USE  OF  CYLLIN  IN. 

Sprue  is  a  complainl  so  baffling,  so 
difficult  to  cure,  recurring  so  frequently 
after  apparent  recovery  thai  any  hint  as 
to  its  treatment  is  worth  recording. 
The    disease    .-bows    itself    in    various 


forms,  and  many  seemingly  favorable 
cases  prove  most  intractable,  while  oth- 
ers make  rapid  and  complete  recoveries. 
In  the  majority  of  cases  which  quickly 
respond  to  treatment  the  disease  is  con- 
fined to  about  the  lower  eighteen  inches 
of  the  bowel,  while  in  the  intractable 
cases  the  upper  portion  of  the  colon  and 
probabl}'  the  lower  part  of  the  ileum  are 
involved.  Hence,  in  the  former,  the  al- 
most certain  efficacy  of  copious  antisep- 
tic lavage,  while  in  the  latter  they  have 
little  or  no  effect  on  the  actual  course  oi 
the  disease.  Little  is  known  of  the 
etiology  of  sprue.  Its  fatality  is  due  to 
inability  to  assimilate  food.  The  usual 
symptoms  are  wasting,  sore  tongue  and 
frequent  and  abundant  frothy  stools. 
The  patients  are  unable  to  take  the 
mildest  or  simplest  nourishment  on  ac- 
count of  the  pain  caused  to  the  mouth 
and  tongue  and  the  almost  immediate 
evacuation  thereby  brought  on.  The 
value  of  antiseptics  applied  locally  to 
the  bowel  has  been  proved.  Boric  acid, 
however,  produces  headaches  and  in- 
creases digestive  troubles.  Carbolic 
acid  is  ill-borne;  salol  makes  the  stools 
more  healthy,  but  does  not  cure  the  dis- 
ease:  perchloride  of  mercury  and  naph- 
thol  are  inefficient.  Cyllin,  a  new  dis- 
infectant of  the  cresol  series,  given  in 
the  form  of  intestinal  platinoids,  3  min- 
ims cyllin  in  each,  is  well-borne,  the 
number  of  stools  rapidly  diminishes,  the 
bowels  are  regulated,  and  the  general 
condition  of  the  patient  improved.  The 
platinoids  may  be  given  every  second 
hour  if  necessary,  but  rarely  more  than 
eight  a  day  are  required.  They  are  best 
given  an  hour  after  food.  All  pain  and 
tenderness  over  the  lower  part  of  the 
abdomen  disappear;  tbere  is  a  steady 
increase  in  weight^-and  the  patient  is 
soon  able  to  return  to  the  ordinary  diet. 


ST0VA1NE. 


STREPTOCOCCI,  DISSEMINATION  OF. 


233 


The  cases  treated  solely  by  rest  and  milk 
diet  take  a  much  longer  time  to  get  well, 
and  their  recovery  is  often  not  complete. 
Relapses,  particularly  on  returning  to  a 
hot  climate,  are  frequent.  W.  Eartigan 
(Journal  of  Tropical  Medicine,  March  1, 
1905). 

STOVAINE. 

Stovaine  as  a  local  anaesthetic  is  ap- 
parently equal  to  cocaine,  and  the  time 
necessary  for  acquiring  local  anaesthesia 
is  the  same  as  that  of  cocaine.  It  ap- 
parently does  not  contract  the  nasal  mu- 
cous membrane  to  so  great  an  extent  as 
do  -iniilar  solutions  of  cocaine.  This  is 
at  times  a  disadvantage  when  the  nasal 
passages  are  desired  to  be  widely  opened 
for  more  thorough  inspection  of  the 
cavities;  on  the  other  hand,  it  is  often- 
times an  advantage,  as  in  snaring  of  re- 
dundant tissue  by  not  too  greatly 
shrinking  it,  and,  therefore,  making  it 
mure  easy  to  be  removed. 

Stovaine  docs  not  produce  nearly  so 
great  a  sense  of  constriction  in  the 
pharynx  as  thai  which  is  produced  by 
cocaine.  In  this  respect  it  has  a  de- 
cided advantage  over  cocaine,  especially 
in  those  patients  to  whom  the  symptoms 
of  constriction  with  constant  desire  to 
hawk  and  remove  a  supposed  foreign 
body  are  very  distressing. 

Solutions  of  stovaine  have  a  peculiar 
odor  of  stale  fish,  which  has  been  an- 
noying to  some  of  the  patients,  and  are 
more  bitter  than  similar  solutions  of 
cocaine.  No  toxic  effects  have  been  Been 
following  the  use  of  atovaine ;  there  have 
been  no  secondary  headaches  or  feeling 
of  lassitude  after  the  local  anaesthetic 
effect  of  the  drug  has  disappeared;  the 
author  is  also  of  the  opinion  that  the 
secondary  swelling  of  the  mucous  mem- 


brane following  the  use  of  stovaine  is 
less  than  that  which  occurs  after  coca  in- 
ization.  C.  G.  Coakley  (Medical  News, 
April  15,  1905). 

STREPTOCOCCI,  DISSEMINATION  OF. 

Streptococci  are'  expelled  from  the 
mouth  in  the  invisible  droplet-  of 
sputum  by  coughing,  .-peaking,  whisper- 
ing, crying,  or  breathing  forcibly 
through  the  mouth.  They  are  expelled 
to  a  distance  of  at  least  3G  centimeters. 
Thirty-three  out  of  50  scarlet  fever  pa- 
tients, most  of  them  children,  were 
found  to  expel  streptococci  in  coughing, 
crying,  or  breathing;  42  out  of  50  nor- 
mal adults  were  found  to  expel  strep- 
tococci in  coughing  or  in  speaking.  The 
streptococci  thus  disseminated  may  be 
inhaled  by  others,  and  may  set  up  strep- 
tococcal complications  or  may  fall  mi 
the  tissues  exposed  at  an  operation  and 
cause  suppuration. 

Just  as  the  virulence  of  an  individual 
strain  of  streptococcus  may  be  raised  by 
planting  on  certain  nutrient  media  or  by 
passing  through  susceptible  animal-,  so, 
in  all  probability,  it  may  be  raised  by 
passage  from  one  human  being  to 
another.  In  this  way  may  be  explained 
the  conversion  of  a  case  of  simple  scarlet 
fever  into  one  of  scarlatinal  sepsis,  and 
in  the  same  way  may  he  explained  the 
cases  of  surgical  sepsis  which  occur 
after  all  usual  precautions  have  been 
taken. 

Oases  of  scarlet  fever  with  strep- 
tococcal complications  should  he  iso- 
lated from  cases  h  ithoiit  such  complica- 
tions. Surgeons  and  nurses  should 
have  their  moul h-  protected  during  the 
time  of  an  operation.  Alice  I  [amiltou 
(Journal  of  the  American  Medical  As- 
sociation, April  8,  11)05). 


234 


STRYCHNINE  AS  A  STIMULANT. 


SURGICAL  SHOCK. 


STRYCHNINE  AS  A  HEART  STIMULANT. 

From  a  study  of  this  question,  the 
writer  concludes  that  strychnine  is  not 
a  direct  heart  stimulant,  and  is  con- 
traindicated  in  erethistic  and  non-com- 
pensated cases.  In  these  conditions 
strychnine  either  does  not  act  at  all  or 
else,  developing  its  cumulative  action, 
makes  the  erethistic  condition  worse 
and  increases  the  subjective  discomfort 
of  the  patient.  The  action  of  strych- 
nine upon  the  nervous  system  is  to  pro- 
duce a  vasoconstriction  with  an  increase 
in  the  blood  pressure,  and  therefore  the 
drug  is  indicated  in  the  adynamic  and 
depressive  forms  in  which  the  tone  of 
the  blood-vessels  is  impaired.  In  de- 
bilitated or  neurasthenic  individuals  it 
produces  a  noteworthy  improvement  in 
the  general  condition  and  increases  the 
appetite  and  the  strength  of  the  patient. 
Carlo  Gennari  (Kiforma  Medica,  March 
4,  1905;  New  York  Medical  Journal 
and  Philadelphia  Medical  Journal,  April 
15,  1905). 

SURGICAL  SHOCK  AND   COLLAPSE. 

Surgical  shock  is  a  condition  produced 
by  exhaustion  of  the  vasomotor  centers 
and  the  resulting  great  fall  in  blood 
pressure.  Collapse  is  a  similar  condi- 
tion caused  by  lowering  of  the  blood 
pressure  from  hemorrhage  or  paralysis 
of  the  vasomotor  centers.  In  surgical 
operations  shock  most  frequently  re- 
sults from  operations  upon  the  abdo- 
men, the  most  important  factors  in  its 
causation  being  injury  to,  or  exposure 
of,  the  peritoneum,  the  length  of  the 
operation,  injury  to  organs  richly  sup- 
plied with  nerve  fibers,  as  the  stomach, 
uterus,  and  kidneys,  evisceration,  and 
extensive  and  prolonged  manipulations. 
In  operation  upon  parts  other  than  the 
abdomen  the  most  important  factors  in 


causing  shock  are  injury  to  parts  richly 
supplied  with  nerve  endings,  the  area  of 
the  wound,  the  time  of  exposure  of  the 
tissues,  and  haemorrhage. 

Another  important  factor  in  the  cau- 
sation of  shock  during  surgical  opera- 
tions is  the  anaesthetic.  Ether  and  the 
C.  E.  mixture  are  the  best  anaesthetics 
for  cases  where  there  is  danger  of  shock, 
chloroform  on  account  of  the  fall  in 
blood  pressure  which  follows  its  admin- 
istration being  very  unsuitable  for  such 
cases.  The  time  occupied  in  perform- 
ing the  operation  is  always  an  important 
factor,  more  especially  in  children  and 
old  people.  The  condition  of  the  pa- 
tient prior  to  operation  is  important,  es- 
pecially as  regards  the  condition  of  his 
nerve  centers. 

In  the  treatment  of  shock,  stimu- 
lants, and  especially  strychnine,  are  ab- 
solutely contraindicated  as  they  tend  to 
increase  the  severity  of  the  condition 
and  to  retard  recovery.  Shock  can  be 
produced  in  an  animal  by  the  adminis- 
tration of  strychnine  alone.  The  posi- 
tion with  the  head  down  and  the  foot  of 
the  bed  raised  is  of  considerable  value  in 
the  treatment  of  shock  and  should  be 
more  extensively  used. 

Compression  of  the  abdomen,  either 
manually  in  an  emergency  or  by  the  ap- 
plication of  a  tight  abdominal  binder, 
is  a  most  effectual  method  of  treating 
shock  in  all  cases.  The  establishment 
of  an  artificial  peripheral  resistance  by 
the  application  of  external  pneumatic 
pressure  affords  an  absolutely  certain 
method  of  maintaining  the  blood  pres- 
sure, and  though  not  at  present  a  practi- 
cal method  should  some  day  prove  of 
great  value.  The  intravenous  infusion 
of  salt  solution  or  physiological  serum 
will  raise  the  blood  pressure  in  all  de- 
grees of  shock.     As  "a  method  of  treat- 


SURGICAL  SHOCK  AND  COLLAPSE. 


235 


ment  in  shock  it  is  disappointing  as  its 
action  is  fleeting  and  it  cannot  be  con- 
tinued indefinitely.  In  the  collapse  of 
severe  haemorrhage  it  is  effectual  and 
lasting  in  its  effects.  The  introduction 
of  saline  solution  into  the  abdomen  at 
the  end  of  an  abdominal  operation  is  a 
valuable  method  of  combating  shock  and 
is  not  contraindicated  by  the  presence 
of  pus  in  the  abdominal  cavity. 

One  of  the  most  effectual  methods  of 
treating  shock  is  by  the  administration 
of  drugs  such  as  adrenalin,  hemisine, 
and  ergot,  which  raise  the  blood  pres- 
sure by  increasing  the  peripheral  re- 
sistance independently  of  the  nerve 
centers. 

Like  sepsis,  shock  can  be  prevented 
much  more  easily  than  it  can  be  cured, 
and  as  is  the  case  with  sepsis,  so  with 
shock.  With  the  exception  of  abdomi- 
nal operations  the  method  of  blocking 
the  main  nerves  with  cocaine  seems  to 
afford  a  ready  and  most  efficient  way  of 
completely  preventing  shock  in  even  the 
most  severe  of  surgical  operations. 
Morphine,  administered  both  before  an 
operation  and  afterward,  is  a  useful  aid 
in  the  prevention  of  shock  and  does  not 
seem  to  have  been  used  in  this  connec- 
tion as  much  as  it  deserves  to  be.  Much 
may  be  done  to  prevent  shock  by  having 
a  chart  of  the  blood  pressure  kept  dur- 
ing all  severe  operations;  procedures 
which  are  harmful  may  thus  be  avoided, 
treatment  may  be  commenced  at  the 
time  when  it  can  be  of  most  value,  and, 
in  fact,  shock  can  be  thus  prevented  or 
treated  upon  scientific  lines. 

The  author  believes  the  best  line  of 
treatment  in  the  event  of  shock  oc- 
curring or  threatening  during  an  opera- 
tioxj  to  bo  as  follows:  If  the  operation 
is  an  abdominal  one  the  peritoneal  cav- 
ity should  be  filled  before  being  closed 


with  physiological  salt  solution,  and  if 
a  severe  degree  of  shock  is  already  pres- 
ent, hemisine  or  adrenalin  should  be  ad- 
ded to  this  solution  in  the  proportion  of 
1  in  40,000.  Whether  the  operation 
be  an  abdominal  one  or  not,  a  firm,  tight 
abdominal  binder  should  be  applied  at 
the  end  of  the  operation,  and  in  bad 
cases  the  limbs  should  be  firmly  band- 
aged from  the  extremities  upward  in  ad- 
dition. When  the  patient  has  been  put 
back  to  bed  the  foot  of  the  bed  should 
be  raised  at  least  12  inches  on  blocks 
and  all  pillows  should  be  removed  from 
beneath  the  head;  the  patient  should 
be  kept  warm  and  some  good  form  of 
nutrient  enema  should  be  administered 
and  repeated  in  a  short  time.  No 
stimulants  should  be  given.  A  hypo- 
dermic, injection  of  aseptic  ergot  should 
be  given  at  the  earliest  sign  of  shock  and 
repeated  if  any  improvement  in  pulse 
tension  follows  its  administration.  Ex- 
cept where  absolutely  contraindicated  an 
injection  of  morphine  should  be  given  at 
the  end  of  the  operation,  Avhether  pain 
be  present  or  not;  and  if  there  is  any 
restlessness  afterward  the  morphine 
should  be  repeated.  If,  in  spite  of 
these  measures,  the  blood  pressure  re- 
mains low  and  the  patient  continues  in 
a  dangerous  condition  of  shock  a  solu- 
tion of  adrenalin  in  physiological  salt 
solution,  in  the  proportion  of  1  in  20,- 
000,  should  be  intravenously  infused  at 
a  rate  of  about  3  to  5  cubic  centimeters 
pei'  minute.  The  intravenous  infusion 
should  be  continued  until  on  stopping 
it  the  blood  pressure  is  found  to  remain 
at  a  safe  level.  In  bad  cases  it  may  he 
necessary  to  continue  the  infusion  of  ad- 
renalin for  a  long  period,  but  it  affords 
a  certain  method  of  maintaining  the  pa- 
tient's blood  pressure  and  therefore  his 
life. 


236  TUBERCULOSIS,  HUMAN  AND  BOVINE. 


URINE  EXAMINATION. 


In  collapse  following  severe  haemor- 
rhage intravenous  infusion  with  physio- 
logical salt  solution,  should  be  per- 
formed as  soon  as  possible.  The 
amount  of  fluid  introduced  into  the 
veins  should  be  as  nearly  as  possible 
equal  to  the  amount  of  blood  lost.  The 
subsequent  treatment  should  be  the 
same  as  for  shock.  In  all  forms  of 
sudden  collapse,  including  the  collapse 
of  chloroform  poisoning,  the  intravenous 
administration  of  adrenalin  is  of  im- 
mense value  in  assisting  to  restore  the 
patient's  life.  This  drug,  by  raising 
artificially  the  blood  pressure,  allows 
the  heart  and  the  vital  nerve  centers  to 
resume  their  functions  very  easily.  It 
should  prove  of  great  value  in  resuscitat- 
ing drowned  persons  and  in  other  simi- 
lar emergencies.  J.  P.  Lockhart  Mum- 
mery (Lancet,  April  1,  1905). 

TUBERCULOSIS,     RELATION     OF     HUMAN 
AND  BOVINE. 

Human  tuberculosis  can  be  trans- 
mitted to  cattle,  but  with  difficulty,  and 
it  seems  highly  improbable  that  such 
transmission  plays  any  great  part  in  the 
production  of  the  disease  among  cattle. 

Bovine  tuberculosis  can  be  transmitted 
to  man,  but  the  evidence  that  such  trans- 
mission occurs  under  ordinary  circum- 
stances is  extremely  scanty,  and  it  is 
highly  improbable  that  such  transmis- 
sion plays  any  important  part  in  the 
spread  of  the  disease  in  man.  David 
Bovaird,  Jr.  (Medical  Eecord,  February 
25,  1905). 

URINE  EXAMINATION. 

Incited  by  a  statement  of  Councilman 
that  the  chemical  and  microscopic  ex- 
amination of  the  urine  failed  to  give 


certain  information  of  the  character  of 
the  renal  lesions,  as  well  as  by  discrep- 
ancies coming  under  his  own  observa- 
tion, the  author  has  compared  critically 
the  records  and  post-mortem  findings  in 
the  cases  that  have  come  to  autopsy  in 
the  Massachusetts  General  Hospital 
since  1893.  Although  the  number  of 
cases  is  not  large,  the  writer  thinks  they 
warrant  the  following  conclusions: 
Many  cases  of  acute  glomerular  nephri- 
tis occur  and  are  unrecognized  by  any 
known  methods  of  examination.  The 
diagnosis  is  at  fault  in  some  cases  of 
subacute  and  chronic  glomerular  nephri- 
tis, but  in  the  great  majority  of  cases 
the  condition  of  the  urine,  taken  in  con- 
nection with  other  symptoms,  foretold 
the  autopsy  findings.  In  chronic  intes- 
tinal nephritis  the  diagnostic  resources 
appear  to  be  neither  so  sufficient  as  in 
the  chronic  glomerular  form,  nor  so  in- 
adequate as  in  the  acute  glomular 
nephritis.  In  about  a  third  of  the  cases 
the  diagnosis  was  correctly  made  before 
death. 

Among  other  conditions  mistaken  for 
nephritis  by  too  much  reliance  on  the 
urinary  findings  are  senile  and  arterio- 
sclerotic condition,  mistaken  for  chronic 
nephritis,  while  in  conditions  involving 
passive  congestion  or  acute  kidney  de- 
generations, the  urine  occasionally  simu- 
lates that  of  acute  nephritis.  Even 
where  no  lesions  are  found  at  autopsy 
the  urine  is  sometimes  highly  albumin- 
ous and  full  of  casts. 

In  ordinary  urinary  examinations  the 
common  errors  are;  (a)  The  attempts 
to  estimate  urea  without  accurate 
knowledge  of  the  patient's  metabolism; 
(b)  stating  that  renal  cells  are  present 
when  all  that  is  seen  are  small  mo- 
nonuclear cells,  perhaps  from  the  kid- 
ney tubules,  perhaps  not. 


UTERUS,  DISPLACEMENT  OF. 


BOOK  REVIEWS. 


237 


Cryoscopy  and  other  attempts  to  test 
the  renal  permeability  more  directly  are 
not  yet  capable  of  supplementing  in 
clinical  work  the  older  methods  of  ex- 
amination. The  author  holds  that  the 
vast  majority  of  estimations  of  urinary 
solids,  including  urea,  arc  a  waste  of 
time,  since  they  are  not  and  can  not  be 
made  part  of  a  general  metabolism  ex- 
periment, and  that  the  attempt  to  esti- 
mate the  anatomic  condition  of  the  kid- 
ney by  measuring  albumin  and  by 
searching  for  casts  is  fallacious.  The 
most  reliable  data  are  the  twenty-four- 
hour  quantity,  the  specific  gravity  and 
the  color.  I.  E.  C.  Cabot  (Journal  of 
the  American  Medical  Association, 
March  18,  25,  1905). 

UTERUS,  RETRODISPLACEMENTS  OF  THE. 

The  writer  makes  a  general  division 
of  retroverted  uteri  into  the  complicated 
and  the  uncomplicated.  The  compli- 
cated are  those  in  which  there  are  co- 
existing ovarian  or  tubal  diseases,  adhe- 
sions, or  anything  which  interferes  with 
the  normal  mobility  of  the  uterus  and 
so  contraindicates  all  surgical  interfer- 
ence of  an  extra-peritoneal  nature.  The 
uncomplicated   include   those   in   which 


the  uterus  is  mobile,  the  tubes  and 
ovaries  normal,  and  the  prolapsus  very 
slightly  developed  if  it  exists  at  all. 
This  condition  can  frequently  be  cured 
by  means  of  tampons  and  pessaries. 
Should  these  fail  the  author  is  accus- 
tomed to  resort  to  the  Alexander  opera- 
tion. The  ordinary  lesions  of  the  cer- 
vix and  vagina  do  not  contraindicate 
this  operation.  It  is  quite  possible  that 
the  patient  may  not  be  benefited  by  the 
operation,  and  that  an  intraperitoneal 
operation  will  be  necessary  before  a  cure 
can  be  obtained.  The  Alexander  oper- 
ation is  always  safer  than  the  intra-ab- 
dominal. All  of  the  intra-abdominal 
operations  may  be  objected  to  for  some 
reason,  and  most  of  them  are  more  or 
less  faulty.  When  the  uterus  is  mova- 
ble and  the  appendages  are  healthy  the 
Alexander  operation  is  recommended. 
Displacements  of  the  uterus  may  pre- 
sent no  symptoms  for  a  long  time,  but 
are  almost  sure  to  come  eventually. 
The  Alexander  operation  is  well  adapted 
for  the  changes  which  occur  with  preg- 
nancy. The  author's  failures  with  this 
operation  have  been  fewer  than  5  per 
cent.  Hayd  (International  Journal  of 
Surgery.  March,  1905). 


5ool<  Reviews. 


Conservative    Gynecology    axd    Electro-therapeutics.      By    Betton    Masscy,    M.D. 

Fourth  Revised   Edition.     Rewritten  and  Carefully   Revised,      [frustrated.      V.  A.   Davis 

Co.,  Philadelphia.      Price,  $3.00. 

It  was  the  privilege  of  the  writer  to  review  the  first  edition  of  Dr.  Massey's  book  when 
a  small  volume  in  L889,  one-fourth  its  present  >ize.  Since  then  it  has  grown  with  the 
progress  of  the  subject,  which  lias  developed  into  an  important  department  of  therapeutics, 

a-   theories  an  1   practical  applications   of  electrolysis  and   phoresis   have   become   amplified. 

As  the  author  states,  quoting  from  Professor  Dolbear,  he  deprecates  all  allusion  to  elec- 
tricity as  a  force  external  to  matter  and  independent  of  it.  Electricity,  light,  heat,  and 
chemie  action  are  inherent  properties  of  matter,  electricity  being  the  rotary  property  of 
atoms:  Light  the  vibratory  property,  etc.  They  are  but  manifestations  of  atomic  energies 
present  in  the  interchanges  of  atoms  in  the  molecular  activities  incident  to  life.  "By  its  use 
we  have  a  means  of  altering  at  will  the  molecular  activities,  the  selective  chemistry  of  both 


238  BOOK  REVIEWS. 

superficial  and  deep-seated  parts  of  the  body,  and  this  is  done,  not  by  the  aid  of  substances 
or  even  forces  foreign  to  the  body,  but  by  a  simple  alteration  of  its  cellular  activities  on  which 
all  organic  functions  depend." 

In  speaking  of  the  limitations  the  author  states  that  he  makes  the  claims  that  electricity, 
or,  in  fact,  anything  else  as  a  cure-all,  is  possible  to  the  scientific  mind;  and  although  these 
pages  are  largely  devoted  to  a  demonstration  of  its  value  in  the  definite  conditions  enumer- 
ated, it  is  not  supposed  that  the  reader  is  to  neglect  any  simpler  means  that  would  be 
effective  in  treatment.  Electricity  is  only  advised  when  it  is  equally  certain  in  effect,  free 
from  danger,  and  more  conservative  of  organs  and  their  functions. 

The  fourth  edition  contains  a  complete,  though  brief,  dissertation  of  "Roentgen  Rays  in 
Diagnosis,"  and  treatment  prepared  by  Dr.  Herman  Crad,  of  New  York.  The  illustrations 
are  admirable,  especially  12  full  page  colored,  12  full  page  half-tones  of  photographs  from 
nature,  and  numerous  engravings  of  clinical  conditions  and  instruments. 

It  is  well  that  the  public  should  know  that  there  are  means  at  command  which  may  be 
tried  before  accepting  the  verdict  of  radical  removal. — J.  M.  T. 

Transactions  of  the  American  Roentgen  Ray  Society.      A.  H.  Sickler  &  Co.,  Phila- 
delphia. 

We  are  in  receipt  of  a  neat  volume  of  transactions  of  this  society,  which  includes  con- 
stitution, by-laws,  a  list  of  officers,  and  minutes  of  the  fifth  annual  meeting,  and  seventeen 
papers.  The  illustrations  are  excellent,  and  apparently  sufficient  without  being  excessive. 
The  work  that  is  being  done  by  these  gentlemen  is  painstaking,  thorough,  and  evidently 
accomplishing  a  large  amount  of  good,  especially  in  conditions  not  otherwise  remediable  — 
J.  M.  T. 

Mental  Defectives,  Their  Training  and  Treatment.     By  Martin  W.  Barr,  Elwyn,  Pa. 

Illustrated  by  53  Full-page  Plates.     Philadelphia:     P.  Blakiston's  Son  &  Co.,  1904. 

Although  a  little  late  to  notice  this  admirable  book  the  reviewer  feels  impelled  to  say 
a  word  to  readers  of  the  Cyclopaedia,  because  of  his  long  association  with  the  author  in 
clinical  work.  Dr.  Barr  has  given  a  lifetime  not  only  to  the  intelligent  care  and  supervision 
of  an  enormous  institution  of  nearly  1000  inmates,  and  he  has,  more  than  most  men  who 
enjoy  such  opportunities,  made  a  most  thorough  study  of  the  problems  which  come  under 
his  observation.  He  has  made  many  contributions  in  papers  and  monographs,  all  of  which 
have  commanded  respect  and  added  much  to  our  knowledge  of  the  difficult  subject  of  the 
Mental  Defectives.  He  has  now  in  his  early  middle  life  produced  a  book  which  is  destined 
to  be  authoritative  in  one  department  of  medical  science. 

The  book  contains  a  careful  and  thorough  review  of  the  history  of  movements  to 
elucidate  mental  disease,  especially  those  which  proceed  from  developmental  defects.  His 
classification  is  excellent,  and  that  is  by  no  means  easy,  indeed  while  it  is  scarcely  possible  to 
classify  these  cases;  nevertheless,  he  has  achieved  an  excellent  system.  Dr.  Barr  has  had 
the  boldness  to  discuss  the  subject  of  asexualization  in  a  temperate  and  lucid  fashion,  and 
any  one  who  will  take  the  trouble  to  read  his  chapter  on  the  subject  will  feel  convinced  that 
whatever  his  personal  prejudices  may  be,  there  is  no  doubt  that  the  evidences  are  strongly 
in  favor  of  rendering  these  defectives  unable  to  propagate  their  kind.  Physicians  generally 
would  do  well  to  familiarize  themselves  with  this  subject,  so  that  they  may  act  with  judg- 
ment when  such  cases  come  under  observation.  In  this  book  they  will  find  not  only  much 
useful  information  but  references  to  literature  so  complete,  that  through  this  means  they 
could  learn  all  that  need  be  known  on  the  subject—  J.  M.  T. 

A  Textbook  on  the  Practice  of  Medicine.     By  Hobart  Amory  Hare,  M.D.,  B.S.C.     Lea 

Brothers  &  Company.      Illustrated.      Octavo,  1120  Pages,  Cloth.      1905.      $5.00. 

Dr.  Hare  has  fulfilled  his  promise  of  presenting  the  profession  with  a  treatise  on  Practice. 

This  with  his  practical  diagnosis  and  practical  therapeutics  form  a  triad  on  which  any  man 

might  well  congratulate  himself.      So  versatile  is  this  author  that  we  need  not  be  surprised 


BOOKS  AND  MONOGRAPHS  RECEIVED.  239 

to  find  him  invading  other  fields.  As  the  preface  sets  forth,  the  author  has  had  the  coopera- 
tion of  Professor  Coplin,  professor  of  pathology  at  Jefferson,  and  Dr.  William  Pickett,  in- 
structor in  neurology,  so  that  these  two  departments  in  the  hook  will  have  been  doubly 
revised.  Further,  the  statement  is  made  that  the  subject  of  tropical  diseases  has  received 
special  attention,  which  is  wise,  in  view  of  the  fact  that  we  live  in  a  time  of  expansion, 
whereby  our  medical  supervision  reaches  out  to  many  tropical  and  sub-tropical  countries. 
Here  the  author  expresses  his  indebtedness  to  Charles  K.  Kieffer,  major  and  surgeon  in  the 
United  States  Army,  who  has  seen  service  in  the  Phillipines,  and  is  lecturing  at  the  Jefferson 
Medical  College.  The  arrangement  of  the  subjects  presents  little  that  is  unusual  and  yet 
does  not  fail  to  give  sufficient  attention  to  all  those  subjects  presented  in  a  book  of  this  scope. 
Of  special  value  may  be  mentioned  the  chapters  of  "Diseases  of  the  Nervous  System,'"  which 
occupy  170  pages. — J.  M.  T. 

Blood  Pressure  as  Affecting  the  Heart,  Brain,  Kidneys,  and  General  Circulation. 
By  Louis  Faugeres  Bishop,  A.M.,  M.D.      E.  B.  Treat  &  Co.,  New  York.      Price,  $1.00. 

This  little  book  of  about  112  pages  deals  with  the  subject  of  the  title  in  a  clear,  succinct 
fashion,  and  with  suitable  thoroughness  for  an  adequate  understanding  of  blood  pressure  in  its 
relation  to  disease.  It  consists  of  nine  chapters,  divided  in  a  rational,  practical  manner,  and 
has  already  met  with  an  excellent  welcome. 

It  embodies  the  researches  of  previous  papers  by  the  author.— J.  M.  T. 


5ool(s  and  /Vlonographs  Received. 


The  editor  begs   to   acknowledge  with  thanks,  the  receipt  of  the  following  books   and 
monographs: — 

"Text-Book  of  Medical  Chemistry  and  Toxicology."      By  James  W.  Holland,  M.D.,  Phila- 
delphia.    W.  B.  Saunders  &  Co.,  1905,  Philadelphia  and  London. "Practical  Paediatrics,  A 

Manual  of  the  Medical  and  Surgical  Diseases  of  Infancy  and  Children."  By  E.  Graetzer. 
Authorized  Translation,  with  Numerous  Additions  and  Notes.      By  H.  B.  Sheffield,  M.D.      F. 

A.  Davis  Co.,  1905,  Philadelphia. "Blood  Pressure  as  Affecting  the  Heart,  Brain,  Kidneys, 

and  General  Circulation."      By  Louis  Faugeres  Bishop,  A.M.,  M.D.      E.  B.  Treat  &  Co.,  New 

York. "Bio-chemistry  of  Muscle  and  Nerve."     By  W.  D.  Halliburton,  M.D.     P.  Blakiston's 

Son  &  Co. "Conservative  Gynecology  and  Electro-Therapeutics."      By  G.  Betton  Massey, 

M.D.,  Philadelphia.  Fourth  Revised  Edition.  F.  A.  Davis  Co.,  Philadelphia. "The  Rela- 
tion of  Diseases  of  the  Stomach  to  Affections  of  the  Mouth,  Nose,  and  Throat."     By  Robert 

Levy,  M.D.,   Denver,   1904. Enuresis   in   Childhood.     By   Maurice  Ostheimer,   M.D.   and   I. 

Valentine  Levi,  M.D.,  Philadelphia,  1904. A  Case  of  Probable  Gummata  of  the  Liver  in  a 

Child  of  Six.     By  Maurice  Ostheimer,  Philadelphia,  1903. Incontinence  of  Faeces  in  Children. 

By  Maurice  Ostheimer,  Philadelphia,  1905.— — Two  Cases  Presented  to  the  Clinical  Society 
of  New  York  Post-Craduate  Medical  School  and  Hospital,  December  1G,  1904.  By  W.  S. 
Bainbridge,  New  York,  1905. A  Case  of  Extensive  Carcinoma  of  Tongue  and  Neck,  Pre- 
senting Points  of  Special  Interest.      By  W.  S.  Bainbridge,  New  York,  1905. The  Genesis  of 

Sympathetic  Ophthalmitis.     By  Samuel  Theobald,  Baltimore,  Md.,  1905. A  Consideration  of 

Some   Tendencies    in    Modern    Medical    Education.       By    J.    D.    Crain,    Albany,    1904. The 

Importance  of  Testing  the  Ocular  Muscle  Balance  for  Near,  as  Well  as  for  Distant  Vision.  By 
Samuel  Theobald,  Baltimore,  Md.,  1905. — The  Importance  of  the  Physical  Examination  of  the 

Back    in    General   Diagnosis.      By   J.    P.    Arnold,   Philadelphia,    1905. Disturbances    of    the 

Vasomotor  Mechanism  as  a  Factor  in  Diagnosis  and  Therapeutics.  By  J.  P.  Arnold,  Phila- 
delphia, 1903. Surdite  et  Fievre  TyphoTde.     Par  Dr.  Marcel  Natier,  1905. 


EDITORIAL  STAFF. 
Sajous's  Analytical  Cyclopaedia  of   Practical  Medicine. 


ASSOCIATE  EDITORS. 


J.  GEORGE  ADAMI,  M.D.. 

MONTREAL,   P.  <J. 


LEWIS  H.  ADLER,  M.D., 

PHILADELPHIA. 


JAMES  M.  ANDERS.  M.D.,  LL.D., 

PHILADELPHIA. 


THOMAS  G.  ASHTON,  M.D., 

PHILADELPHIA. 


A.  D.  BLACKADER,  M.D., 

MONTREAL,  P.  Q,. 


E.  D.  BONDURANT,  M.D., 

MOBILE,  ALA. 


DAVID  BOVAIRD,  M.D., 

NEW  YORK  CITY. 


WILLIAM  BROWNING,  M.D., 

BROOKLYN,  N.  Y. 


WILLIAM  T.  BULL,  M.D., 

NEW  YORK  CITY. 


CHARLES  W.  BURR,  M.D., 

PHILADELPHIA. 


HENRY  T.  BYFORD,  M.D., 

CHICAGO,  ILL. 


HENRY  W.  CATTELL,  M.D., 

PHILADELPHIA. 


WILLIAM  B.  COLEY,  M.D., 
NKW  YORK  CITY. 


FLOYD  M.  CRANDALL,  M.D., 

NEW  YORK  CITY. 


ANDREW  F.  CURRIER,  M.D., 

NEW  YORK  CITY. 


ERNEST  W.  CUSHING,  M.D.. 

BOSTON,  MASS. 


GWILYM  G.  DAVIS,  M.D., 

PHILADELPHIA. 


N.  S.  DAVIS,  M.D., 

CHICAGO,  ILL. 


AUGUSTUS  A.  ESHNER,  M.D., 

PHILADELPHIA. 


SIMON  FLEXNER,  M.D., 

PHILADELPHIA. 


LEONARD  FREEMAN,  M.D., 

DENVER,  COL. 


S.  G.  GANT.  M.D., 

NEW  YORK  CITY. 


J.  McFADDEN  GASTON,  Sli..  M.D., 

ATLANTA.  GA. 


J.  McFADDEN  GASTON,  Jr.,  M.D., 

ATLANTA,  GA. 


E.  B.  GLEASON,  M.D., 

PHILADELPHIA. 


EGBERT  II.  GRAN  DIN,  M.D., 
MW  YOBK  OUT. 


J.  P.  CROZER  GRIFFITH,  M.D  , 

PHILADELPHIA. 


C.  M.  HAY,  M.D., 

PHILADELPHIA. 


FREDERICK  P.  HENRY,  M.D., 

PHILADELPHIA. 


L.  EMMETT  HOLT,  M.D., 

NEW  YORK  CITY. 


EDWARD  JACKSON,  M.D., 

DENVER,  COL. 

W.  W.  KEEN,  M.D., 

PHILADELPHIA. 

EDWARD  L.  KEYES,  Jr.,  M.D., 

NEW  YORK  CITY. 

ELWOOD  R.  KIRBY,  M.D., 

PHILADELPHIA. 

L.  E.  LaFETRA,  M.D., 

NEW  YORK  CITY. 

ERNEST  LAPLACE,  M.D.,  LL.D., 

PHILADELPHIA. 

R.  LEPINE,  M.D., 

LYONS,  FRANCE. 

F.  LEVISON,  M.D., 

COPENHAGEN,  DENMARK. 

A.  LUTAUD,  M.D., 

PARIS,  FRANCE. 

G.  FRANK  LYDSTON,  M.D., 

CHICAGO,  ILL. 

F.  W.  MARLOW,  M.D., 
SYRACUSE,  N.  Y. 

SIMON  MARX.  M.D., 
NEW  YORK  CITY. 

ALEXANDER  McPHEDRAN,  M.D., 

TORONTO,  ONT. 

E.  E.  MONTGOMERY,  M.D., 
PHILADELPHIA. 

HOLGER  MYGIND,  M.D., 
COPENHAGEN,  DENMARK. 

W.  P.  NORTHRUP.  M.D., 
NEW  YORK  CITY. 

RUPERT  NORTON,  M.D., 

WASHINGTON,  D.  C. 

H.  OBERSTEINER.  M.D.. 

VIENNA,  AUSTRIA. 

CHARLES  A.  OLIVER,  M.D., 

PHILADELPHIA. 

WILLIAM  OSLER.  M.D., 

BALTIMORE,  MD. 

LEWIS  S.  PILCHER,  M.D., 

BROOKLYN,  N.  Y. 

WILLIAM  CAMPBELL  POSEY,  M.D., 

PHILADELPHIA. 


W.  B.  PRITCHARD,  M.D.. 

NEW  YORK  CITY. 


JAMES  J.  PUTNAM,  M.D., 

BOSTON. 


B.  ALEXANDER  RANDALL.  M.D., 

PHILADELPHIA. 


CLARENCE  C.  RICE,  M.D., 

NEW  YORK  CITY. 


ALFRED  RUBINO,  M.D., 

NAPLES,  ITALY. 


REGINALD  II.  SAYRE,  M.D., 

NEW  YORK  CITY. 


JACOB  E.  SCHADLE,  M.D., 

ST.  PAUL,  MINN. 


JOHN  B.  SIIOBER,  M.D., 

PHILADELPHIA. 


J.  SOLIS-COHEN.  M.D., 

PHILADELPHIA. 


SOLOMON  SOLIS-COHEN,  M.D., 

PHILADELPHIA. 


H.  W.  STELWAGON,  M.D., 

PHILADELPHIA. 


D.  D.  STEWART.  M.D., 

PHILADELPHIA. 


LEWIS  A.  STIMSON,  M.D., 
NEW  YORK  CITY. 


J.  EDWARD  STUBBERT,  M.D., 

LIBERTY,  N.  Y. 


A.  E.  TAYLOR,  M.D., 

SAN  FRANCISCO,  CAL. 


J.  MADISON  TAYLOR,  M.D., 
PHILADELPHIA. 


M.  B.  TINKER,  M.D., 

PHILADELPHIA. 


CHARLES  S.  TURNBULL,  M.D.. 

PHILADELPHIA. 


HERMAN  F.  VICKERY,  M.D., 

BOSTON,  MASS. 


F.  E.  WAXHAM,  M.D., 

DENVER,    COL. 


J.  WILLIAM  AVHITE,  M.D., 
PHILADELPHIA. 


JAMES  0.  WILSON,  M.D., 

PHILADELPHIA. 


C.  SUMNER  WITHERSTINE.  M.D., 

PHILADELPHIA. 


ALFRED  C.  WOOD,  M.D., 

..PHILADELPHIA. 

WALTER  WYMAN.  M.D.. 
WASHINGTON,  D.  a 


THE    MONTHLY   CYCLOPEDIA 

OF 

PRACTICAL   MEDICINE 


(Published  the  Last  of  Each  Month) 


Vol.  XVIII. 
Old  Series. 


PHILADELPHIA,  JUNE,  1905. 


Vol.  VIII,  No.  G 
—  New  Series. 


TABLE  OF  CONTENTS. 


EDITORIALS 

ADOLESCENCE.  G.Stanley 
Hall 241 

THE  DISORDERS  OF  ADOLESCENCE. 

J.  Madison  Taylor 244 

CLINICAL    SIGNIFICANCE    OF    TEE 

RBFLEXE8.     Philip  Zenner 247 

ALKALINE  BEVERAGES  IN  PNEU- 
MONIA.    C.  E.  de  M.  Sajous 249 

CYCLOPAEDIA    OF   CURRENT 
LITERATURE 

ADENOIDS    IN   THE  ADULT.     D.  M. 

Barstow 251 

ANEURISM  AND  ARTERIOSCLE- 
ROSIS.    C.  N.  M.  Camac 251 

ASTHENIA.     P.  Londe 251 

BILIARY    TRACT,    INFECTION    OF. 

H.  W.  Longyear 252 

BILIOUSNESS,  THE  HEPATIC  FAC- 
TOR IN.     F.  Hare 252 

BREAST  FEEDING     FOR     INFANTS. 

G.  Martin 253 

CEREBROSPINAL  MENINGITIS, 
EPIDEMIC,  TREATMENT  OF. 
H.  Lenhartz 254 

COBRA  VENOM,  THE  INFLUENCE 
OF,  ON  THE  PROTEID  META- 
BOLISM.   James  Seott 254 

COLITIS  AND  APPENDICITIS,  RE- 
LATIONSHIP BETWEEN.  C.  B. 
Lockwood 254 

COLON  BACILLUS,  ACTION  OF  THE 
INTRACELLULAR  POISONS  ON 
THE.     V.  C.  Vaughan,  Jr 255 

C0N8TIPATI0N,    CHRONIC.      W.   A. 

Lane 255 

COPPER,  ACTION  OF  COLLOIDAL 
SOLUTIONS  OF,  UPON  BACIL- 
LUS TYPHOSUS.     A.  H.  Stewart..  256 

CUTANEOUB  AFFEOTION8,  RIFR1G- 
ERATION  IN  TREATMENT  OF. 
M.  Juliusberg 257 

DIABETES  MELLITUB,  THE  NATURE 

OF.     W.  C.  Bosanquet 257 

ECZEMA.  CHRONIC,  AS  A  COMPLI- 
CATION OF  THE  SENILE  DE- 
GENERATIONS     Medwin  Leale..  259 

ENTEROSTOMY.     J.  \V.  Long 259 

EPILEP8Y,  AUTOP8Y  FINDINGS  IN. 

B.  Onuf. 200 

ETHER  NARCOSI8  BY  RECTUM.  J. II 

Cunningham,  Jr.  and  F.  II.  Laliey..  260 


GALL-STONE   DI8EA8E,  FEVER   IN. 

H.  Ehret 261 

HAND    STERILIZATION.     J.  C. 

Webster 261 

HEMOPHILIA,     RESEARCHES     IN. 

H.  Sahli 262 

HEMORRHAGES  OF  THE  INTES- 
TINES, TREATMENT  OF. 
Mathieu  and  Passier 263 

HEART,    ACTION     OF    STRYCHNINE 

ON  THE.     Gennari 263 

HEART  8TRAIN  IN  GROWING  BOYS. 

A.  Lambert 263 

INFLUENZA  BACILLI,  INFECTIONS 
OF  THE  RESPIRATORY  TRACT 
WITH.     F.  T.  Lord 264 

INSANITY,  MEDICAL   TREATMENT 

OF.     R.  Jones 264 

MENSTRUAL  FEVER  IN  PHTHISICAL 

WOMEN.     Sabourin 265 

MENTOPOSTERIOR  POSITIONS.  C.  B. 

Reed 266 

MERCURY,  ACTION  OF.     During 266 

MILK.  DIGESTION  OF.    Leon  Meunier  267 

MYOPIA.    Helbron 267 

NEPHROPEXY.     A.  E.  Gallant 267 

NERVES,    REGENERATION    OF.       B. 
Kilvington 268 

NON-MALIGNANT  DISEASES, 
TREATMENT  OF,  BY  THE 
ROENTGEN  RAYS.    R.  H.  Boggs.  268 

NURSING, TECHNIQUE  OF.  O.Rommel.  268 

PAROTID  GLAND.     E.  A.  Zherbovski..  269 

PLEURAL  AND  CEREBRO-8PINAL 
FLUIDS,  CYTODIAGNOSIS  OF. 
Edward  Turton 269 

PNEUMONIA,  CARBONATE  OF  CRE- 
OSOTE IN.     C.  P.  Stackhouse 270 

!  POTT'S   DISEASE,  TREATMENT    OF. 

Arturo  Campani 270 

PROSTATECTOMY,    CONSERVATIVE 

PERINEAL.     H.  H.  Young 271 

PROSTATIC    ENLARGEMENT.     C.  E. 

Barnett 271 

PUERPERAL     FEVER,     CLINICAL 

ASPECTS  OF.     Herman 271 

PUERPERAL  SEPTICEMIA,  PRE- 
VENTION OF.     Berry  Hart 272 

RHEUMATOID  ARTHRITIS  AND 
RAYNAUD'S  DISEASE  R.  L. 
Jones 272 

RINGWORM  OF  THE  SCALP,  TREAT- 
MENT OF.     T.  C.  Fox 273 


ROENTGEN  RAY8  AND  STERILITY. 

Brown  and  Osgood 273 

8EPTIO     PERITONITIS,     GENERAL. 

I.  B.  Perkins 273 

8PONDYLOSE  RHIZOMYELIQUE.     D. 

J.  McCarthy 274 

BUPRARENIN  GLYCOSURIA, EFFECT 
OF  FEVER,  INFECTION,  AND 
RENAL  INJURY  ON.  Ellinger 
and  Seelig 274 

SYPHILIS  AND  LONGEVITY.  J.  N. 
Hyde 274 

TAPEWORM,    TREATMENT    OF.       I. 

Boas 276 

TENDON  TRANSPLANTATION.   H.A. 

Wilson 276 

TETANUS  AND  QUININE.  E.  Vincent.  276 

THIERSCH'S  IKIN  GRAFTING,  MOD- 
IFICATION OF.     Isnardi 277 

THYROID  GLAND;  INFLUENCE  OF 
DIET  ON  ITS  STRUCTURE  AND 
FUNCTION.    Watson 277 

TOURNIQUET,    DANGERS     OF    THE. 

A.  Ahlberg 277 

TUBERCULOSIS,  ADAPTATION  AND. 

J.  G.  Adami 278 

TUBERCUL08IS,  EFFECT  OF  RAW 
MEAT  ON  NITROGEN  META- 
BOLISM IN.     J.  J.  Galbraiih 279 

TUBERCULOSIS,  STOMACH  FUNC- 
TION IN.     J.E.Mnnson 279 

TUBERCULOUS  DEP08IT8  IN  THE 
TONSILS,  SIGNIFICANCE  OF. 
G.  B.  Wood 280 

TYPHOID    FEVER,    PERFORATION 

IN.     J.  A.  Scott 280 

ULCERATIVE  PROCE88EB,  CHLOBO- 
BROMIDE  OF  SODIUM  IN.  H. 
W.  Mitchell 281 

UTERINE  MYOMA.   W.M.Thompson..  282 

WATER  CURES,  ERRORS  IN.    Winter- 

nitz 282 

X-RAYS,  METHOD  OF  MEASURING. 

M.  Franklin 283 

YBLLOW-FEVER,     TREATMENT    OF. 

A.  M.  Fernandez  de  Ybarra 2S3 

CORRESPONDENCE  :      WORKS     AND 

NOT  WORDS 284 

BOOK    REVIEW8 285 

BOOKS  AND  MONOGRAPHS  RE- 
CEIVED   287 

STAFF   LIST 28 


Editorials. 


DEPARTMENT   IN   CHARGE   OF 

J.  MADISON  TAYLOR,  A.M.,  M.D. 


ADOLESCENCE. 

At  the  request  of  the  editors  of  the  Monthly  Encyclopedia  of  Practical 
Medtcine,  I  am  very  glad  to  jot  down  in  a  hasty  way  the  following  opinions  which 
I  have  formed  concerning  the  need  of  a  new  field  of  medical  practice.     It  is  now 

(241) 


242  ADOLESCENCE. 

some  ten  or  fifteen  years  since  I  began  to  issue  circulars  and  deliver  public  lectures 
and  gather  the  literature  upon  adolescence.  Very  soon  I  began  to  be  approached 
by  both  friends  and  strangers  for  guidance  concerning  their  children  who  were 
in  or  near  this  critical  age.  As  I  printed  articles  upon  it  here  and  there  the  letters 
increased  in  number.  Most  of  them  were  from  parents  or  relatives  of  young 
people  who  had  given  them  cause  for  anxiety  in  their  development,  and  I  had  at 
one  time  over  twelve  hundred  such  letters,  mostly  representing  different  cases,  on 
file  in  my  office.  Although  I  have  done  various  researches  in  physiological  labora- 
tories and  spent  much  time  in  the  study  of  the  insane  in  asylums,  I  am  not  a 
physician  and  have  had  no  motive  except  that  of  humanity  to  answer  the  innumer- 
able questions  that  have  been  asked  me. 

Five  years  ago  I  began  to  realize  that,  had  I  been  a  physician,  I  might  have 
easily  worked  up  a  lucrative  practice  from  such  cases.  These  letters  have  never 
been  as  numerous  as  within  the  last  year  or  two.  I  am  confronted  with  all  kinds 
of  practical  and  even  impossible  questions  concerning  young  people  who  are  bright, 
geniuses,  dullards,  born  short,  one-sided  in  their  mental,  physical,  or  moral  devel- 
opment, etc.  Many  of  these  questions  I  am  utterly  incompetent  to  answer,  and 
in  any  case  should  be  able  to  give  but  little  help  to  strangers.  Some  of  my  letters 
contain  long  and  pitiful  tales  of  obvious  ignorance,  misunderstanding,  wandering 
from  doctor  to  doctor,  and  getting  no  relief  and  no  insight.  Perhaps  more  than 
half  of  these  cases  do  not  require  treatment  that  would  be  called  medical  so  much 
as  pedagogical  and  psychological  treatment.  Suggestions  concerning  regimen, 
attendance  at  school,  what  school,  occupation  for  vacations,  etc.,  are  desired.  I 
have  often  been  told  that  I  ought  to  have  a  competent  private  secretary  to  devote 
his  or  her  time  entirely  to  such  correspondence,  both  with  a  view  to  doing  good  in 
the  way  of  instructing  parents,  and  in  order  to  collect  data. 

These  experiences  have  convinced  me  that  there  is  in  our  communities  a  class 
far  larger  than  is  supposed  of  young  people  in  or  near  the  teens  who  give  too  good 
cause  for  anxiety,  but  who  are  not  fit  subjects  for  restraint  and  who  do  not  need 
drugs,  but  should  be  given  sensible  physiologic  and  pedagogic  advice.  Hippocrates, 
I  believe,  is  the  author  of  the  maxim,  "Godlike  is  the  physician  who  is  also  a 
philosopher."  But  in  the  treatment  of  these  cases  there  is  crying  need  of  some 
such  qualified  man.  Therefore,  I  conclude  that  as  children's  diseases  and  women's 
diseases  have  become  a  specialty,  there  is  now  place  for  another  medical  specialty 
for  the  treatment  of  adolescent  troubles  of  mind  and  body.  Fortunately,  we  have 
a  recent  new  interest  in  what  Kahlbanm  first  discovered  and  named  hebephrenia, 
but  which,  with  better  knowledge,  we  now  call  dementia  praicox.  I  have  taken 
much  pains  to  become  somewhat  familiar  with  this  very  rapidly  growing  body  of 
literature.     The  above  term  is  an  omnibus  term,  designating  and* including  a  vast 


ADOLESCENCE.  243 

variety  of  symptom  groups  which   may  ultimately  develop  independence  into  a 
great  variety  of  types. 

Virchow  always  insisted  that  every  disease  must  have  a  location,  and  taught 
his  pupils  always  to  ask,  ubi  est  morbus?  This  has  heen  the  maxim  of  pathologists 
for  several  decades.  In  every  post-mortem  they  seek  to  find  somewhere  the  seat 
of  the  lesion.  If  there  was  ever  a  disease,  however,  which  belied  this  view  it  is 
dementia  praecox.  It  is  not  without  significance  that  the  principle  itself  is  now 
challenged  and  that  the  belief  in  the  existence  of  ailments,  which  may  be  mortal 
but  which  are  nevertheless  so  purely  functional  as  to  defy  the  quest  of  definite 
lesions  sought  after  death,  is  now  coining  into  prominence.  Kraepelin's  view,  that 
it  is  due  to  autointoxication,  is  now  generally  discredited.  An  eminent  neurologist 
showed  me  some  two  or  three  years  since  what  he  deemed  microscopic  evidence  of 
disturbances  in  the  lenticular  nucleus,  but  he  has  since  abandoned  this  view.  Brain 
weights  have  not  yet  yielded  any  substantial  results.  Wernicke,  in  his  "Grundriss 
der  Psychiatric,"  has  made  much  use  of  what  he  calls  sejunction  or  dissociation 
between  neurons.  This  was  doubtless  suggested  by  Cajal's  famous  make  and  break 
theory  of  association,  but  this  has  been  abandoned  by  its  author.  Dementia  precox 
seems  to  me  as  loose  and  all-comprehensive  a  term  as  female  or  childhood  diseases, 
but  one  of  the  distinguishing  characteristics  of  these  complaints  is  their  essentially 
psychic  quality.  Jenet's  conclusions  concerning  psycholepsy  and  Meltzers  recent 
protest  against  a  purely  post-mortem  and  somatic  pathology  applies  peculiarly  here 
where  the  mortality  is  so  slight  and  the  deterioration  so  subtle,  but  so  calamitous. 
Adolescence  is  a  period  when  young  people  have  not  entirely  escaped  liability  from 
many  of  the  disorders  of  infancy  and  early  childhood,  and  when  many  diseases  of 
maturity  have  not  yet  acquired  their  full  strength,  so  that  human  beings  arc  then 
peculiarly  prone  to  slight  ailments,  although  the  mortality  rates  are  low.  It  is, 
however,  just  these  slight  ailments  that  are  effective  in  causing  the  subtle  processes 
of  cellular  arrest  or  perversion  at  this  crucial  period  when  the  higher  faculties  are 
born.  As  a  result  of  a  work  which  1  have  recently  published  I  have  already  heard 
of  at  least  one  young  physician  who  has  determined  to  make  practice  among  those 
of  this  age  his  specialty.  1  think  it  would  be  vastly  for  the  interests  of  the  young 
people  of  this  land  if  others  would  do  so;  but  it  would  be  very  necessary  that,  while 
they  should  know  the  main  results  of  neurological  and  pathological  studies,  they 
should  also  know  something  of  the  vast  but  yet  undeveloped  resources  which  psy- 
chology and  pedagogy  are  ere  long  to  supply  to  the  medical  profession. 

G.  Stanley  Hall,* 

Worcester,  Mass. 


"President  Clark  University, 


244  THE  DISORDERS  OF  ADOLESCENCE. 


THE  DISORDERS  OF  ADOLESCENCE. 

At  our  request  Dr.  G.  Stanley  Hall  has  given  us  a  short  but  deeply  significant 
editorial  on  the  work  to  which  he  has  devoted  a  useful  lifetime.  The  perusal  of 
his  great  book,  "Adolescence,"  has  impressed  me  with  the  momentous  desirability 
of  a  wider  diffusion  of  a  knowledge  which  such  researches  afford  the  medical  pro- 
fession. He  speaks  as  a  psychologist,  not  as  a  physician,  it  is  true,  but  as  a  pro- 
found student  of  childhood  from  the  standpoint  at  all  times  of  physiology,  in  which 
department  of  medical  training  he  spent  years  in  Ludwig's  laboratory.  To  rightly 
appreciate  the  force  of  my  opinion  that  a  study  of  at  least  certain  portions  of  this 
book  will  enlighten  any  practitioner  of  medicine,  it  is  only  necessary  to  refer  to 
the  ample  chapter  headings  and  express  the  hope  that  this  will  be  done  by  those 
who  can  gain  access  to  a  copy.  It  will  be  found  that  here  is  displayed  a  breadth 
of  reading  all  but  impossible  to  the  physician,  unless  he  devote  himself  to  the  sub- 
ject as  a  specialty,  along  with  a  clarity  of  judgment,  the  product  of  personal 
familiarity  with  vast  numbers,  not  only  of  specialists  and  teachers,  but  also  with 
children  themselves,  which  fits  him  to  speak  with  authority.  Myself,  having  devoted 
much  time  and  attention  to  childhood  study,  and  particularly  to  neuroses  and  psy- 
choses, endeaving  for  many  years  to  do  my  duty  as  consulting  physician  to  three 
large  institutions  for  the  backward-minded,  have  striven  to  learn  something  from 
literature.  My  reading,  however,  is  as  nothing  to  his,  nor  has  it  been  possible,  in 
the  course  of  an  exacting  practice,  to  sufficiently  digest  and  formulate  this  data. 
Here  it  is  done  in  such  a  fashion  that  it  forms  a  bibliography  as  well  as  a  systematic 
presentation  of  the  essence  of  those  facts  and  conclusions  most  helpful  in  the  daily 
round  of  practice  among  the  young,  and  is  most  illuminating  to  the  whole  field  of 
disease,  physical  as  well  as  psychical. 

It  may  be  permitted  to  offer  some  brief  quotations  from  a  paper  of  my  own 
expressing  opinions  on  the  need  for  attention  to  the  subjects  elaborated  in  Dr.  Hall's 
book. 

The  subject  of  disease  in  childhood  or  youth  can  never  become  plain  as  it  should 
till  the  physiologic  variations  between  the  young  and  the  adult  are  differentiated  for 
the  student.  This  knowledge  may  exist,  but  it  is  seldom  formulated  and  presented 
to  the  undergraduate.  Few  text-books  allude  to  childhood  physiology  except  in  early 
chapters,  and  then  inadequately. 

We  must  know  more  of  normal  growth  and  the  phenomena  of  development. 
The  energy  of  growth  is  a  colossal  force  and  significant  in  many  departments. 

In  diagnosis  our  primal  purpose  is  to  recognize  and  elucidate  the  onset  of  func- 
tional derangements  and  detect  disease  in  any  stage  or  form.  Jf,  however,  we  fail 
to  devote  sufficient  attention  to  morbid  phenomena  of  the  mind  and  morals  we  per- 


THE  DISORDERS  OF  ADOLESCENCE.  245 

form  less  than  half  our  duty.  Disorders  of  the  mind  are  dependent  upon  one  of 
two  factors :  either  defects  of  development  in  the  brain,  or  disused  processes  of  the 
brain,  or  retroactively.  The  purpose  and  aim  of  diagnosis  rest  upon  the  concept 
that  by  the  early  recognition  of  manifestations  of  morbid  physiology  we  shall 
thereby  find  means  to  check  the  changes  which  would  otherwise  pass  on  to  destruc- 
tive alterations. 

If  this  proposition  obtains  for  the  disorders  of  the  physical  functions,  how  much 
more  should  it  fulfill  a  valuable  service  for  those  of  the  brain,  which  is  a  far  more 
sensitive  structure  and  especially  liable  to  sustain  permanent  damage  from  slight 
irritation.  It  is  a  great  privilege  to  mitigate  bodily  suffering,  to  limit  the  progress 
of  structural  degenerations,  to  pevent  disablement  and  save  life;  but  how  vastly 
higher  is  the  prerogative  to  turn  aside  those  perils  which  jeopardize  the  budding 
intellect  and  rescue  a  tottering  moral  nature.  Yet  how  little  of  this  subject  is  the 
student  taught,  or  again  how  much  interest  does  the  average  practitioner  display 
in  this  incomparably  higher  phase  of  his  duties? 

Diagnosis  of  the  morbid  conditions  of  childhood  involves  something  more  than 
a  mere  search  for  evidences  of  disease.  During  the  period  of  plasticity  numerous 
influences  prevail  in  all  ranks  of  life  to  alter  normal  growth  and  organic  development, 
by  which  the  foundations  of  constitutional  weakness  are  often  laid.  These  are  in 
a  great  measure  preventable,  at  least  in  part.  It  is  the  duty  of  the  physician  to 
recognize  and  promptly  rectify  the  evil  effects  of  environment  and  training,  and 
in  as  far  as  possible,  of  inheritance.  Hence  it  is  the  most  important  accomplish- 
ment in  differentiation  to  possess  clearly  defined  standards  of  growth,  proportion, 
activities,  sensitiveness,  functional  competence,  intelligence,  and  capacity  for  en- 
durance. These  standards  should  be  the  products  of  wide  observation,  reading,  and 
experience,  among  normal  as  well  as  abnormal  conditions,  but  unless  tempered  by 
judgment  of  a  high  order,  right  conclusions  are  not  assured. 

The  standards  for  each  pediatrist  is  the  ideal  child,  a  composite  picture  of 
normal  children,  and  cannot  he  formed  too  carefully  nor  from  too  thorough  an 
interpretation  of  the  data  at  command.  Next  to  the  ideal  child  the  diagnostician 
must  erect  for  himself  examples  of  permissible  variants. 

Difficulties  of  diagnosis  are  many  enough  among  children  normal  in  structure, 
in  neural  balance,  and  in  mind;  but  these  grow  greater  where  constitutional  varia- 
tions or  deviations  are  present.  Hence  it.  is  desirable  to  consider  variants  of  types; 
peculiar  and  exceptional  children.  The  normal  processes  are  profoundly  modified 
by  peculiarities  of  temperament  ^uv  to  inheritance  or  acquired. 

A    Few  years  ago   nothing  was   known   of  child   study.      Now   a    literature   has 
developed   about  child  growth,  both   physical   and    mental,   which  displays  the   most 
brilliant  promise  and  is  already  of  immense  utility. 
3 


246  THE  DISORDERS  OF  ADOLESCENCE. 

For  a  long  time  the  subject  has  occupied  the  attention  of  acute  minds.  Here 
and  there  valuable  observations  were  recorded,  and  these  now  form  the  groundwork 
on  which  the  new  impetus  built  the  structure  which  is  now  an  important  branch  of 
preventive  medicine.  Certain  facts  are  now  plain.  Growth  in  human  beings  is 
not  uniform  and  consistent  as  in  animals.  A7ariants  are  more  noticeable  in  propor- 
tion as  our  powers  of  observation  and  critical  differentiation  become  elaborated.  Edu- 
cators must  take  into  account  the  lines  on  which  growth  can  be  predicated.  For 
example,  the  sons  or  daughters  of  the  same  parents  reared  under  presumably  similar 
conditions  and  influences,  yet  vary  widely  in  capacities,  tendencies,  education,  abili- 
ties. Educational  methods  are  evolved  to  suit  the  needs  of  the  lower  averages  and 
applied  to  all  alike,  or  with  small  modifications.  Parents  naturally  cherish  the 
conviction  that  each  of  their  children  are  at  least  well  up  to  this  average  or  standard 
and  resent  any  discrimination,  particularly  if  below  the  normal.  This  attitude  is 
unfortunate,  for  it  often  happens  that  a  child  has  not  the  inherent  powers  and  im- 
pulses which  are  to  be  trusted  to  carry  it  on  without  other  aid  than  suitable  oppor- 
tunities and  environment.  Certain  aspects  of  the  mind,  psychoses,  and  neuroses, 
abound  in  early  adolescent  years  more  than  at  any  other  period  of  life.  This  causes 
great  emotional  strain,  which  by  some  has  been  described  as  a  kind  of  depressed 
insanity,  that  is  nevertheless  so  frequently  met  at  this  period  as  to  be  almost  ex- 
pected. To  keep  down  morbid  impulses  is  often  a  difficult  matter  in  this  age  of 
stress.  There  is  an  intense  antagonism  between  egoistic  and  racial  motives.  One 
writer  would  have  us  almost  believe  that  the  relative  reduction  of  the  individual 
involves  a  latentizing  of  energy  which  builds  up  the  great  organs  involved  in  re- 
production which  are  not  used,  but  only  prepared  for  the  future.  This  expenditure 
of  energy  is  not  immediate,  but  the  race  ought  to  carry  the  day  and  accumulate 
energy  not  immediately  spent.  On  this  view  pubescence  to-day  probably  involves 
great  waste  of  energy  that  should  be  stored  up  into  active  channels,  and  hence  arises 
a  tendency  toward  slow  progressive  race  failure.  This  is  also  the  most  plastic  period 
of  life  as  seen  in  the  very  wide  differentiation  of  size,  brightness,  dullness,  etc.  Thus 
in  a  sense  the  child  is  not  completely  born  until  he  has  achieved  this  great  revolution 
and  established  a  law  of  division  between  stored  and  used  energy. 

Only  by  knowing  most  of  these  facts  and  applying  them  in  the  daily  happen- 
ings can  the  medical  practitioner  note,  foresee,  and  adjust  factors  of  gravest  imme- 
diate and  future  import. 

J.  Madison  Taylor,* 

Philadelphia. 


Physician  to  the  Philadelphia  Hospital,  Children's  Hospital,  etc. 


CLINTCAL  SIGNIFICANCE  OF  THE  REFLEXES.  247 

CLINICAL  SIGNIFICANCE  OF  THE  EEFLEXES. 

Since  Westphal  and  Erb  published  their  observations  on  the  knee-jerk  and 
other  tendon  phenomena,  in  1875,  very  much  attention  has  been  given  to  the 
reflexes.  The  number  of  observed  phenomena  of  this  order  is  constantly  multi- 
plying; in  fact,  is  almost  passing  beyond  the  reach  of  the  busy  practitioner.  Some 
of  the  newer  ones  have  but  the  same  significance  as  other  older  and  better  known 
reflexes.  Others  have  as  yet  little  practical  value.  But  the  clinical  significance 
of  these  phenomena  is  constantly  increasing.  They  have  been  assisting  us  to  dif- 
ferentiate organic  from  functional  nervous  disease,  disease  of  the  gray  from  that  of 
the  white  matter  of  the  cord,  infantile  cerebral  from  infantile  spinal  paralysis; 
to  diagnose  multiple  sclerosis,  multiple  neuritis,  etc.;  and  recently  what  have  ap- 
peared to  be  of  much  value,  even  in  such  general  conditions,  the  diagnosis  and 
prognosis  of  acute  infectious  diseases. 

Time  must  tell  what  is  to  be  accomplished  in  some  of  these  directions,  and  of 
what  importance  are  some  of  the  newer  reflexes. 

But  there  are  conditions  of  disease  in  which  some  of  these  reflexes  are  of 
paramount  importance.  They  may  mean  everything  in  diagnosis  or  prognosis.  And 
these  facts,  simple  as  they  are,  are  apparently  not  yet  fully  known  to  the  profession ; 
at  least  are  not  the  "finger-end  knowledge"  that  they  should  be. 

One  of  these  facts  is  the  value  of  the  knee-jerk  and  the  pupillary  reflex  in  the 
diagnosis  of  locomotor  ataxia  and  paresis.  In  a  case  where  one  of  these  diseases 
is  suspected  to  be  present,  the  absence  of  the  knee-jerk,  or  the  presence  of  the  reflex 
rigidity  of  the  pupil,  makes  the  diagnosis  very  probable,  while  the  presence  of  both 
of  these  signs  at  the  same  time  makes  the  diagnosis  practically  assured. 

What  makes  these  symptoms  specially  valuable  is  not  only  that  they  are  com- 
monly present  in  these  diseases,  but  that  they  are  usually  among  the  earliest  mani- 
festations. 

Nor  is  it  necessary  that  either  of  these  reflexes  should  be  entirely  absent,  that 
we  should  have  the  aid  of  their  diagnostic  import.  For  they  become  gradually 
abolished,  and  the  decrease  in  their  response  has  nearly  the  same  significance  as 
their  loss.  We  may  observe  this  gradual  decrease  as  we  watch  the  progress  of  the 
disease,  or  we  may  be  made  cognizant  of  it  by  the  fact  that  the  response  on  the  one 
side  becomes  abolished  sooner  than  on  the  other.  So  we  may  find  that  one  pupil  is 
larger  than  the  other,  or  that  the  knee-jerk  on  one  side  is  more  difficult  to  elicit  or 
of  smaller  excursion  than  the  other,  or  is  altogether  absent. 

The  method  of  examination  to  elicit  these  reflexes  is  important.  The  knee- 
jerk  is  often  difficult  to  elicit  in  normal  individuals,  and  the  grave  error  may  be 
made  in  such  cases  of  pronouncing  it  absent.  Before  doing  so  the  patient  should  be 
placed  in  a  position  with  the  legs  swinging  freely  and  tested  by  Jendrassik's  method, 
linking  the  hands  into  each  other,  and  then  pulling  forcibly  the  instant  the  blow  is 


248  CLINICAL  SIGNIFICANCE  OF  THE  REFLEXES. 

made  on  the  patellar  tendon.  In  some  eyes,  too,  the  pupillary  response  is  difficult 
to  see.  In  that  case,  testing  with  the  aid  of  a  lens  in  a  dark  room  will  bring  out  the 
reaction  more  clearly. 

The  Achilles  reflex  has  been  carefully  studied  in  recent  years.  It  is  also 
abolished  in  paresis  and  locomotor  ataxia,  and  is  even  a  more  valuable  symptom 
of  those  diseases  than  the  loss  of  the  knee-jerk,  because  it  is  likely  to  disappear 
sooner  than  the  latter. 

It  is  most  easily  elicited  by  having  the  patient  rest  upon  the  knees,  with  legs 
flexed,  and  then  striking  the  tendo  Achillis. 

The  increase  of  the  tendon  reflexes  has  as  great  clinical  significance  as  their 
decrease  or  loss.  These  reflexes  vary  greatly  in  intensity  in  different  individuals; 
but  their  pathological  increase  may  be  known  by  their  marked  difference  on  the 
two  sides  of  the  body,  or  by  the  presence  of  "clonus"  phenomenon.  Practically  the 
most  valuable  of  the  latter  phenomena  is  the  ankle  clonus.  It  is  the  rhythmic 
movement  of  the  foot  upon  the  leg,  caused  by  sharply  flexing  the  foot  dorsally, 
the  clonus  continuing  as  long  as  the  foot  is  held  firmly  in  this  flexed  position. 

Pathologic  excess  of  the  tendon  reflexes  almost  invariably  indicates  disease  of 
the  pyramidal  tracts,  found  in  disease  of  the  lateral  tracts  of  the  cord,  in  multiple 
sclerosis,  in  secondary  degeneration  of  these  tracts  following  apoplectic  attacks,  etc. 

Increased  tendon  reflexes  at  times  possess  a  high  prognostic  value.  Their 
appearance  in  the  paralyzed  limbs  shortly  after  an  apoplectic  stroke  indicates  that 
the  paralysis,  at  least  to  a  considerable  extent,  will  remain  permanently.  In  these 
instances  it  is  as  significant  as  is  the  early  appearance  of  the  reaction  of  degen- 
eration in  peripheral  paralysis. 

The  superficial  reflexes  are  more  inconstant  and  more  variable  than  the  tendon 
reflexes,  and  in  general  have  far  less  value  in  diagnosis.  But  one  symptom  of  this 
order  is  not  less  significant  than  the  tendon  reflexes — that  is,  the  Babinsky  phe- 
nomenon. Normally — except  in  very  young  infants — the  plantar  reflex  is  a  flexion 
of  the  toes.  The  Babinsky  phenomenon  is  a  slow  extension  of  the  big  toe,  the 
action  of  the  other  foes  being  variable.  This  phenomenon  is  found  in  cases  of  dis- 
ease of  the  pyramidal  tracts.  It  has,  therefore,  the  same  significance  as  exaggerated 
tendon  reflexes.  But  there  is  one  place  where  it  counts  for  much  more  than  the 
latter.  In  Case  of  apoplexy  it  may  be  present  at  once  on  the  paralyzed  side.  It  has 
been  found  within  five  minutes  of  the  onset  of  the  attack. 

There  are  cases  of  coma,  with  cause  unknown,  in  which  there  is  complete  relaxa- 
tion of  all  the  muscles  of  the  body,  so  that  it -may  otherwise  be  impossible  to  say 
that  here  is  a  one-sided  paralysis. 

In  such  a  case  the  presence  of  the  Babinsky  phenomenon  may  entirely  clear  up 
the  diagnosis.  Philip  Zenner,* 

Cincinnati,  Ohio. 

*  Lecturer  on  Neurology,  Medical  Department,  University  of  Cincinnati. 


ALKALINE  BEVERAGES  IN  PNEUMONIA.  249 


ALKALINE  BEVERAGES  IN  PNEUMONIA. 

In  the  last  edition  of  his  excellent  "Pathology"  (1904),  Lazarus  Barlow, 
referring  to  the  diminution  of  the  blood's  alkalinity  during  fever,  says:  "The 
cause  of  this  change  is  quite  unknown,  though  suggestions  have  been  made  that 
it  depends  upon  altered  tissue  metabolism  induced  by  fever,  upon  acid  substances 
formed  by  micro-organisms,  upon  the  formation  of  acid  by-products  during  the 
disintegration  of  protoplasm  that  has  been  killed  by  bacterial  toxins.  But  what- 
ever the  true  explanation  may  be,  it  is  probable  that  the  change  is  highly  impor- 
tant for  the  organism,  for  it  is  an  unfavorable  sign  in  febrile  disease,  and  it  is 
known  that  diminished  alkalinity  of  the  blood  goes  hand  in  hand  with  increased 
susceptibility  to  infection."  In  the  first  volume  of  "Internal  Secretions,"  I  em- 
phasized the  very  great  importance  of  this  feature  in  all  febrile  processes,  con- 
cluding with  the  sentence  (page  782)  :  "Steadily  as  the  febrile  process  advances, 
I  he  alkaline  salts  are  consumed,  and,  being  inadequately  renewed,  the  vital  and 
defensive  functions  are  increasingly  hampered  until  life  ceases." 

Experimental  bacteriology  forcibly  emphasizes  the  importance  of  an  alkaline 
reaction  of  the  blood-fluids  in  disease.  Behring  and  Nissen  have  shown  that  it 
is  because  of  the  intense  alkalinity  of  their  blood  that  rats  are  refractory  to  anthrax. 
Paul  not  only  confirmed  this  observation,  but  found  that  when  the  alkalinity  of 
the  serum  of  rabbits  was  neutralized  its  germicidal  powers  disappeared;  von 
Fndor  found  that  the  resistance  of  rabbits  to  anthrax  could  be  actually  increased 
by  the  injection  of  alkaline  solution;  Blumenthal,  that  the  formation  of  bac- 
tericidal agents  coincided  with  the  blood's  alkalinity,  etc. 

The  more  advanced  teachings  of  biology  point  in  the  same  direction.  "We 
know,"  says  Jacques  Loeb  in  his  recently  published  "Studies  in  General  Phys- 
iology,'1 "that  the  peculiar  phenomena  of  oxidation  in  living  matter  are  determined 
by  fermentative  processes,  and  we  venture  to  say  that  fermentations  form  the  basis 
of  all  life-phenomena."  This  coincides  with  my  interpretation  of  the  body's  auto- 
protcctive  processes,  viz.,  that  trypsin,  a  ferment— activated  by  the  interaction  of 
the  blood's  oxidizing  substance  (as  catalytic)  and  the  phosphorus-laden  fibrinogen— 
underlies  the  bactericidal  and  antitoxic  properties  of  the  blood  and  cells.  This 
view  assimilates  the  immunizing  attributes  of  the  organism  not  only  to  the  digestive 
processes,  but  also  to  the  "life-phenomena"— all  being  regarded  as  "fermentations." 
Linked  to  this  fundamental  principle  is  another,  however— a  sine  qua  non  of  the 
intrinsic  cellular  interchanges  to  which  Loeb  gives  voice  when  he  says:  "The 
sodium  ions  of  the  blood  as  well  as  of  the  sea-water  are  essential  for  the  main- 
tenance of  life-phenomena."  Hence  my  conclusion  that  in  febrile  diseases  there 
exists  a  close  relationship  between  a  deficiency  of  sodium  and  death. 


250  ALKALINE  BEVERAGES  IN  PNEUMONIA. 

Even  under  normal  conditions  nearly  one-half  ounce  of  sodium  chloride  is 
excreted  each  day  with  the  urine,  the  loss  being  constantly  made  up  by  the  food 
along  with  the  potassium  salts.  But  the  altered  conditions  during  toxaemias, 
reduced  diet,  impaired  assimilation,  anorexia,  etc.,  greatly  diminish  the  intake, 
and  unless  measures  be  taken  to  compensate  for  this,  the  defensive  functions  are 
increasingly  hampered  and  the  chances  of  death  are  correspondingly  increased. 
And  this  applies  not  only  to  pneumonia,  but  to  all  febrile  toxcemias.  Considerable 
work  done  since  the  first  volume  of  "Internal  Secretions,"  etc.,  was  written,  and 
personal  clinical  observations,  have  convinced  me  that  we  have  in  the  judicious  use 
of  alkaline  salts  in  all  morbid  processes  of  this  kind,  an  important  life-saving 
measure. 

Inspired  by  these  facts,  Dr.  J.  B.  Todd,  of  Syracuse,  New  York,  in  an  article, 
entitled  "Alkaline  Beverages  in  the  Treatment  of  Pneumonia,"  published  in  the 
New  York  Medical  Journal  and  Philadelphia  Medical  Journal,  of  May  20,  1905, 
introduces  what  I  regard  as  a  very  important  step  in  the  successful  treatment  of 
pneumonia,  i.e.,  the  oral  use  of  saline  solution.  The  two  cases  selected  to  illustrate 
his  results  and  several  others,  all  of  which  terminated  safely  (as  stated  in  a  per- 
sonal letter),  are  very  suggestive.  In  the  first  case,  a  woman  of  84  years,  the 
solution  was  used  from  the  start;  in  the  second,  a  child  of  8  years,  the  improve- 
ment coincided  Avith  the  use  of  alkaline  beverages. 

I  earnestly  hope  that  this  method  of  treatment  will  be  extensively  tried.  Some 
opposition  to  the  use  of  saline  solution  in  this  and  other  diseases  has  been  based 
on  the  fact  that  the  sudden  elimination  of  waste  products  tends  to  cause  inflam- 
matory renal  lesions,  or  to  augment  them  if  present.  In  truth,  such  lesions  occur 
because  the  toxic  wastes  are  allowed  to  accumulate  in  the  organism;  on  being 
suddenly  liberated  when  the  saline  solution  is  used,  they  overtax  the  kidneys.  This 
is  prevented  when  the  saline  solution,  which  facilitates  and  insures  their  gradual 
elimination  of  toxic  waste  products  is  administered  from  the  start.  Dr.  Todd's 
formula  is  admirably  adjusted  to  this  purpose  and  provides  "a  refreshing  effer- 
vescent drink,  which  is  gratefully  accepted  by  the  patient." 

It  is  as  follows: — 

^   Sodium  chloride,  320  grains. 

Potassium  bicarbonate,   160  grains. 

Aromatic  fluid  extract   (U.S.  P.),  30  minims. 

Water  enough  to  make  4  ounces. 

M.  Teaspoonful  in  six  to  eight  ounces  of  water  every  two  hours  with  a  tea- 
spoonful  of  lemon  juice. 

The  patient  is  also  allowed  to  drink  water  at  will. 


ADENOIDS  IN  THE  ADULT. 


ASTHENIA. 


251 


Hypodermoclysis,  first  used  by  F.  P.  Henry  in  1889  in  pneumonia,  is  of  great 
value,  but  it  is  usually  employed  late  and  often  as  a  last  resort.  This  is  not  in 
keeping  with  the  principles  I  have  advanced  as  regards  the  need  of  salts  in  the 
various  fevers,  namely,  that  the  alkalinity  of  the  blood  should  be  insured  from 
the  start  in  all  febrile  toxaemias.  We  cannot  begin  with  so  surgical  (formidable 
to  the  patient)  a  procedure  as  hypodermoclysis;  we  need  a  measure  as  simple  as 
the  taking  of  a  remedy  of  any  kind,  and  the  oral  use  of  saline  beverage  advocated 
by  Dr.  Todd  fulfills  this  purpose  admirably. 

C.  E.  de  M.  Sajous. 


Cyclopaedia  of  Current  blteratur?. 


ADENOIDS  IN  THE  ADULT. 

Adenoid  growths  in  the  adult  are 
much  more  common  than  is  generally 
supposed.  The  condition  is  a  frequent, 
cause  of  nasopharyngeal  catarrh,  with 
dropping  back  of  mucus  and  frequent 
clearing  of  the  throat.  It  is  also  a 
frequent  cause  of  nasal  obstruction,  and 
is  the  causative  lesion  in  some  cases  of 
apparent  hypertrophic  rhinitis.  A 
thorough  examination  of  the  naso- 
pharynx should  be  made  in  all  cases  of 
ear  disease  and  pulmonary  tuberculosis. 
The  treatment  is  not  difficult,  and  the 
results  arc  occasionally  brilliant  and 
rarely  unsatisfactory.  D.  M.  Barstow 
(New  York  Medical  Journal  and  Phila- 
delphia Medical  Journal,  May  6,  1905). 

ANEURISM  AND  ARTERIOSCLEROSIS. 

Arterial  disease  appears  to  lie  rare, 
almost  unknown,  in  animals.  Syphilis 
being  probably  peculiar  to  man.  is  by 
this  observation  placed  more  firmly  in 
the  list  of  etiological  factors.  Arterial 
disease  in  children  under  6  years,  e\  en 
in  those  who  are  victims  of  congenital 
sypbilis,  is  practically  unknown.  In 
those  from  6  to  15  years  it  is  rare.  It 
is  found  in  the  initial  stage  most  com- 
monly between  the  ages  of  30  and  40 


years.  The  teratologic  factor,  though 
an  undeterminable  one,  is  of  great  im- 
portance. Arterial  disease  seems  to  be 
attributable  to  syphilis  in  about  32  per 
cent.;  to  tuberculosis  in  about  l(i  per 
cent.  The  facts  presented  go  to  show 
that  the  colored  race  is  affected  about 
four  times  more  frequently  than  the 
white. 

General  arteriosclerosis  seems  to  be 
not  commonly  found  with  aneurism  and 
its  presence  may  lie  considered  as  evi- 
dence against  the  probable  development 
of  aneurism. 

Staining  with  selective  stains  and 
treating  with  a  chemical  which  digests 
tissue  show  the  elastic  tissue  to  he  five 
of  histological  alterations,  suggesting 
that  this  tissue  undergoes  physical  or 
molecular  rather  than  histological 
change.  C.  N.  B.  Camac  (American 
Journal  Medical  Sciences,  May,  L905). 

ASTHENIA. 

The  writer  defines  asthenia  as  an  im- 
possibility of,  or  at  least  a  difficulty  in, 
making  a  muscular  effort,  particularly 
if  prolonged.  This  condition  may  be 
general  or  Local.  General  asthenia  may 
he  subjective  or  objective.  The  pros- 
tration     of     acute     diseases,     such     as 


252 


BILIARY    TRACT,    INFECTION. 


BILIOUSNESS,    HEPATIC    FACTOR    IN. 


typhoid  fever,  acute  peritonitis,  or  Ad- 
dison's disease,  is  an  example  of  the  ob- 
jective   form,    while    the    less    strongly 
marked  weakness  which  accompanies  in- 
fection or  chronic  poisoning  is  an  ex- 
ample   of    the    subjective.       The    etio- 
logical conditions  are:      (1)  Infections, 
autointoxications,  intoxications;   (2)  ab- 
dominal diseases;    (3)    central  nervous 
lesions;     (4)    neuroses    and    psychoses. 
Sometimes  the  asthenia  is  of  cerebellar 
origin,  more  often  of  visceral  and  ab- 
dominal, or  sympathetic  origin.      In  a 
great    variety    of    diseases,    peritonitis, 
Addison's  disease,  grippe,  diabetes,  mu- 
comembranous    enteritis,    exophthalmic 
goiter,    melancholia,    etc.,    the    sympa- 
thetic is  at  fault  as  is  shown  by  the  fre- 
quent association   of  vasomotor  or  se- 
cretory troubles.      This  has  also  been 
confirmed    by  experiment.     The  author 
also  believes  that  there  are  anatomical 
relations  between   the   cerebellum   and 
the    sympathetic    which    explain    their 
physiological     and     pathological     asso- 
ciated  actions.      By  localized   asthenia 
is  meant  predominating  or  confined  to 
one  place,  as  in  chronic  nervous  dyspho- 
nia,     accommodative     asthenopia,     and 
perhaps  nocturnal  incontinence  of  urine 
in    children,    which    is    a    bulbospinal 
asthenia.         P.  Londe  (Semaine  Medi- 
cal, April  5,  1905). 

BILIARY  TRACT,  INFECTION  OF. 

Infection  of  the  biliary  tract  may  oc- 
cur either  with  or  without  the  presence 
of  gall-stones,  and  may  be  due  to  a  va- 
riety of  causes  producing  symptoms 
which,  while  frequently  obscure,  are  al- 
ways sufficiently  characteristic  to  permit 
of  a  diagnosis  by  careful  analysis.  Medi- 
cal dietetic  treatment  of  especial  value 
in  eases  of  recent  infection,  where  by 
maintaining  a  patulous  duct  and  fluid 
condition   of   bile,   good   drainage   thus 


secured  may  result  in  recovery,  and  in 
some  cases  where  operation  is  contra- 
indicated  because  of  other  complicating 
diseases,  extreme  debility,  etc. 

Operative  treatment,  to  be  of  greatest 
service,  should  be  resorted  to  early — 
before  gross  pathologic  changes  have 
occurred  in  and  around  the  ducts  and 
bladder.  Discontinuance  of  drainage 
should  be  tentative,  so  as  to  provide  for 
its  re-establishment  if  the  ducts  are 
found  inadequate.  Acetozone  solution, 
a  safe  and  efficient  disinfectant  for  irri- 
gation of  the  tract,  should  be  used  prior 
to  closure  of  fistula.  H.  W.  Longyear 
(Journal  of  the  Michigan  State  Medical 
Society,  May,  1905). 

BILIOUSNESS,  THE  HEPATIC  FACTOR  IN. 

The  writer  points  out  that  the  etio- 
logical factors  commonly  regarded  as 
responsible  for  biliousness  concur  in 
tending  to  cause  accumulation  of  gly- 
cogen in  the  liver.  Biliousness  may  be 
divided  into:  (1)  The  acute  form,  due 
as  a  rule  to  some  distinct  error  of  diet, 
snch  as  a  surfeit  of  plum  pudding;  (2) 
the  subacute  (recurrent)  form,  due  not 
to  isolated  indiscretions  in  diet,  but  to 
continued  habitual  '  over-indulgence; 
and  (3)  the  chronic  form,  usually  met 
with  in  adults,  especially  old  residents 
of  the  tropics,  and  extending,  it  may  be, 
to  months  in  duration.  Conformably, 
we  may  speak  of:  (1)  Acute  glycogenic 
distention  of  the  liver,  due  to  a  large 
sudden  irruption  of  -glycogen  forming 
material  into  the  portal  venous  system; 
(2)  subacute  or  recurrent  glycogenic  dis- 
tention of  the  liver,  in  which  there  is 
a  continued  absorption  of  glycogen, 
forming  material  in  excess  of  consump- 
tion, and  a  consequent  progressive  ac- 
cumulation of  hepatic  glycogen,  which 
attains  its  maximum  at  more  or  less 
regular  intervals;   and  (3)  chronic  gly- 


BREAST-FEEDING  FOR  INFANTS. 


253 


oogenic  distention  of  the  liver,  in  which 
recurrent  relief  fails,  and  in  which  con- 
sequently  the   organ   remains   more   or 
less  continuously  packed  with  glycogen. 
Factors,  most  of  which  are  admittedly 
capable  of  dispersing  biliousness,  con- 
cur in  tending  to  reduce  the  amount  of 
glycogen  in  the  liver.      Some  of  these 
may  be  regarded  as  therapeutic,  namely, 
abstention  from  food,  physical  exercise, 
climate,  purgatives,  restriction  of  meat 
and  nitrogenous  foodstuffs,  and  restric- 
tion of  carbohydrates.     Others  must  be 
regarded   as   pathological,   namely,   py- 
rexia   and    glycosuria.       The    rational 
treatment  of  recurrent  and  other  forms 
of  biliousness  consists  simply  in  limit- 
ing the  intake  of  carbohydrate  material, 
and  sugar  is  the  first  foodstuff  to  be  ex- 
cluded.     Herein   is  involved   no  func- 
tional   impairment    in    any    direction. 
The   treatment   consists   merely   in   cut- 
ting down  excess   of  supply.      But  an 
increase    in    regular    physical    exercise 
must  also  be  advised,  in  order  to  obvi- 
ate the  necessity  for  any  severe  degree 
of  carbohydrate   restriction.      F.   Hare 
(British    Medical    Journal,    April     15, 
1905). 

BREAST-FEEDING  FOR  INFANTS. 

A  valuable  contribution  to  the  efforts 

now  made  to  dimmish  infant  mortality 
by  insisting  mi  the  mother  nursing  her 
own  child  whenever  possible,  is  based 
on  a  series  of  11,000  cases  at  the  Mater- 
nity Hospital  in  Stuttgart.  The 
mother's  milk  agrees  with  almost  all  in- 
fants, and  not  even  a  wet-nurse  is  an 
efficient  substitute.  The  indications 
against  nursing  should  be  restricted  as 
much  as  possible,  and  in  many  cases  the 
inability  to  nurse  is  only  apparent  and 
will  not  withstand  serious  criticism. 
The  influence  of  nursing  on  the  proper 
involution   of   the    internal   genitals   is 


especially  valuable  in  those  women  who 
may  be  compelled   to  take  up  manual 
labor  after  only  a  brief  interval  spent  in 
bed.      In  the  institution  where  the  ob- 
servations were  made,  it  was  found  pos- 
sible to  increase  the  number  of  nursing 
mothers  so  that  from  98  per  cent,  to 
100  per  cent,  of  the  women  were  able  to 
satisfy  their  children.      Of  the  breast- 
fed babies,  40.9  per  cent,  reached  their 
birth-weight  on  the  eighth  day,  and  54.8 
per  cent,  on  the  thirteenth  day  of  the 
puerperium,  while  25.4  per  cent,  of  the 
bottle  babies  only  reached  their  birth- 
weight  on  the  eighth  day,  and  35.6  per 
cent,  on  the  thirteenth  day.      An  un- 
favorable effect  of  nursing  on  other  dis- 
eases  was   never    observed — in    cardiac 
disturbances,     the     compensatory     dis- 
turbances usually  subsided,  and  in  renal 
troubles,      the      albumin     disappeared. 
These  patients  are,  moreover,  protected 
from  a  longer  period  from  subsequent 
pregnancies,    and    the    latter    exert    a 
much   more  debilitating  influence  than 
the  nursing.     Syphilis  is  not  considered 
by  the  author  to  constitute  a  contraindi- 
cation,   if   a   shield    is   employed.       He 
claims  that  the  so-called  psychical   rea- 
sons for  inability   to  nurse  are   merely 
mi  proven  theories,  and  the  secretion  is 
entirely  dependent  on  the  stimuli  which 
are  exerted  on  the  milk  glands.    Among 
the  most  marked  reflex  stimuli  are  the 
suckling   efforts    of   the    child,    and    the 
hitler  may  prove  sufficient  to  cause  a  re- 
turn   of    the    milk   secretion    even    when 
this  may   have   keen    interrupted   for  a 
period   of  several   weeks  or  months.      A 
mother  must  show  a  desire  and  inclina- 
tion to  nurse  her  child,  and   this  is  one 
of  the  most  important  factors.      A  <}>■- 
termined  effort  should  be  made  on  the 
part  of   the   profession   to   instill   these 
thoughts  into  the  minds  of  parents  and 
nurses.     If  the  baby  is  given  the  breast 


254 


CEREBROSPINAL  MENINGITIS. 


COLITIS  AND  APPENDICITIS. 


early  and  the  efforts  continued,  the  milk 
will  appear  with  certainty  in  most  cases. 
(t.  Martin  (Archiv  fiir  Gynecologie,  Bd. 
74,  Nu.  3;  Medical  News,  May  20 
1905). 

CEREBRO-SPINAL        MENINGITIS,        EPI- 
DEMIC, TREATMENT  OF. 

The  writer  had  had  occasion  to  treat 
4-5  cases  of  epidemic  eerebro-spinal 
meningitis  during  the  last  ten  years. 
His  experience  has  confirmed  him  more 
and  more  in  the  belief  that  systematic 
and  repeated  lumbar  puncture  has  a  de- 
cided and  favorable  effect  on  the  dis- 
ease. In  the  case  of  one  young  woman 
the  punctures  were  repeated  daily  for 
six  days,  and  then  twice  more  at  longer 
intervals.  The  eerebro-spinal  fluid  was 
under  pressure  of  360  and  430  at  the 
two  first  punctures,  and  14  and  24  cubic 
centimeters  of  the  fluid  were  allowed  to 
escape.  It  was  very  turbid.  The  leu- 
cocytes numbered  22,000  once,  but  gen- 
erally ranged  from  15,000  to  19  000. 
The  author  also  cites  a  case  illustrative 
of  the  group  in  which  the  punctures 
were  first  made  late  in  the  case  to  ward 
off  threatening  acute  hydrocephalus. 
The  aggravation  of  symptoms  about 
the  fortieth  day  suggested  this  com- 
plication and  puncture  showed  a  pres- 
sure of  490  and  320  millimeters. 
After  escape  of  25  and  37  cubic  centi- 
meters the  condition  improved  remark- 
ably, but  severe  symptoms  recurring  two 
days  later,  the  punctures  were  repeated 
morning  and  evening,  and  again  the 
next  morning,  after  which  the  patient, 
a  young  man  of  21,  was  able  to  sit  up 
for  an  hour.  This  was  the  sixty- 
seventh  day  of  his  illness,  and  complete 
recovery  soon  followed.  No  ill  effects 
from  the  puncture  were  observed  in  any 
instance;  the  technique  is  simple  and 
easy,  and  can  be  applied  in  the  home. 


The  writer  warns  against  allowing  more 
than  50  cubic  centimeters  of  the 
eerebro-spinal  fluid  to  escape.  The 
Weichselbaum-Jager  intracellular  dip- 
lococcus  was  found  in  40  out  of  his  45 
cases.  H.  Lenhartz  (Miinchencr  medi- 
cinische  Wochenschrift,  March  21, 
1905). 

COBRA  VENOM,  THE  INFLUENCE  OF,  ON 
THE  PROTEID  METABOLISM. 

Practically  no  change  in  rate  of  pro- 
teid  metabolism  was  induced  by  the  ad- 
ministration, in  spite  of  well-marked 
local  reaction.  A  slight  decrease  in  the 
proportion  of  urea  nitrogen,  quite  insig- 
nificant compared  with  that  produced 
by  diphtheria  toxin  and  various  drugs, 
was  observed.  A  slight  rise  in  the  pro- 
portion of  ammonia  nitrogen  occurred. 
There  was  a  slight  rise  in  the  proportion 
of  nitrogen  in  purin  bodies.  The  nitro- 
gen in  other  compounds  showed  no  con- 
stant change.  The  P205  excreted 
showed  no  constant  change,  but  in  two 
experiments  there  was  a  slight  rise. 

The  change  produced  in  the  proteid 
metabolism  is,  therefore,  small,  and 
such  as  it  is,  being  in  the  directions  of 
decreased  elaboration  of  urea  and  in- 
crease in  the  proportion  of  nitrogen  ex- 
creted as  ammonia,  it  seems  to  indicate 
a  slight  toxic  action  on  the  hepatic 
metabolism  rather  than  a  general  ac- 
tion of  the  proteid  changes;  and  tends 
to  confirm  the  view  that  the  poison  acts 
chiefly  upon  the  nervous  system.  James 
Scott  (New  York  Medical  Journal  and 
Philadelphia  Medical  Journal,  May  13, 
1905).   ' 

COLITIS   AND   APPENDICITIS,   RELATION- 
SHIP BETWEEN. 
It  is  easy  to  understand  how  an  ap- 
pendicitis may  give  rkc  to  a  colitis  by 
contiguity,  and  this  inflammation  may 


COLON  BACILLUS. 


CONSTIPATION,  CHRONIC. 


255 


spread  up  the  ascending  colon  and  into 
the  other  parts  of  the  large  howel.  In 
fact,  the  colitis  may  be  so  prominent  as 
to  overshadow  the  symptoms  pointing 
to  appendiceal  inflammation.  The  fa- 
miliar form  of  mucous  colitis  due  to  co- 
prostasis  may  be  indirectly  caused  by 
appendicitis,  since  the  latter  disease 
often  causes  constipation,  probably  by 
interference  with  the  nervous  mechan- 
ism of  the  bowel.  The  author  cites  two 
cases  in  which  a  colitis  obscured  a  coex- 
isting appendicitis  because  the  inflamed 
appendix  was  situated  behind  a  dis- 
tended right  colon;  when  the  latter  was 
cleared  of  gas  and  fasces,  the  appendi- 
citis came  to  light.  The  form  of  colitis 
termed  mucomembranous  may  exist  for 
years  without  any  serious  disturbances; 
but  it  is  possible  for  the  same  process  to 
extend  to  the  mucous  membrane  of  the 
appendix,  and  in  this  case  the  peculiar 
anatomic  features  of  the  organ  greatly 
increase  the  dangers  of  the  disease.  A 
true  ulcerative  colitis  may  also  extend  to 
the  appendix,  adding  an  additional  ele- 
ment of  danger  to  an  already  serious 
condition.  C.  B.  Lockwood  (British 
Medical  Journal,  March  4,  1905). 

COLON  BACILLUS,  ACTION  OF  THE  INTRA- 
CELLULAR POISONS  ON  THE. 

The  colon  bacillus  produces  a  power- 
ful poison  when  grown  on  artificial 
media.  This  poison  is  intracellular  in 
character,  and  is  contained  within  both 
(lie  living  and  the  dead  bacterial  cell. 
The  poison  can  be  separated  from  the 
other  constituents  of  the  bacterial  cell 
only  by  means  which  chemically  break 
up  the  latter. 

The  peritonitis  which  occurs  after 
intraperitoneal  inoculation  with  the 
colon  bacillus  is  due  to  the  presence  of 
the  poison  in  a  combined  and  not  in  a 
free  state.     The  intracellular  poison  of 


the  colon  bacillus  causes  a  marked  fall 
in  the  body  temperature.  The  poison 
of  the  colon  bacillus  apparently  causes 
death  by  paralysis  of  respiration. 

The  intracellular  poison  is  an  essen- 
tial group  of  the  bacillus  and  can  be 
built  up  synthetically  on  proteid-free 
media.  This  intracellular  poison  is  the 
poison  which  causes  death  in  animals 
inoculated  with  cultures  of  the  living 
colon  bacillus.  V.  C.  Vaughan,  Jr. 
(Journal  of  the  American  Medical  Asso- 
ciation, April  29,  1905). 

CONSTIPATION,  CHRONIC. 

The  writer  discusses  particularly  the 
conditions  consequent  on  an  imperfect 
evacuation  of  the  large  bowel.  In  the 
majority  of  cases  this  is  associated  with 
the  symptoms  popularly  comprehended 
under  the  term  constipation,  but  in  a 
small  proportion,  while  the  large  bowel 
up  to  the  hepatic  flexure  or  even  to  the 
splenic  flexure  may  be  constantly  or  fre- 
quently loaded,  yet  the  patient  obtains 
from  the  overflow  a  daily  movement 
which  is  usually  solid,  and,  conse- 
quently, makes  no  complaint  of  consti- 
pation. The  large  intestine,  whose 
vitality  has  been  depreciated,  both  by 
local  inflammatory  changes  and  by  the 
general  loss  of  tone,  is  thereby  rendered 
liable  to  some  specific  infection,  and  ul- 
cerative, membranous  or  other  Forms  of 
colitis  may  develop  in  consequence.  The 
condition  frequently  dates  from  a  very 
early  period,  when,  owing  to  the  unsuit- 
able feeding  of  a  child,  the  intestine, 
and  particularly  the  large  bowel,  are 
distended  with  gas,  rendering  the  whole 
of  the  abdomen  abnormally  prominent. 
The  caecum  and  ascending  colon  appear 
to  Buffer  most  severely,  owing  to  the  fact 
thai  this  portion  of  the  bowel  is  hung 
up  at  the  hepatic  flexure,  which  is  ren- 
dered more  acute  by  the  distention  and 


256 


COPPER,  ACTION  UPON  BACILLUS  TYPHOSUS. 


consequent  elongation  of  the  transverse 
colon  in  a  downward  direction.  This 
distention,  by  dragging  on  the  band 
which  supports  the  splenic  flexure,  ren- 
ders it  difficult  for  the  contents  of  the 
transverse  colon  to  pass  into  the  de- 
scending colon.  In  consequence  of  this 
distention,  the  large  bowel  becomes 
more  or  less  inflamed,  and  this  inflam- 
mation may  be  sufficient  to  produce  a 
distinct  peritonitis,  as  manifested  by  ef- 
fusion. The  inflammation  of  the 
caecum  and  ascending  colon  produces  an 
adhesive  process  between  the  outer  wall 
of  the  bowel  and  the  peritoneum. 
These  adhesions  help  to  support  the  in- 
creasing weight  of  this  portion  of  the 
bowel  and  to  some  extent  oppose  its  dis- 
tention and  downward  displacement. 
Precisely  similar  changes  take  place  at 
the  splenic  flexure.  After  a  time  these 
adhesions  develop  into  distinct  mesen- 
teries and  strong  bands.  The  bowel  is 
less  able  to  perform  its  functions;  the 
intestine  finally  becomes  bound  down; 
the  sigmoid  is  so  contracted  that  it 
ceases  to  be  a  loop  and  forms  a  straight 
conduit,  the  presence  of  the  inflamed 
bowel  in  the  true  pelvis  interferes  with 
the  functions  of  the  ovary  and  the  fallo- 
pian tube,  and  in  this  way  constipation 
would  appear  to  play  an  important  part 
in  the  sterility  so  common  among 
women.  The  stomach  function  is  fi- 
nally interfered  with  and  the  kidneys 
become  mobile.  The  treatment  is 
purely  operative.  W.  A.  Lane  (British 
Medical  Journal,  April  1,  f905). 

COPPER,  ACTION  OF  COLLOIDAL  SOLU- 
TIONS OF,  UPON  BACILLUS  TYPHO- 
SUS. 

There  is  a  natural  tendency  for  ty- 
phoid bacilli  to  die  when  the  water  con- 
taining them  is  allowed  to  stand  for  a 
long   period.       There    may   be    a    tem- 


porary increase  in  the  number,  but  this 
is  followed  in  several  hours  or  days  by  a 
decrease  and  a  final  disappearance. 

Trials  were  made  as  to  the  period  of 
total  disappearance  of  typhoid  organ- 
isms which  had  been  placed  in  sterile 
Schuylkill  water  and  in  that  taken  di- 
rectly from  the  tap,  and  from  the  river 
surface,  containing  large  numbers  of 
water  organisms.  These  waters  were 
placed  in  vessels  of  glass,  porcelain,  tin, 
and  copper,  and  their  contents,  kept  at 
room  temperature,  were  plated  every 
fifteen  minutes  for  periods  ranging 
from  three  to  six  hours.  All  the 
experiments  were  repeated  many  times. 

Sterile  drinking  water  in  clean  copper 
vessels  inoculated  with  typhoid  bacilli 
invariably  showed  that  the  bacilli  had 
all  perished  in  one  hour.  Water  simi- 
larly treated  in  tin  vessels  invariably 
showed  living  organisms  at  the  end 
of  twenty-four  hours.  Water  simi- 
larly treated  in  glass  vessels  exposed  to 
light  showed  varying  results,  but  in  no 
instance  had  the  typhoid  organisms  all 
perished  in  three  hours.  Water  simi- 
larly treated  in  enamel  vessels  showed 
v  slight  diminution  of  the  number  of 
typhoid  organisms  in  three  hours. 
Water  similarly  treated  in  aluminium 
vessels  showed  a  disappearance  of  the 
typhoid  organisms  in  three  hours. 

Raw  tap-water  in  glass  vessels  showed 
an  increase  in  the  number  of  organisms 
in  three  hours;  occasionally,  there  was 
a  slight  diminution  in  their  number. 
Raw  tap-water  in  copper  vessels  in  one 
experiment  showed  a  diminution  from 
384,000  germs  per  cubic  centimeter  to 
18,000  per  .cubic  centimeters  in  three 
hours.  Usually  the  diminution  was  not 
so  great.  Raw  tap-water  containing 
large  numbers  of  river  organisms  and 
considerable  vegetable  jnatter,  when  in- 
oculated with  millions  of  typhoid  organ- 


CUTANEOUS  AFFECTIONS,  REFRIGERATION  IN.     DIABETES  MELLITUS.         257 


isms  and  placed  in  a  copper  vessel 
showed  that  the  typhoid  were  killed  off 
in  from  one  and  three-fourths  hours  to 
two  and  one-half  hours. 

Water  containing  collodial  copper  has 
a  more  rapid  tonic  action  upon  typhoid 
organisms  than  upon  river-water  organ- 
isms. The  quantity  of  colloidal  copper 
given  off  from  a  one-liter  copper  vessel 
in  three  hours  was  1  part  to  4,000,000. 
This  amount  killed  off  the  added  ty- 
phoid organisms  in  from  one  and  three- 
fourths  to  two  and  one-half  hours,  and 
chemical  experience  has  shown  that  this 
amount  of  colloidal  copper  is  harmless 
when  taken  into  the  human  system. 

In  epidemics  of  typhoid  fever  water 
could  be  purified  of  typhoid  organisms 
by  allowing  it  to  stand  in  a  copper  vessel 
for  three  hours.  A.  H.  Stewart  (Ameri- 
can Journal  of  the  Medical  Sciences, 
May,  1905). 

CUTANEOUS  AFFECTIONS,  REFRIGERA- 
TION IN  TREATMENT  OF. 
Carbonic  acid  is  the  refrigerating 
ftuid  preferred  for  this  purpose  at  Neis- 
ser's  clinic  at  Breslau.  The  surface  is 
sprayed  with  the  carbonic  acid  as  when 
making  frozen  sections.  The  broad 
perforated  nozzle  of  the  vial  is  held 
about  1  cubic  centimeter  from  the  skin, 
and  the  fluid  is  forced  out  by  a  bull). 
In  half  a  minute  the  skin  is  frozen  hard. 
There"  is  anaemia  at  first;  this  is  fol- 
lowed by  intense  hyperaemia,  and  half 
iin  hour  later  by  profuse  serous  trans- 
udation. In  twelve  hours  an  inflamma- 
tory redness  develops,  wilh  blisters. 
When  the  freezing  1ms  been  very  in- 
tense, actual  ulceration  may  follow. 
When  it  is  necessary  to  repeat  the  ap- 
plication, an  interval  of  five  to  ten  days 
is  interposed.  Three  sittings  in  less 
than  a  month  are  generally  sufficient. 
This  method  of  treatment  proved  par- 


ticularly effectual  in  9  cases  of  lupus 
erythematodes  thus  treated.  From 
three  to  nine  applications  were  made 
and  the  patches  healed  remarkably 
promptly,  but  traces  of  recurrence  be- 
came visible  after  a  few  months,  show- 
ing that  the  refrigeration  needs  to  be 
combined  with  some  other  measure  to 
ensure  permanency.  The  writer  thinks 
the  ideal  combination  is  with  crude  hy- 
drochloric acid,  according  to  Dreuw's 
technique,  substituting  carbonic  acid  for 
the  ethyl  chloride.  Tuberculous  skin 
affections  are  evidently  the  chosen  field 
for  this  mode  of  treatment  when  photo- 
therapy is  impracticable  for  any  reason. 
A  lupous  patch  about  six  months  old, 
on  the  forearm,  healed  with  a  keloid 
cicatrix  after  two  applications  of  the 
carbonic  acid  and  hydrochloric  acid.  In 
another  case,  two  lupous  patches  on 
hand  and  arm  ulcerated  at  first  under 
three  weeks  of  the  combined  treatment, 
but  then  healed  over  smoothly.  All 
were  favorably  influenced  and  appar- 
ently cured  to  date.  The  experiences 
at  the  clinic  were  with  psoriasis,  pri- 
mary sores,  leg  ulcers,  and  sycosis,  be- 
sides the  tuberculous  affections.  The 
primary  sores  all  healed  rapidly  after  a 
single  application  of  the  refrigeration 
and  hydrochloric  acid,  before  mercurial 
treatment  had  been  instituted.  M. 
Juliusberg  (Berliner  klinische  Wbchen- 
schrift,  March  6,  1905). 

DIABETES  MELLITUS,  THE  NATURE  OF. 

Excess  of  sugar  in  (lie  blood,  which  is 
the  condition  precedent  of  glycosuria, 
may  be  caused  by  overproduction  of 
sugar  in  the  system  or  by  diminished 
use  or  excretion.     There  is  practically 

no  evidence  of  either  of  these  last 
processes.  There  is  convincing  evidence 
thai  :d  one  Btage,  at  all  events,  of  dia- 
betes there  is  increased  production. 


258 


DIABETES  MELLITUS,  NATURE  OF. 


Overproduction  of  sugar  may  depend 
upon  some  digestive  irregularity,  where- 
by more  sugar  than  normal  is  poured 
into  the  blood  from  the  food,  or  upon 
manufacture  of  sugar  from  the  tissues 
of  the  body.  We  have  sufficient  evi- 
dence that  both  these  processes  are  at 
work  in  diabetes,  in  that  at  first  the  out- 
put in  the  urine  can  be  controlled  by 
limiting  the  diet,  whereas,  later,  this  is 
not  possible.  But  whereas,  there  are 
a  considerable  number  of  conditions  in 
which  sugar  appears  in  the  urine  appar- 
ently as  a  result  of  absorption  of  addi- 
tional sugar  from  the  alimentary  canal 
— these  conditions  being  identical  with 
diabetes  only  in  the  single  fact  of  the 
appearance  of  sugar  in  the  urine,  while 
they  run  an  entirely  different  clinical 
course — it  is  in  diabetes  mellitus  alone 
that  we  have  at  any  time  evidence  of 
formation  of  sugar  from  the  tissue-cells 
of  the  patient.  This  autolytic  forma- 
tion of  sugar,  if  it  may  be  so  called,  is 
the  characteristic  feature  of  diabetes  in 
so  far  as  the  production  of  sugar  is  con- 
cerned. 

It  involves  less  of  an  assumption  to 
suppose  that  this  autolytic  formation  of 
sugar  is  present  in  diabetes  all  through 
the  disease  than  to  suppose  that  it  en- 
sues after  a  time  as  a  result  of  the  pres- 
ence in  the  blood  of  excess  of  the  very 
substance — sugar — into  which  the  cells 
finally  break  down.  The  absence  of 
proof  of  the  existence  of  this  process  in 
the  early  stages  of  the  disease,  when  the 
glycosuria  is  controlled  by  diet,  may  be 
due  to  the  body  possessing  a  certain 
power  of  utilizing  sugar  in  its  nutritive 
processes,  so  that  only  the  excess  above 
a  definite  quantum  appears  in  the  urine. 

There  is  sufficient  evidence  available 
to  establish  beyond  the  possibility  of 
doubt  the  fact  that  there  is  some  con- 
nection between  the  pancreas  and  dia- 


betes. Although  it  is  not  yet  proved, 
yet  it  is  becoming  increasingly  probable 
that  the  pancreas  is  diseased  in  all  cases 
of  diabetes  mellitus.  An  increasing 
hulk  of  evidence  is  also  accumulating  to 
show  that  the  function  of  the  pancreas 
which  is  in  abeyance  in  diabetes  is 
normally  performed  by  certain  special 
groups  of  cells  known  as  the  islands  of 
Langerhans,  which  are  distinct  from  the 
ordinary  secreting  cells  of  the  gland,  but 
which  are  not  improbably  formed  from 
the  acini.  The  special  lesion  of  these 
islands — hyaline  degeneration — which 
has  been  associated  with  diabetes  by 
some  writers,  is  not  present  in  all  cases 
of  the  disease,  and  may  be  found  (in  a 
less  developed  state)  in  other  condi- 
tions. 

The  action  of  the  pancreas  may  be  ex- 
erted in  the  direction  either  of  supply- 
ing a  substance  necessary  for  the  as- 
similation of  sugar  by  the  cells  of  the 
body  or  in  that  of  counteracting  a  poi- 
son which  in  some  way  causes  accumula-. 
tion  of  sugar  in  the  blood.  There  is  lit- 
tle or  no  evidence  in  favor  of  the  former 
possibility;  in  favor  of  the  latter  there 
arc  the  results  of  experimental  intoxi- 
.  cation  with  phloridzin,  with  suprarenal 
extract,  and  with  other  substances,  and 
a  few  inconclusive  results  obtained  by 
injection  of  secretions  derived  from  dia- 
betic patients. 

We  are  not  yet  in  a  position  to  state 
with  any  certainty  what  tissue  in  the 
body  gives  rise  to  the  sugar  formed  in 
diabetes.  The  theoretical  possibility 
that  sugar  may  be  derived  from  fat  is 
supported  by  certain  observations  which 
prove  that  a  serious  disturbance  of  the 
ndipose  tissue  exists  in  diabetes. 
Further,  if  this  hypothesis  be  admissi- 
ble, a  certain  unity  will  be  introduced 
into  the  conception  of  diabetes,  the 
phenomena  of  which  will  be  explicable 


ECZEMA,  CHRONIC,  IN  SENILE  DEGENERATIONS.         ENTEROSTOMY. 


259 


as    manifestations    of    a    single    process 
occurring  in  a  single  tissue. 

Lastly,  glycosuria  as  opposed  to  dia- 
betes may  be  due  to  mere  excess  of 
sugar  poured  into  the  blood  from  the 
alimentary  canal  in  excess  of  what  the 
system  is  capable  of  assimilating;  or  it 
may  be  due  to  causes  acting  analogously 
to  the  diabetic  puncture  of  Claude  Ber- 
nard and  leading  to  a  discharge  of  sugar 
by  the  liver  from  its  stores  of  glycogen. 
W.  C.  Bosanquet  (Lancet,  April  22, 
1905). 

ECZEMA,  CHRONIC,  AS  A  COMPLICATION 
OF  THE  SENILE  DEGENERATIONS. 
This  skin  lesion  having  its  initial  on- 
set during  old  age  can  usually  be  at- 
tributed to  the  circulatory  changes, 
and  their  consequent  degenerations. 
Usually  it  is  an  eczema  erythematosum. 
The  pathological  changes  in  the  skin  are 
due  to  deficient  nutrition,  resulting  in 
an  alteration  in  the  epithelial  layers  as- 
sociated with  a  dekeratinization  in  the 
upper  layers,  oedema,  and  an  immigra- 
tion of  exuded  cells.  After  considering 
the  symptoms  and  clinical  picture  of  the 
disease,  which  he  regards  as  purely  a 
local  manifestation  of  the  circulatory 
and  other  changes,  he  states  that  al- 
though these  cases  often  prove  very  re- 
feistanl  to  treatment,  yet  in  the  majority 
of  cases  a  more  or  less  permanent  cure, 
and  in  all  cases  a  great  amelioration  of 
the  symptoms,  can  be  effected  by  care 
and  perseverance  in  a  rational  line  of 
<  reatment.  The  writer  lays  great  stress 
on  making  a  careful  general  physical  ex- 
amination, determining  accurately  ihe 
conditio]]  of  the  heart  and  blood  vessels, 
the  lungs,  kidneys,  etc.,  and  meeting 
any  pathological  condition  by  its  appro- 
priate treatment.  The  circulation 
should  he  properly  maintained  and  the 
emunetory   carefully   watched.       Water 


should  be  taken  freely,  but  in  small 
quantities  at  a  time,  to  secure  rather  a 
constant  flushing,  than  an  overdisten- 
tion  of  the  heart  and  blood-vessels. 
Moderate  exercise  is  advantageous. 

The  local  treatment  should  have  for 
its  object  stimulating  and  thereby  im- 
proving the  peripheral  circulation  of 
the  blood  and  lymphatics.  Carefully 
regulated  and  systematic  rubbings  and 
frictions  best  meet  these  conditions. 
Using  the  greatest  amount  of  surface  of 
the  palms  of  the  hands  and  fingers  as 
can  be  well  adapted  to  the  affected  sur- 
face, the  writer  adopts  a  combination  of 
efrleurage  and  massage  a  friction,  the 
strokes  of  the  hands  following  as  nearly 
as  possible  the  course  of  the  veins  and 
lymphatics.  For  lubrication  a  fine 
quality  of  olive-oil  is  used,  and  with  this 
for  medication  a  pure  finely  powdered 
zinc  oxide;  each  application  lasting 
from  twenty  to  forty  minutes,  given 
every  night,  preferably  just  before  re- 
tiring to  secure  sleep.  Where  more 
stimulation  is  necessary  a  strong  tinc- 
ture of  pix  liquida  is  used.  Every  sec- 
ond night  before  the  application,  the 
patient  is  given  a  bath  at  94°  F.,  using 
a  pure  olive-oil  soap.  Under  these 
methods  of  procedure,  if  carefully  fol- 
lowed, a  more  or  less  permanent  cure 
may  be  expected  in  most  cases  within 
from  two  to  eight  weeks.  ftfedwiu  Leale 
(American  Medicine.  April   15,  1905). 

ENTEROSTOMY. 

Enterostomy  is  always  a  life-saving 
measure,  never  an  operation  of  choice. 
It  is  not  indicated  when  a  more  ideal 
surgical  procedure  is  feasible.  In  the 
hands  of  an  experienced,  carefully- 
trained  abdominal  surgeon,  capable  of 
dealing  with  grave  emergencies,  an  en- 
terostomy is  rarely  resorted  to:  hut  the 
better   the   surgeon,   the   more   quickly 


260 


EPILEPSY,  AUTOPSY  FINDINGS  IN.        ETHER  NARCOSIS. 


will  he  adopt  any  measure  that  will  save 
his  patient.  Every  abdominal  surgeon, 
according  to  the  abundance  of  his  mate- 
rial, must  find  cases  in  which  only  an 
enterostomy  can  with  propriety  be  done. 
When  an  enterostomy  is  indicated,  to 
hesitate  is  to  lose  the  patient;  to  oper- 
ate promptly,  dextrously,  and  with  ce- 
lerity, means  to  tide  the  patient  over 
the  imminent  peril  and  spare  him  for 
future  consideration.  J.  W.  Long 
(American  Medicine,  April  8,  1905). 

EPILEPSY,  AUTOPSY  FINDINGS  IN. 

The  writer  reports  the  results  of  care- 
ful autopsies  on  16  epileptics  at  the 
New  York  State  Institution  for  Epilep- 
tics. In  12  cases  there  were  valvular 
changes  of  the  heart,  most  frequently 
of  the  mitral  valve  (80  per  cent.),  less 
so  of  the  aortic,  and  still  less  frequently 
of  the  tricuspid  valves.  These  he  con- 
siders generally  as  secondary  results  of 
the  special  strain  due  to  the  major  epi- 
leptic attacks.  Capillary  changes,  tor- 
tuosity, and  aneurysmal  dilatations  were 
observed  in  several  cases,  and  were  at- 
tributed to  the  same  causes.  In  8  of 
the  cases  where  the  lungs  were  ex- 
amined there  was  acute  pneumonia  as  a 
contributory  cause  of  death.  The 
cerebral  changes  were  very  striking. 
In  10  cases  there  was  a  marked  thicken- 
ing of  the  pia,  chiefly  over  the  fronto- 
parietal lobe.  In  other  cases  there 
were  vascular  lesions,  circumscribed 
atrophy  of  1  frontal  lobe,  subdural 
haemorrhage  (1  case),  internal  hydro- 
cephalus (1  case),  cerebellar  cyst  (1 
case),  and  shrinkage  of  convolutions  of 
vermis  and  adjoining  cortex  (3  cases). 
The  most  striking  changes  were  noted 
in  the  thalmic  region.  The  writer 
suggests  that  there  was  probably  an  op- 
tic atrophy  in  some  of  these  cases,  and 
hence  the  importance  of  fundal  exami- 


nation in  epileptics.  The  importance 
of  good  clinical  histories  in  these  cases 
is  also  emphasized.  B.  Onuf  (Journal 
of  the  American  Medical  Association, 
April  29,  1905). 

ETHER  NARCOSIS  BY  RECTUM. 

Experience  has  shown  that  with  this 
method  of  producing  narcosis  with 
ether,  the  patient  passes  under  the  in- 
fluence of  the  drug  rapidly  and  with  no 
sense  of  suffocation;  that  less  ether  is 
used,  not  only  in  producing  the  narcosis, 
but  also  in  maintaining  it;  that  the 
stage  of  excitement  is  lessened  or  ab- 
sent; that  the  ether  recovery  is  more 
rapid,  and  that  the  disagreeable  after- 
effects of  inhalation  ether  narcosis  are 
diminished  or  absent.  It  is  also  note- 
worthy that  alcoholics  pass  through  the 
stage  of  excitement  with  little,  if  any, 
resistance  or  struggling.  Although  the 
greater  part  of  the  ether  is  eliminated 
through  the  lungs,  the  direct  irritation 
of  the  concentrated  vapor  is  overcome 
and  postoperative  pneumonia  should  be 
lessened.  A  free  and  continuous  access 
to  the  field  of  operation  is  a  great  ad- 
vantage to  the  surgeon.  In  operations 
on  the  head,  face,  mouth,  nose,  throat, 
ear,  eye,  and  neck,  the  absence  of  the 
ether  cone  not  only  lessens  the  technical 
difficulties  of  the  operation,  but  also 
minimizes  the  chances  of  sepsis,  and 
lessens  considerably  the  time  necessary 
to  perform  the  operation.  To  over- 
come irritation  of  the  rectum  the  au- 
thors use  a  specially  devised  apparatus 
for  producing  narcosis.  To  obtain  the 
best  results  it  is  essential  that  the 
bowels  should  be  thoroughly  cleaned 
out.  "The  authors  report  41  cases,  17 
of  which  received  ether  by  mouth  pre- 
liminary to  the  rectal  method,  and  21 
cases  which  were  started  by  rectum. 
Among  this  series  were  cases  of  fracture 


GALL-STONE  DISEASE,  FEVER  IN. 


HAND  STERILIZATION. 


261 


of  the  skull,  tubercular  glands  of  the 
neck,  carcinoma  of  the  upper  lip,  skin 
graft,  plastic  operations  on  the  face, 
adenoids,  amputation,  circumcision,  os- 
teotomy, etc.  J.  H.  Cunningham,  Jr., 
and  F.  H.  Lahey  (Boston  Medical  and 
Surgical  Journal,  April  20,  1905). 

GALL-STONE  DISEASE,  FEVER  IN. 

The  investigations  of  the  writer  dis- 
prove the  older  theory  that  fever  in 
gall-stone  disease  is  due  to  reflex  action 
on  the  heat  centers.  There  can  he  no 
doubt  that  the  fever  is  of  infectious 
origin;  if  there  is  no  infection,  there 
can  be  no  fever.  Not  every  case  of  in- 
fection of  the  biliary  passages,  however, 
produces  a  general  febrile  reaction. 
The  fever  depends  upon  the  nondevel- 
opment  of  sufficient  protective  powers 
in  the  organism.  The  protection  of  the 
body  against  the  effects  of  infection  may 
lie  in  the  development  of  an  antitoxic 
immunity,  or  in  the  production  of  local 
conditions  in  the  biliary  passages  that 
limit  the  action  of  the  bacteria  on  the 
body.  If  a  new  organism  is  introduced 
into  the  gall-bladder  and  becomes  ac- 
tive, a  fresh  febrile  reaction  will  be  set 
up.  Likewise,  if  those  organisms  al- 
ready present  in  the  biliary  tract  reach 
parts  as  yet  unaffected,  a  fresh  outbreak 
of  disease  may  be  produced.  The  ab- 
sence of  fever  in  gall-stone  disease  does 
not  indicate,  therefore,  that  there  is  no 
infection,  unless  it  can  be  shown  that 
there  has  never  been  afebrile  reaction  to. 
the  presence  of  the  gall-stones.  Diag- 
nostic and  prognostic  conclusions  must 
be  drawn  only  with  the  greatest  care 
from  the  tendency  of  fever  to  recur  with 
more  severity  and  greater  frequency,  or 
vice  versa.  A  series  of  severe  attacks 
indicates  a  spreading  infection,  but  this 
may  occur  even  with  very  slight  febrile 
reaction.     The  persistence  of  high  fever 


in  chronic  cases  is  a  bad  sign.  The 
later  the  fever  sets  in  during  an  attack 
of  gall-stones,  the  more  favorable  the 
prognosis.  Eepeated  attacks  of  fever 
with  undiminished  intensity  point  to 
chronic  impaction  in  the  common  duct. 
A  fall  by  crisis  indicates  that  the  in- 
fected zone  has  again  become  sterile;  if, 
however^  the  fever  falls  by  lysis,  it  does 
not  indicate  a  termination  of  the  infec- 
tion. If  icterus  accompanies  the  fever, 
it  indicates  that  the  infection  has 
reached  the  smaller  biliary  passages, 
whore  moderate  swelling  produces  ob- 
struction. The  regular,  simultaneous 
occurrence  of  fever  with  jaundice  points 
tc  chronic  impaction  of  a  stone  in  the 
common  duct.  Regarding  operative 
therapy,  the  author  has  noticed  that 
death  from  operation  always  occurs  in 
cases  that  come  to  operation  during  high 
fever.  Rise  of  temperature  after  oper- 
ation is  almost  invariably  due  to  bac- 
terial infection  of  the  bile.  H.  Ehret 
(Zeitschrift  fiir  klinische  Medicin,  Bd. 
lv,  p.  249 ;  American  Medicine,  May  20, 
1905). 

HAND  STERILIZATION. 

In  carrying  out  hand  sterilization, 
mechanical  and  chemical  methods  are 
employed.  (1)  Mechanical.  —  Careful 
use  of  a  stiff  nail  brush  with  soap  and 
hot  water  removes  many  bacteria  and 
detaches  superficial  epidermal  cells  and 
grease  with  contained  organisms.  The 
time  required  and  the  injurious  effect  on 
the  hands  render  it  beyond  the  limit  of 
practicability  to  produce  efficient  steril- 
ization by  this  method  alone.  (2) 
( 'hemicdl.  —  Ordinary  operating-room 
methods  are  to  a  considerable  extent  in- 
efficacious in  rendering  the  hands  ster- 
ile. The  fact  that  cultures  of  a  staphy- 
lococcus could  be  obtained  from  an  in- 
oculated     silk      thread      after      thirty 


262 


HEMOPHILIA,  RESEARCHES  IN. 


minutes  in  a  watery  solution  of  corro- 
sive sublimate  (1  in  1000)  speaks  for  the 
weakness  of  this  popular  preparation. 
Absolute  alcohol  has  but  a  slight  germi- 
cidal power,  but  the  diluted  fluid  (70 
per  cent.)  has  a  far  greater  action  than 
a  watery  solution  of  bichloride  or  bin- 
iodide  of  mercury  (1  in  1000)  or  a  sat- 
urated solution  of  permanganate  of 
potash.  Prolonged  use  of  alcohol,  how- 
ever, will  cause  pain,  roughen  the  skin, 
and  may  produce  eczema. 

The  writer  has  held  that  the  ideal 
cleansing  agent  must  be  a  solution  capa- 
ble of  dissolving  fatty  matter  and  of 
penetrating  the  epidermis,  strongly 
germicidal,  rapid  in  action,  and  non-in- 
jurious to  the  skin.  After  long  experi- 
mentations the  writer  suggests  the  un- 
purified  clove  oil  as  an  approach  to  the 
ideal.  After  five  minutes'  scrubbing 
with  soap  and  hot  water  the  skin  should 
be  dried  with  a  sterile  towel  and  rubbed 
for  one  minute  with  alcohol  to  remove 
any  remaining  moisture.  Clove  oil  is 
then  rubbed  into  the  skin  for  five  min- 
utes and  afterward  washed  off  with  alco- 
hol. A  slight  burning  sensation  may 
result,  but  the  skin  is  not  injured.  The 
hands  should  then  be  covered  with  dry 
sterile  rubber  gloves.  Wet  gloves  mac- 
erate the  skin,  which  may  readily  yield 
organisms  which  have  not  been  de- 
stroyed through  any  undetected  hole  in 
the  glove.  The  use  of  various  "hand 
coatings,"  wax  parafnnes,  and  rubber  so- 
lutions are  not  to  be  recommended,  as 
they  arc  prone  to  crack  and  peel  off  in 
long  operations.  J.  C.  Webster  (Amer- 
ican Journal  of  Obstetrics.  April,  1905). 

HEMOPHILIA,  RESEARCHES  IN. 

The  writer  had  the  rare  luck  to  ob- 
serve four  typical  cases  of  haemophilia 
and  to  study  the  peculiarities  of  the 
blood  in  this  strange  disorder.     Accord- 


ing to  some,  the  condition  is  due  to  high 
blood-pressure,  but  this  is  improbable, 
since  diseases  commonly  associated  with 
high  blood-pressure,  such  as  chronic 
nephritis,  do  not  usually  run  with 
haemophilia  symptoms.  In  the  author's 
case,  the  figures  obtained  with  the  Biva- 
I.'occi  instrument  were  normal  or  below 
normal.  Microscopical  examination  of 
the  blood  showed  only  a  moderate,  rela- 
tive diminution  of  polynuelear  leuco- 
cytes, with  relative  increase  of  lympho- 
cytes. The  absolute  number  of  leu- 
cocytes was  normal  or  diminished.  In 
two  cases,  the  platelets  were  also 
counted  repeatedly,  but  their  number 
was  never  above  normal.  The  alkalin- 
ity of  the  blood,  the  dry  residue  of  the 
serum,  the  depression  of  the  freezing 
point  and  the  amount  of  fibrin  in  the 
blood,  were  not  altered.  The  time  of 
coagulation  was  estimated  most  care- 
fully and  it  was  found  that  in  the  inter- 
vals between  the  haemorrhages,  clotting 
was  much  delayed,  but  normal,  or  even 
hastened,  during  severe  bleeding.  The 
following  new  method  was  employed: 
A  column  of  blood,  about  one  centi- 
meter high,  is  allowed  to  flow  into  a 
capillary  pipette,  one  to  two  millimeters 
in  diameter.  An  absolutely  clean,  white 
strand  of  horse-hair  is  then  passed  into 
the  blood,  and  drawn  oiit  a  short  dis- 
tance every  half  to  one  minute.  If 
the  hair  has  been  carefully  deprived  of 
all  grease,  no  blood  will  adhere  to  it  at. 
.  first,  but  as  soon  as  coagulation  has 
set  in,  the  withdrawn  section  will  no 
longer  appear  white,  but  red.  The 
rapid  clotting  during  bleeding,  despite 
continued  haemorrhage,  is  probably  due 
to  an  abnormal  quality  of  the  vessel 
walls.  Under  normal  conditions,  the 
latter  probably  furnish  certain  sub- 
stances necessary  for  the  production  of 
fibrin-ferment    (thrombo-kinase)    locally 


HEMORRHAGES,  INTESTINAL. 


HEART  STRAIN  IN  BOYS. 


263 


at  the  site  of  injury,  so  that  a  clot  will 
soon  obstruct  the  opening  in  the  vessel. 
During  haemophilia,  the  torn  edges  of 
the  vessel  do  not  supply  the  blood  with 
this  substance,  hence  no  local  clot 
forms.  The  imperfect  clotting  during 
the  intervals  is  due  to  a  similar  defi- 
ciency on  the  part  of  the  blood  cells  and 
the  haematopoietic  apparatus.  Chem- 
ical changes  in  the  vessel-walls  will  also 
explain  the  occurrence  of  spontaneous 
haemorrhages  and  the  reported  cases  of 
haemophilia  of  single  organs  (Senator's 
renal  haemophilia).  Very  little  can  be 
done  for  the  disease,  except  to  improve 
the  general  constitution.  The  local 
haemorrhages  are  best  controlled  with 
compression,  gelatine  and  adrenalin, 
but  the  latter  two  drugs  should  never  be 
injected  subcutaneously.  It  is  not 
likely  that  the  local  application  of 
thrombo-kinase  will  do  much  good. 
There  is  as  yet  no  drug  from  which  good 
results  can  be  expected  on  internal  ad- 
ministration. H.  Sahli  (Zeitschrift  fur 
klinische  Medicin,  Bd.  lxv,  Nu.  3  und  4; 
Medical  News,  May  6,  1905). 

HEMORRHAGES     OF     THE     INTESTINES, 
TREATMENT  OF. 

Excellent  results  have  been  obtained 
by  the  writers  in  the  treatment  of  intes- 
tinal haemorrhages  of  typhoid  fever  by 
hot  water  and  calcium  chloride,  admin- 
istered by  irrigation.  The  amount  of 
calcium  chloride  in  twenty-four  hours 
which  is  given  to  a  patient  is  one  gram 
by  mouth  and  three  grams  by  irrigation. 
These  workers  have  found  thai  the 
calcium  chloride  is  habitually  well  toler- 
ated. The  duration  of  treatment  varies 
according  to  the  dose.  Four  days  is 
considered  long  enough  by  certain  au- 
thorities. Others  continue  it  for  a 
longer  time  when  the  doses  are  very 
small.      The  elimination  of  the  salt  is 


sufficiently  rapid  so  that  it  does  not  ac- 
cumulate in  the  organism.  It  is  well 
always  to  find  out  first  if  the  patient  has 
normal  kidneys  before  giving  it.  It  is 
considered  beneficial  to  clear  the  intes- 
tine of  extravasated  blood.  Putrefac- 
tion cannot  then  take  place,  and  one 
cause  of  intoxication  is  removed.  The 
irrigations  should  be  given  carefully  and 
slowly.  About  a  liter  of  water  is  used; 
the  patient  should  be  in  dorsal  de- 
cubitus, and  the  operation  should  take 
about  fifteen  minutes.  Mathieu  and 
Passier  (Revue  Franchise  de  Medecine 
et  de  Chirurgie,  March  20,  1905;  Medi- 
cal Record,  April  8,  1905). 

HEART,     ACTION     OF     STRYCHNINE     ON 
THE. 

From  clinical  experiences  and  re- 
search, the  writer  concludes  that  strych- 
nine does  not  act  directly  on  the  heart. 
Its  action  is  exerted  on  the  nervous  sys- 
tem, inducing  vasoconstriction  with  in- 
creased blood-pressure.  It  is  indicated 
in  cases  of  heart  trouble  and  neuras- 
thenia with  depressed  vitality  and  les- 
sened elasticity  of  the  vessel  walls.  He 
has  frequently  found  that  it  produced 
great  subjective  improvement  with  in- 
creased strength  and  appetite.  Ho 
gives  about  5  milligrams  a  day  for  ten 
days  as  the  maximum  dosage,  bearing  in 
mind  the  cumulative  action  of  the  drug. 
(Jennari  (Riforma  Medica,  February  25, 
1905;  Journal  of  the  American  Medical 
Association,  May  13,  1905). 

HEART  STRAIN  IN  GROWING  BOYS. 

The  author  states  that  the  passage 
from  physiologic  to  pathologic  disten- 
tion is  abrupt.  The  muscle  Tails  to  re- 
spond to  increased  functional  stimulus 
and  nutritive  supply,  from  protoplasmic 
inadequacy.  Fibrous  hyperplasia  and 
changes    in    the    muscle    fibers    follow. 


264 


INFLUENZA  BACILLI  IN  RESPIRATORY  TRACT. 


INSANITY. 


Thus  can  be  explained  the  symptoms  of 
overstrain  produced  by  mental  shock, 
direct  violence,  or  illness.  The  exercis- 
ing boy  is  accustomed  to  extreme 
breathlessness,  but  he  recognizes  acute 
dilatation  as  a  sudden  evil.  It  may 
bear  no  relation  to  the  severity  of  the 
strain  to  which  he  has  been  exposed. 
The  writer  doubts  whether  the  heart  of 
the  truly  healthy  boy  ever  breaks  down 
as  the  result  of  athletics  as  practiced  in 
the  great  schools.  There  must  have  ex- 
isted some  cardiac  insufficiency,  either 
inherent  or  due  to  some  condition  such 
as  anaemia  or  recent  influenza.  Ten- 
dency to  recurrence  is  common  to  all 
cases.  There  may  or  may  not  be  con- 
stant symptoms  or  signs  of  inefficiency. 
The  prognosis  must  be  guarded,  and 
every  return  to  active  exercise  looked  on 
as  an  experiment.  The  heart  may  be 
strong  enough  for  a  life  work  that  does 
not  entail  great  stress,  but  not  strong 
enough  to  stand  an  anaesthetic  or  some 
acute  illness.  A  good  muscle  may  com- 
pensate for  a  faulty  valve,  but  there  can 
be  no  compensation  when  it  is  the  myo- 
cardium itself  which  is  at  fault.  A. 
Lambert  (Medical  Chronicle,  February, 
1905). 

INFLUENZA  BACILLI,  INFECTIONS  OF 
THE  RESPIRATORY  TRACT  WITH. 
Of  186  non-tubercular  infections  of 
the  respiratory  tract,  observed  clinic- 
ally, for  the  most  part,  bronchitis,  a 
mixed  infection  with  various  organisms, 
has  been  found  in  120  (64  per  cent.).  A 
comparatively  pure  infection  with  one 
group  of  organisms  was  found  in  66 
cases  (36  per  cent.).  Of  these  pure  in- 
fections those  due  to  influenza  bacilli 
comprise  the  largest  group,  with  a 
smaller  number  of  cases  of  pure  infec- 
tion with  the  pneumococcus,  micro- 
coccus catarrhalis,  etc.      The  pure  in- 


fections, however,  tend  to  become 
mixed,  as  the  case  progresses,  and  the 
observer  must  then  remain  in  doubt,  in 
the  presence  in  the  sputum  of  two  or 
more  groups  ;of  organisms,  as  to  the 
relative  importance  of  any  one  of  the 
infecting  agents. 

In  the  clinical  picture,  the  symptoms 
of  onset,  the  course  and  duration  of  the 
different  pure  infections,  there  seems  to 
be  nothing  distinctive.  They  all  tend 
to  set  up  diffuse  or  local  bronchitis  and 
a  varying  degree  of  broncho-pneumonia. 
The  amount  of  prostration  may  be  as 
great  in  one  as  in  the  other. 

The  pathological  picture  in  cases  of 
broncho-pneumonia,  due  to  the  different 
organisms,  likewise  seems  to  be  similar 
in  the  character  of  the  exudate,  its  vary- 
ing extent  and  intensity  and  the  ten- 
dency, in  a  small  proportion  of  cases,  to 
end  in  permanent  damage  to  the  pul- 
monary substance.  These  results  of 
pulmonary  invasion  are  not  infrequently 
mistaken  clinically  for  pulmonary  tu- 
berculosis. Of  85  cases  of  pneumonia, 
associated  with  various  organisms,  well 
marked  localized  pulmonary  abscesses 
or  induration,  or  both,  were  found  in  8. 
No  tuberculosis  could  be  demonstrated 
at  autopsy.  From  the  clinical  resem- 
blance of  such  cases  to  pulmonary  tu- 
berculosis, the  presence  of  the  tubercle 
bacillus  in  the  sputum  must  be  regarded 
as  the  only  infallible  indication  of  this 
condition.  F.  T.  Lord  (Boston  Medical 
and  Surgical  Journal,  May  18,  1905). 

INSANITY,  MEDICAL  TREATMENT  OF. 

In  the  acute  stage  of  no  disease  is 
care  and  attention  more  necessary,  nor 
more  expensive,  nor  is  there  more  hope 
of  cure  than  there  is  in  the  early  stages 
of  insanity.  It  is  .essential  to  prevent 
exhaustion  and  to  maintain  the  patient's 
strength  by  giving  unirritating  foods, 


MENSTRUAL  FEVER  IN  PHTHISICAL  WOMEN. 


265 


easy  of  digestion,  frequently  and  in 
small  quantities.  Plenty  of  sleep  is 
necessary.  For  this  purpose  sedatives 
and  hypnotics  should  be  given.  When 
there  is  delirium  and  when  the  pulse  is 
full,  hounding  and  firm,  and  there  are 
symptoms  of  sthenic  inflammation, 
venesection  may  prove  beneficial.  The 
wine  of  tartarated  antimony  for  furious 
excitement,  with  vascular  and  cerebral 
congestion,  especially  when  combined 
with  morphine,  is  very  effective.  Aco- 
nite ice-bags  to  the  head  and  continuous 
immersion  are  also  useful.  As  a  form 
of  electric  stimulation,  electricity  ad- 
ministered in  the  form  of  currents 
through  water  at  100°  F.,  given  daily, 
or  several  times  a  week,  for  about  ten  to 
thirty  minutes,  is  particularly  com- 
mendable. For  controlling  motor  ex- 
citement, succus  condii  in  doses  of  from 
3  0  minims  to  1  drachm,  is  efficient.  It 
is  best  to  begin  with  small  doses  and  to 
combine  these  with  strychnine  or  some 
other  cardiac  stimulant.  As  to  hypnot- 
ics, for  the  cure  or  relief  of  insomnia, 
paraldehyde,  in  doses  of  1/2  drachm  to 
2  drachms,  is  the  safest.  It  is  not  re- 
commended in  lung  affections.  Hyos- 
cin,  or  hyoscyamin  combined  with  mor- 
phine, are  effective  for  excitement  and 
sleeplessness.  However,  the  bromides 
are  the  most  useful.  They  may  be 
combined  with  chloral  and  tincture  of 
hyoscyamus,  when  these  are  not  contra- 
indicated.  In  rases  of  so-called  hys- 
terical insanity,  as  a  possible  remedy 
may  be  mentioned  the  use  of  thorium 
hydroxide,  500  grams  to  be  placed  in  a 
cap  over  the  head,  worn  day  and  night. 
This  drug  possesses  radio-active  pro- 
perties. The  writer  states  that  two  of 
his  cases  recovered  under  such  treat- 
ment. Laxatives  and  purgatives  are 
absolutely  necessary,  and  in  free  doses, 
usually  twice  the  amount  required  by  a 


healthy  person.  The  action  of  the  skin 
should  be  assisted.  This  is  done  best 
by  outdoor  exercise.  Speaking  of  alco- 
hol, the  author  says  that  in  the  great 
majority  of  cases  of  insanity  it  is  not 
essential,  but  he  does  not  hesitate  to  use 
it  in  small  doses,  every  few  hours,  in  the 
exhaustion  of  acute  mania,  more  espe- 
cially in  the  puerperal  form  of  insanity. 
It  often  interferes  with  digestion,  and 
if  is  always  best  administered  with 
liquid  nourishment.  However,  it  is  a 
dangerous  remedy  in  the  various  forms 
of  mental  depression,  for  it  gives  the 
patient  a  feeling  of  buoyancy  and  stimu- 
lation without  any  lasting  benefit  and 
without  the  sustaining  action  of  food. 
Strychnine  and  nux  vomica  are  useful 
in  cases  of  exhaustion  from  acute  in- 
sanity and  in  cases  of  cerebral  anaamia. 
They  should  be  given  alternately  for  a 
few  weeks,  and  with  about  one  week's 
interval.  E.  Jones  (British  Medical 
Journal,  April  22,  1905). 

MENSTRUAL  FEVER  IN  PHTHISICAL 
WOMEN. 
This  recurring  fever  in  women  who, 
in  many  instances,  menstruate  not  at  all 
or  only  very  little,  is  not  a  matter  of 
great  importance,  notwithstanding  the 
monthly  repetition  of  more  or  less  pro- 
nounced congestive  phenomena  relating 
to  the  lungs.  The  author  was  unable  to 
discover  that  it  had  any  bearing  upon 
the  development  of  tuberculous  lesions. 
They  may  remain  in  bed  or  not  during 
the  existence  of  this  fever,  the  same  as  if 
the  sufferers  were  not  tuberculous.  For 
those  who  have  a  tendency  to  haemopty- 
sis if  is  better  to  remain  in  bed  when  the 
catamenial  crisis  is  present,  and  remain 
there  during  its  entire  duration. 
Haemoptysis  almost  always  precedes  the 
menstrual  flow  and  is  arrested  after  the 
flow  lias  been  established.     In  cases  of 


266 


MENTOPOSTERIOR  POSITIONS. 


MERCURY,  ACTION  OF. 


dysmenorrhea  one  may  administer  hot 
drinks,  sinapisms,  foot-baths,  hot  appli- 
cations to  the  abdomen,  etc.  Should 
haemoptysis  persist  after  the  menstrual 
flow  has  occurred  it  may  be  treated  by 
simply  restricting  the  diet  for  twenty- 
four  or  forty-eight  hours  as  a  means  of 
reducing  the  congestion.  If  amenor- 
rhea has  supervened  no  treatment  will 
be  of  much  use,  except  that  which  will 
improve  general  nutrition.  Sabourin 
(Revue  de  Medecine,  March,  1905; 
New  York  Medical  Journal  and  Phila- 
delphia Medical  Journal,  April  29, 
1905). 

MENTOPOSTERIOR  POSITIONS. 

Engagement  of  the  face  in  mentopos- 
terior positions  does  occur,  and  the  face 
may  reach  the  pelvic  floor  without  ante- 
rior rotation.  In  almost  all  cases  the 
anterior  rotation  spontaneously  occurs. 
Failure  of  chin  to  rotate  anteriorly  is  a 
definite  indication  for  interference.  In 
entering  the  pelvis,  the  length  of  the 
child's  neck  may  permit  the  head  to  sink 
well  down  into  the  pelvis  before  the 
thorax  is  involved.  Delivery  of  the  un- 
rotated  chin,  although  extremely  rare, 
is  by  no  means  impossible,  -and  occurred 
in  the  author's  series  in  22.6  per  cent,  of 
the  impacted  cases. 

In  75  cases  of  impacted  mentopos- 
terior position,  the  maternal  mortality 
(11.6  per  cent.)  under  all  circumstances 
about  equals  the  maternal  mortality  (12 
per  cent.)  of  placenta  prsevia  under 
aseptic  conditions.  The  foetal  mortal- 
ity under  all  conditions  is  only  a  trifle 
higher  than  the  foetal  mortality  of  intra- 
partum eclampsia  under  the  best  and 
most  modern  conditions,  and  is  far  bet- 
ter than  the  reputed  (100  per  cent.) 
mortality. 

In  the  management,  the  position  must 
always  be  corrected  if  the  rotation  does 


not  occur  spontaneously.  Version  is  the 
operation  of  election  if  the  head  is  not 
engaged  and  manual  flexion  has  failed. 
Version  is  contraindicated  after  engage- 
ment. Manual  correction  by  the  Bau- 
delocque,  De  Lee,  Thorn,  or  Volland 
methods  should  always  be  attempted. 
Forceps  should  be  used  with  the  utmost 
caution,  if  at  all,  and  as  a  last  re- 
sort before  mutilating  operations,  for 
the  fcotal  mortality  is  very  high  (50  per 
cent.),  and  if  employed,  only  the  axis 
traction  instrument  should  be  chosen. 
If  symphyseotomy  is  done,  case  should 
be  taken  to  operate  while  the  child  is 
vigorous  enough  to  justify  it.  Asepsis 
in  the  conduct  of  these  cases  ought  to 
show  a  considerable  reduction  in  the 
mortality  figures.  C.  B.  Beed  (Ameri- 
can Journal  of  Obstetrics,  May,  1905). 

MERCURY,  ACTION  OF. 

The  writer  reviews  various  theories 
that  have  been  promulgated  to  explain 
the  therapeutic  effect  of  mercury  in 
syphilis,  and  says  that  so  far  at  least 
they  have  led  to  but  little  definite  in- 
formation. The  older  action  is  proba- 
bly unfounded,  for  the  amounts  ab- 
sorbed are  far  too  small  to  be  able  to 
unfold  a  diffuse  power  of  this  sort.  The 
most  recent  view  is  that  of  Schade,  who, 
starting  with  the  work  of  the  synthet- 
ical chemists  in  the  production  of  arti- 
ficial indigo,  has  developed  the  subject 
of  the  catalytic  action  of  the  heavy 
metals  as  oxidizing  agents.  This  action 
of  mercury  is  shown  by  the  blueing  it 
produces  in  tincture  of  guaiac  in  the 
presence  of  resinified  oil  of  turpentine, 
or  of  peroxide  of  hydrogen.  That  this 
action  is  due  to  electrical  changes  is  il- 
lustrated by  the  change  of  form  mani- 
fested by  a  globule  of  the  metal  when 
placed  in  turpentine  or  in  tincture  of 
guaiac.     In  the  first  fluid  it  becomes  a 


MILK,  DIGESTION  OF. 


NEPHROPEXY. 


267 


flattened  mass  which  resembles  melted 
lead  and  retains  any  shape  that  may  he 
given  it,  while  on  transfer  to  the 
tincture  it  at  once  resumes  its  normal 
characteristics.  The  phenomenon  is 
ascribed  to  a  positive  electrical  charge 
in  the  one  fluid  and  a  negative  one  in 
the  other.  Schade  believes  that 
through  its  catalytic  stimulating  effect 
on  the  tissues  the  mercury  enables  the 
latter  to  repair  the  damage  caused  by 
the  syphilitic  poison.  The  process  is 
not  one  of  antitoxin  stimulation,  as 
seme  authors  have  averred,  but  one  of 
simple  antagonism  to  the  toxins. 
During  (Miinchener  medicinische  Woch- 
ensehrift,  March  14,  1905). 

MILK,  DIGESTION  OF. 

The  amount  of  casein  coagulating 
ferment  produced  in  the  stomach  varies 
considerably  in  different  persons  in  both 
normal  and  pathological  conditions,  and 
those  who  have  a  gastric  juice  poor  in 
this  ferment  are  subject  to  gastrointes- 
tinal troubles  when  placed  on  a  milk 
diet.  The  chemical  study  of  the  di- 
gestion of  milk  and  the  determination 
of  the  coefficient  of  the  intestinal  utili- 
zation of  the  constituent  elements  of 
milk  show  that  there  is  a  distinct  rela- 
tion between  the  secretion  of  this  fer- 
ment and  the  digestion  of  fatty  mate- 
rial. It  retards  the  passage  of  the  milk 
along  the  intestinal  tract  so  that  the  fat 
vi  subjected  for  a  longer  time  to  the 
action  of  saponifying  ferments,  while  at 
the  same  time  the  absorption  of  fatty 
material  during  intestinal  digestion  is 
favored.  But  when  this  ferment  is  not 
present  in  sufficient  quantity  the  fatty 
material  in  the  milk  is  badly  digested, 
and  this  indigestion  gives  rise  to  the 
above  mentioned  intestinal  troubles 
when  persons  with  this  lack  in  their  gas- 
tric juice  are  put  on  an  exclusive  milk 


diet.  Leon  Meunier  (Presse  Medicate, 
April  1,  1905;  New  York  Medical  Jour- 
nal and  Philadelphia  Medical  Journal, 
May  C,  1905). 

MYOPIA. 

The  writer  considers  the  causes  of 
myopia  due  to  increase  of  the  intraocu- 
lar pressure  in  the  posterior  portion  of 
the  bulb,  such  as  sewing  by  persons  with 
a  tendency  to  myopia,  anatomical  pecu- 
liarities in  the  eyes  of  myopics,  etc. 
These  conditions  are  due  primarily  to 
diminished  resistance  of  the  posterior 
portion  of  the  myopic  eye.  The  mod- 
ern method  of  treatment  is  to  correct 
fully  far  and  near  vision,  but  in  high  de- 
grees of  myopia  and  in  elderly  person.-, 
under-correction  is  necessary.  Eelbron 
(Berliner  klinische  Wochenschrift, 
March  20,  1905). 

NEPHROPEXY. 

Nephropexy  is  justifiable  on  a  dis- 
placed kidney  after  operation  thereon, 
involving  it  or  its  pelvis  or  ureter,  or  to 
relieve  hydronephrosis  or  hamuli uria 
from  anon-replaceable  kidney.  Hepat- 
opexy,  splenectomy,  gastroplicat  ion.  gas- 
trojejunostomy, and  suture  of  the  recti 
may  be  occasionally  indicated. 

The  main  obstacle  to  nephropexy  in 
women  lies  in  the  greater  obliquity  of 
the  lower  ribs,  which  prevent  suturing 
the  kidney  high  enough  to  avoid  harm- 
ful compression  by  the  ordinary  corsel 
and  waist  hands.  Nephropexy  is  unjus- 
tifiable when,  in  order  to  place  (he  su- 
tures, it  is  necessary  to  drag  the  kidney 
farther  down. 

Nephropexy  may  relieve  the  symp- 
toms due  to  kidney  mobility,  hut  ill 
order  to  overcome  those  caused  by  the 
general  ptoses  it.  has  been  necessary  to 
adopt,  a  new  principle,  viz.,  (a)  gravity 
r<  placement    by    the    semiopisthotonos 


268 


NERVES,  REGENERATION  OF. 


NURSING,  TECHNIQUE  OF. 


posture;  (b)  support  of  the  replaced 
viscera  by  a  corset  made  to  order  from 
measurements  taken  while  the  woman  is 
lying,  down,  laced  with  two  strings,  in- 
serted from  above  down,  put  on  while  in 
the  inclined  dorsal  posture,  and  fastened 
in  front  from  below  upward.  By  this 
method  the  viscera  cannot  prolapse 
while  the  corset  is  worn,  and  with  this 
support  nephropexy  for  replaceable  kid- 
ney, per  se,  is  but  rarely  indicated,  mul- 
tiple operations  can  be  avoided,  and  the 
patient  be  placed  under  curable  condi- 
tions. A.  E.  Gallant  (New  York  Medi- 
cal Journal  and  Philadelphia  Medical 
Journal,  April  29,  1905). 

NERVES,  REGENERATION  OF. 

It  is  possible  to  functionate  two  op- 
posing groups  of  muscles  by  a  single 
nerve,  which  previously  supplied  one 
group  only;  it  is  possible  to  innervate 
fairly  completely  muscles  with  a  much 
smaller  number  of  motor  horn  cells  than 
usually  bring  about  this  effect.  When 
the  central  end  of  one  nerve  is  joined 
to  the  peripheral  ends  of  two  nerves 
there  are  many  more  fibers  in  the 
peripheral  nerves  than  in  the  central 
nerves,  so  that  the  nerve  fibers  in  the 
proximal  trunk  divide  on  going  to  the 
distal  trunks.  In  some  cases  at  least 
some  of  the  branches  from  one  nerve 
fiber  g®  to  supply  one  set  and  others  the 
opposing  set  of  muscles.  This  may  pre- 
vent very  delicate  movement  being  re- 
stored. After  this  form  of  suturing  the 
arrangement  of  the  nerve  fasciculi  in 
the  peripheral  nerves  is  considerably  al- 
tered. B.  Kilvington  (British  Medical 
Journal,  April  29,  1905). 

NON-MALIGNANT  DISEASES,  TREATMENT 
OF,  BY  THE  ROENTGEN  RAYS. 

It  is  necessary  to  distinguish  between 
the     non-malignant     diseases     which 


should,  and  those  which  should  not,  be 
treated  by  the  x-ray.  While  the  con- 
tinual cry  of  technique  may  become  tire- 
some to  some  who  think  the  subject  can 
be  mastered  in  a  few  days  or  a  couple  of 
months,  the  method  of  application  of 
the  rays  and  the  judgment  of  the  oper- 
ator accounts  largely  for  successful  or 
unsuccessful  work.  It  is  just  as  essential 
to  administer  a  therapeutic  dose  when 
applying  the  Boentgen  rays  as  it  is  when 
prescribing  powerful  drugs.  Idiosyn- 
crasy is  not  a  frequent  cause  of  exces- 
sive dermatitis.  A  dosage  which  causes 
stimulation  of  healthy  tissues  will 
usually  produce  a  slight  reaction  in  dis- 
eased tissues.  At  all  times  it  should  be 
remembered  that  it  is  not  so  much  the 
x-ray  that  cures  as  the  judgment  with 
which  it  is  employed. 

The  x-ray  is  one  of  the  best  therapeu- 
tic agents  known  for  the  treatment  of 
acne  and  many  other  skin  diseases,  but 
it  is  unnecessary  in  many  instances  to 
treat  the  trivial  and  less  obstinate  cases 
by  this  method.  The  x-ray,  supple- 
mented by  Finsen  light,  is  the  most  effi- 
cient therapeutic  agent  for  the  treat- 
ment of  lupus.  The  x-ray  is  the  most 
efficient  agent  for  the  treatment  of 
certain  tuberculous  glands,  Hodgkin's 
disease,  and  selected  cases  of  goiter.  R. 
H.  Boggs  (Medical  News,  May  6,  1905). 

NURSING,  TECHNIQUE  OF. 

Among  the  points  emphasized  by  the 
writer  in  his  study  of  the  best  means  to 
promote  the  nursing  capacity,  is  the  ad- 
visability of  giving  the  child  only  one 
breast  at  a  meal.  This  allows  the  one 
breast  used  to  be  thoroughly  emptied, 
while  the  other  breast  has  a  doubly  long 
rest.  The  longer  the  intervals  between 
meals,  the  hungrier  ilie  child,  and  the 
more  energetically  it  sucks.  This  en- 
ergetic sucking  is  the  most  important 


PAROTID  GLAND. 


PLEURAL  AND  CEREBROSPINAL  FLUIDS. 


269 


factor  for  the  development  of  a  good 
nursing  capacity.  The  breast  generally 
responds  to  energetic  sucking  with  a  co- 
pious secretion  of  milk;  feeble  sucking 
elicits  but  a  feeble  secretion.  The  au- 
thor has  had  wealthy  women  with 
weakly  infants  come  to  his  maternity 
for  a  week  or  so  to  give  the  breast  to 
strong,  energetically  sucking  infants, 
while  their  infant  was  nursed  by 
someone  else  with  well-developed 
breasts.  When  they  left  their  in- 
fants were  much  stronger,  while 
their  breasts  had  responded  to  the 
energetic  sucking  with  a  copious  secre- 
tion of  milk.  A  generous  diet  without 
any  special  restrictions  should  be  ad- 
vised. It  seems  to  be  immaterial 
whether  the  woman  drinks  milk  or 
water  for  her  beverage,  but  two  to  two 
and  a  half  quarts  of  fluid  should  be  in- 
gested during  the  twenty-four  hours. 
One  of  the  wet  nurses  trained  on  these 
principles  secretes  3610  grams  of  milk  a 
day,  and  has  been  nursing  five  infants 
for  several  weeks,  and  is  in  robust 
health.  0.  Eommel  (Miinchener  medi- 
cinische  Wochenschrift,  Bd.  lii,  Nu.  10, 
1905). 

PAROTID   GLAND. 

The  function  of  the  parotid  gland  is 
the  subject  of  a  scientific  research  by 
the  writer  who  found  that  the  secretion 
of  the  gland  varies  in  amount  and  qual- 
ity according  to  the  stimulus  given  by 
contact  with  various  substances  in  the 
mouth.  The  amount  of  secretion  of  I  ln- 
parotid  varies  as  the  square  root  of  the 
amount  <>\'  stimulant  applied  to  the 
mouth.  Chewing  has  much  to  do  with 
the  rapidity  of  the  secretion  from  the 
parotid,  and  the  saliva  is  not  only  more 
abundant,  but  more  viscid  when  masti- 
cation is  vigorous  and  prolonged.  "When 
food  is  chewed  on  one  side,  the  corres- 


ponding parotid  gland  works  more  than 
the  opposite  gland,  while  when  chewing 
goes  on  both  sides  both  glands  work 
equally.  The  alkalinity  of  the  saliva  is 
in  proportion  to  the  amount  of  ash 
therein.  As  the  amount  of  ash  in- 
creases, and  as  the  rapidity  of  the  secre- 
tion is  enhanced,  the  alkalinity  grows 
more  marked.  The  digestive  power  of 
the  saliva  is  proportionate  to  the 
amount  of  organic  matter  therein.  The 
digestion  of  starch  by  the  parotid  se- 
cretion, after  it  reaches  the  stomach,  is 
possible  in  proportion  to  the  alkalinity 
of  the  saliva.  The  action  of  ptyalin  in 
the  stomach  is  only  possible  during  the 
beginning  and  the  final  stages  of  di- 
gestion. At  the  acme  of  gastric  di- 
gestion, when  the  free  hydrochloric  acid 
is  abundant,  the  action  of  the  saliva  is 
only  possible  when  there  are  large 
amounts  of  highly  alkaline  saliva  in  the 
stomach.  The  influence  of  saliva  in  the 
digestion  of  proteids  reduces  itself  to 
a  dilution  of  the  hydrochloric  acid  of  the 
gastric  juice,  and  in  disease  makes  hypo- 
acidity worse,  while  it  tends  to  make  hy- 
peracidity less  severe.  E.  A.  Zher- 
bovski  (Eoussky  Vratch,  March  5,  1905; 
New  York  Medical  Journal  and  Phila- 
delphia Medical  Journal,  April  29, 
1905). 

PLEURAL  AND  CEREBRO-SPINAL  FLUIDS, 
CYTODIAGNOSIS  OF. 
In  pleural  effusions  the  cytological 
formulas  stated  by  Widal  and  Ravant 
hold  good  in  the  great  majority  of  cases. 
An  excess  of  lymphocytes  indicates  gen- 
erally  a  tubercular  origin;  a  preponder-' 
ance  of  polymorphonuclear  cells  an  in- 
flammatory process,  due,  for  instance,  t" 
a  pneumococcal  or  streptococcal  infec- 
tion. A  passive  or  mechanical  transuda- 
tion contains,  as  a  rule,  a  large  number 
of  endothelial  cells.     It  must  be  borne 


270        PNEUMONIA,  CARBONATE  OF  CREOSOTE  IN. 


POTT'S  DISEASE. 


iii  mind,  however,  that  especially  in  the 
earlier  stages  of  tubercular  effusions,  de- 
partures from  the  rule  frequently  occur. 

The  cerebrospinal  fluid  in  meningitis 
of  tubercular  origin  usually  shows 
lymphocytosis,  while  in  inflammatory 
states  caused  by  the  meningococcus  of 
Weichselbaum,  the  pneumococcus  or 
streptococcus,  and  in  posterior  basic 
meningitis  it  is  characterized  by  an  ex- 
cess of  polymorphonuclear  cells.  Many 
discordant  results,  however  due  it  may 
be  in  some  cases  to  a  secondary  infec- 
tion, have  been  recorded.  Cytological 
examinations  may  thus  help  us,  not  only 
in  differentiating  the  various  kinds  of 
meningitis,  but  also  in  distinguishing 
meningitis  from  such  conditions  as  the 
cerebral  irritation  of  typhoid  fever  and 
other  infectious  diseases,  from  tetanus, 
and  hysterical  pseudo-meningitis,  in 
which  there  is  no  increase  of  cells  in  the 
cerebro-spinal  fluid. 

The  presence  of  lymphocytosis  is 
almost  constant  in  general  paralysis  of 
the  insane,  in  tabes  dorsalis,  in  syphilitic 
diseases  generally  of  the  central  nervous 
system,  and  may  be  useful  for  diagnostic 
purposes  in  distinguishing  these  diseases 
from  other  affections  more  or  less  re- 
sembling them.  General  paralysis  and 
tabes  promise  to  be  diagnosed  even  in 
early  stages  by  the  use  of  cytological 
examinations,  as  shown  by  Maillard. 
The  importance  of  early  antisyphilitic 
treatment  in  these  diseases  is  generally 
acknowledged,  and  cytology  would  seem 
to  afford  the  means  of  making  an  early 
diagnosis. 

The  author  contends  that  in  no  case 
should  a  diagnosis  be  based  wholly  on 
the  result  of  the  cytological  examina- 
tion, but  this  should  form  merely  a 
valuable  link  in  the  chain  of  clinical  evi- 
dence. As  in  ordinary  blood  examina- 
tion, the  great  importance  of  making 


more  than  one  cytological  count  of  the 
pleural  or  cerebro-spinal  fluid,  whenever 
this  is  possible,  is  emphasized.  Edward 
Turton  (Practitioner,  April,  1905). 

PNEUMONIA,    CARBONATE    OF   CREOSOTE 
IN. 

Creosotol  is  of  decided  value  in  both 
the  bronchial  and  lobar  forms  of  pneu- 
monia, but  response  is  more  prompt  in 
the  bronchial  varieties.  Children  re- 
spond more  promptly  than  adults. 
Mild  cases  seen  early  are  practically  well 
in  twenty-rour  hours.  In  severe  cases 
there  is  usually  a  response  within 
twenty-four  hours  and  normal  condi- 
tions are  reached  in  from  two  to  five 
days  by  lysis.  Complications  are  rare, 
and  if  present  are  mild.  Convalescence 
is  shortened,  the  return  to  health  being 
remarkably  rapid.  C.  P.  Stackhouse 
(Pennsylvania  Medical  Journal,  April, 
1905). 

POTT'S  DISEASE,  TREATMENT  OF. 

In  speaking  of  the  non-surgical 
methods  in  treating  Pott's  disease,  the 
author  says  that  the  old  routine  of  giv- 
ing codliver-oil  and  iodides  is  not  to  be 
commended,  as  it  does  not  give  good  re- 
sults, and  is  apt  to  produce  disturbances 
of  digestion.  He  prefers,  above  all,  the 
use  of  hydrotherapy  in  the  form  of  cold 
sponging.  This  method  increases  the 
appetite,  promotes  nutrition,  and  the 
general  development  of  the  child,  as 
well  as  the  formation  of  new  blood  cells. 
In  five  cases  reported,  the  writer  came 
across  abscesses,  of  which  one  healed 
spontaneously;  one  had  to  be  opened 
widely,- and  the  rest  were  punctured  by 
means  of  Plessi's  cannula.  In  all  cases 
local  healing  followed.  He  prefers 
puncture,  with  lavage  of  the  cavity,  to 
all  other  methods  of  treating  abscesses 
of  Pott's  disease.     The  operation  is  easy 


PROSTATE'  TOW  V,  PERINEAL. 


PUERPERAL  FEVER. 


271 


and  harmless.  The  antiseptic  liuid  to 
be  used  should  be  mild,  such  as  salicylic 
acid,  1  part  in  1000.  The  pressure  to 
be  employed  in  injecting  it  should  be 
sufficient  to  distend  the  walls  of  the  sac. 
The  injections  of  iodine,  iodoform,  oil, 
etc.,  are  useless.  Hydrotherapy  acts 
not  only  by  its  antiphlogistic,  but  also 
by  its  special  stimulating  effects  on  the 
spinal  nerve  roots.  The  author  thinks 
that  it  should  be  used  always  in  Pott's 
disease,  except  in  those  acute  cases  in 
which  there  is  high  fever  and  great 
pain,  and  in  which  immobility  is  de- 
manded. Arturo  Campani  (Riforma 
Medica,  April  8,  1905;  Xew  York  Medi- 
cal Journal  and  Philadelphia  Medical 
Journal,  May  20,  1905). 

PROSTATECTOMY,    CONSERVATIVE    PERI- 
NEAL. 

After  about  200  operations  on  ac- 
count of  hypertrophied  prostate,  among 
which  were  85  Bottini  operations  with  6 
deaths,  20  superapubic  prostatectomies 
with  3  deaths,  the  author  has  come  to 
the  conclusion  that  for  most  cases  peri- 
neal prostatectomy  is  the  safest  and 
surest  and  quickest  method  of  curing 
the  patient.  Whereas,  the  Bottini 
method  is  the  simplest  and  quickest  for 
a  certain  limited  number  of  cases,  which 
can  best  be  determined  by  the  eysto- 
scope,  it  is  not  so  safe,  and  nothing  like 
so  uniformly  sure  of  relieving  the  ob- 
struction as  the  perineal  enucleation. 
The  suprapubic  route  may  be  used  in 
certain  large  intravesical  Lobes. 

The  recognition  of  diverticula,  incar- 
cerated calculi,  pedunculated  prostatic 
outgrowths,  and  early  carcinoma  of  the 
prostate  cannot  be  made  without  the 
cystoscope,  and  an  accurate  mapping  out 
of  the  prostatic  enlargements  is  of  greal 
advantage  in  performing  a  perinea]  op- 
eration  where    careful    [(reservation    of 


important  and  non-obstructive  struc- 
tures is  the  aim  of  the  operator.  EL  H. 
Young  (Annals  of  Surgery,  April,  1905). 

PROSTATIC  ENLARGEMENT. 

The  general  practitioner  should  be 
prepared  at  least  to  make  a  rectal  ex- 
amination of  the  prostate  whenever 
symptoms  point  to  that  region,  and  if 
hypertrophic  changes  are  found,  and 
after  careful  treatment  if  the  tumor 
does  not  diminish  in  size,  surgical  inter- 
vention should  be  advised  and  insisted 
upon. 

If  infection  has  not  preceded  catheter 
life,  it  is  sure  to  follow.  In  this  condi- 
tion the  patient's  life  is  most  pitiable. 

Early  prostatic  operations  are  not 
dangerous;  late  ones  are  always  dan- 
gerous, and  frequently  fatal.  The  gen- 
eral practitioner  has  the  fate  of  the 
prostatic  in  his  hands,  either  to  guide 
him  oyer  his  trouble,  or  to  advise  him  to 
continue  a  life  of  miserable  suffering 
which  intensifies  itself  toward  the  end. 
C.  E.  Barnctt  (American  Medicine, 
April  8,  1905). 

PUERPERAL    FEVER,    CLINICAL    ASPECTS 
OF. 

The  writer  defines  puerperal  fever  as 
a  disease  which  results  from  the  inocula- 
tion of  wounds  witli  pathogenic  organ- 
isms. Puerperal  ulcers  may  be  present 
upon  the  vagina!  mucous  membrane, 
with  False  membrane  and  fever.  Hos- 
pital gangrene,  with  fever  -and  prostra- 
tion, is  now  rarely  seen.  Spreading 
traumatic  gangrene  is  also  rare.  It  is 
accompanied  with  false  membrane  and 
suppurative  inflammation  of  the  veins, 
lymphatics,  and  muscular  structure  of 
the  uterus.  It  quickly  extends  to  other 
tissues  and  Is  usually  fatal.  Sapramiia 
is  a  local  poisoning  which  disappears 
when   the   infecting   cause    is    removed. 


272 


PUERPERAL  SEPTICEMIA. 


RHEUMATOID  ARTHRITIS. 


Septicaemia  means  the  entrance  of  toxic 
microbes  into  the  blood  with  intense  sys- 
temic disturbance.     It  is  usually  quickly 
fatal.       Pyaemia    usually    results    from 
uterine  phlebitis.     Fever  is  intense,  and 
there    arc    many    secondary    abscesses. 
Death  is  the  usual  result.      Peritonitis 
quickly  follows  delivery,  from  direct  in- 
jury, from  the  extension  of  endometritis 
or  from  extension  of   inflammation  of 
the   pelvic   cellular   tissue   and   uterine 
muscular  tissue.      It  is  usually  quickly 
fatal.      Late  peritonitis  may  be  caused 
by  substances  retained  in  the  uterus,  by 
the  extension  of  gonorrhoea,  or  by  the 
injury  to  a  pre-existing  tumor  or  abscess 
during  labor,   the   inflammatory   symp- 
toms  being   deferred   until   a   week   or 
longer   from   the   occurrence    of   labor. 
Pelvic  cellulitis  usually  develops  rapidly 
to  peritonitis,  and  may  be  quickly  fatal 
or  it  may  result  in  a  chronic  condition 
resulting  in  absorption  or  suppuration, 
surgical    interference   being    eventually 
required  in  the  latter  case.      Herman 
(Practitioner,  March,  1905). 

PUERPERAL    SEPTICEMIA,    PREVENTION 
OF. 

In  puerperal  septicaemia  the  lym- 
phatics are  invaded  by  microbes  con- 
veyed on  the  fingers  of  the  attendant  or 
from  the  patients'  uncleansed  external 
genitals.  Infection  may  also  arise  from 
pre-existing  disease  in  the  uterus  or  its 
appendages.  Preventive  measures  con- 
sist: 1.  In  avoidance  of  infection  by 
clean  hands  with  or  without  gloves.  2. 
In  cleansing  the  external  genitals.  3. 
In  avoiding  laceration  by  skillful  con- 
duct during  the  labor.  4.  In  avoiding 
uterine  manipulation  to  separate  the 
placenta,  which  docs  not  exclude  ma- 
nipulation during  hemorrhage.  5.  In 
general  hygienic  care  during  pregnancy. 


A  vaginal  douche  may  be  given  at  the 
end  of  labor,  but  subsequently  cleansing 
should  be  accomplished  with  cotton 
moistened  in  bichloride  solution.  Puer- 
peral infection  is  preventable,  and 
should  be  prevented  by  conscientious  in- 
dividual effort.  Berry  Hart  (Prac- 
titioner, March,  1905). 

RHEUMATOID      ARTHRITIS      AND      RAY- 
NAUD'S DISEASE. 

The  so-called  "dead"  fingers,  local 
syncopes,  and  asphyxias  are  often  pre- 
cursors or,  so  to  speak,  prodromal  symp- 
toms of  rheumatoid  arthritis.  They  are 
not  invariably  present  before  peri- 
articular swellings  occur,  and  in  some 
cases  they  appear  to  arise  contem- 
poraneously with  the  joint  swellings; 
but  the  fact  still  remains  that  people 
who  suffer  with  them  are  likely  to  de- 
velop rheumatoid  joints,  especially  if 
exposed  to  any  infection — sore  throats, 
influenza,  etc. 

The  diverse  etiology  of  Raynaud's  dis- 
ease and  rheumatoid  arthritis  teaches 
that  both  these  disorders  are,  as  a  rule, 
secondary  to  some  other  disorder;  in 
other  words,  that  they  are  both  of  them 
symptoms  complex.  This  supplies  us 
with  a  therapeutic  indication,  namely, 
that  in  any  given  case,  if  such  vasomotor 
phenomena  present  themselves,  a  search 
should  be  made  for  some  concurrent  dis- 
order, and  treatment  directed  thereto. 
Unfortunately,  in  many  cases  no  source 
of  toxaemia  can  be  discovered,  but  the 
author  would  emphasize  the  importance 
of  treating  gastro-intestinal  disorders 
and  uterine  affections.  Macalister  lays 
great  stress  upon  affections  of  the  nasal 
mucous  membrane,  and  cites  cases  in 
support. 

In  cases  of  rheumatoid  arthritis 
where  such  prodromal  vasomotor  phe- 


RINGWORM  OF  SCALP. 


SEPTIC  PERITONITIS. 


273 


riomena  have  been  absent,  others  may 
take  their  place,  such  as  those  pertain- 
ing to  the  muscular  sphere — sudden 
weakness,  painful  cramps  and  muscular 
atrophy;  in  others,  sensory  phenomena 
predominate,  namely,  definite  neuralgic 
pains  or  paresthesias. 

One  important  feature  of  all  these 
prodromata  is  their  tendency  to  be  more 
marked  in  those  extremities  which  af- 
terward become  the  seat  of  peri-articu- 
lar swellings. 

Eealizing  the  intractable  nature  of 
rheumatoid  arthritis  when  well  marked, 
too  much  stress  cannot  be  laid  upon  any 
symptoms,  which,  though  apparently 
trivial  in  themselves,  may  give  timely 
warning  and  enable  us  possibly  to  avert 
the  development  of  rheumatoid  ar- 
thritis. K.  L.  Jones  (Birmingham 
Medical  Review,  April,  1905). 

RINGWORM  OF  THE  SCALP,  TREATMENT 
OF. 

The  writer's  preference  in  the  treat- 
ment of  ringworm  of  the  scalp  is  for  the 
croton-oil  treatment,  which  is  the  most 
certain  and  effective  of  all.  Attention 
is  called  to  the  fact  that  it  requires  most 
careful  control  and  cannot  be  left  to  in- 
experienced hands.  As  practiced  by 
him,  it  consists  in  the  daily  application 
of  an  ointment  which  contains  1  drachm 
of  croton  oil  to  1  ounce  of  a  suitable 
base.  It  may  be  used  oftener  than  once 
a  day  if  necessary  to  produce  a  suitable 
degree  of  inflammation.  The  treat- 
ment must  be  continued  until  all  the 
diseased  hair  stumps  have  fallen  away 
or  have  been  epilated.  The  tissues  are 
kept  scrupulously  clean,  and  crusts  are 
not  allowed  to  form.  For  the  treat- 
ment of  residual  and  isolated  stumps 
there  is  no  method  which  will  compare 
with  croton-oil  needling.  T.  C.  Fox 
(Practitioner,  April,  1905). 


ROENTGEN  RAYS  AND  STERILITY. 

Attention  is  called  to  the  fact  that 
abrogation  of  spermatogenesis  has  been 
found  to  occur  among  those  who  have 
worked  much  in  an  x-ray  atmosphere. 
It  is  not  known  as  yet  to  what  degree 
and  kind  of  x-ray  exposure  the  worker 
of  average  age  and  health  must  have 
experienced  before  this  condition  re- 
sulted, or  whether  there  is  a  gradually 
progressive  tendency  from  the  first  or 
a  sudden  climax  after  some  particularly 
long  and  intense  action  of  the  rays. 
The  cases  examined  show  that  all  who 
have  been  working  at  x-rays  as  a 
specialty  for  years,  whether  physicians 
or  artisans  in  electrical  apparatus,  suffer 
with  this  condition.  The  question  of 
prognosis  is  of  great  importance,  but 
upon  this  point  the  authors  are  not  yet 
prepared  to  report.  Brown  and  Osgood 
(Archives  of  the  Roentgen  Rays,  March, 
1905). 

SEPTIC  PERITONITIS,  GENERAL. 

An  early  diagnosis  and  immediate 
operation  are  urged  by  the  writer.  Free 
flushing  of  the  abdominal  cavity  with  re- 
moval of  all  poison  possible  is  of  great- 
est importance  when  the  infection  is 
general.  An  elevated  position,  drain- 
ing the  contents  of  the  abdomen  into 
the  pelvis,  the  point  of  greatest  resist- 
ance, is  of  great  benefit.  In  profoundly 
septic  cases  in  which  general  infection 
is  present  adhesions  form  slowly,  allow- 
ing frequenl  subsequent  flushing  of  the 
abdominal  cavity  with  hot  salt  solution, 
which  does  no  harm  and  aids  materially 
by  removing  large  quantities  of  toxic 
material  from  the  abdomen.  The  sub- 
cutaneous or  intravenous  dose  of  salt 
solution  is  valuable  in  that  it  dilutes  the 
poison,  lessens  the  toxaemia,  and  stimu- 
lates the  kidneys  to  free  action.  Free 
catharsis    should    be    obtained    at    the 


274         SPONDYLOSE  RHIZOMYELIQUE. 


SYPHILTS  AND  LONGEVITY. 


earliest  possible  moment,  and  should  be 
kept  up  during  the  entire  convalescent 

period,  thereby  aiding  in  the  elimina- 
tion of  much  septic  material  which  has 
been  cast  into  the  bowel  and  which 
would  be  reabsorbed  if  let  alone.  Fur- 
thermore, troublesome  adhesions  are 
less  liable  to  form  if  the  bowel  is  kept 
active.  The  use  of  some  cathartic  salt 
in  the  water  used  for  washing  out  the 
stomach  aids  materially  in  establishing 
peristalsis.  1.  B.  Perkins  (Denver 
Medical  Times,  April,  1905). 

SPONDYLOSE  RHIZOMYELIQUE. 

Ankylosis  and  rigidity  of  the  spinal 
column  is  a  frequent  manifestation  of 
advanced  rheumatoid  arthritis.  It  may 
develop  early  in  the  course  of  the  disease 
and  be  associated  with  irritative  root 
symptoms.  If  the  disease  described  by 
von  Bechterew  is  to  be  considered  as  a 
distinct  clinical  entity  separate  from 
rheumatoid  arthritis,  it  should  only  be 
diagnosticated  as  such  after  the  disease 
has  progressed  over  a  considerable  pe- 
riod of  time  without  involving  joints 
oihcr  than  those  of  the  spinal  column. 
D.  J.  McCarthy  (New  York  Medical 
Journal  and  Philadelphia  Medical  Jour- 
nal, April  8,  1905). 

SUPRARENIN  GLYCOSURIA,  EFFECT  OF 
FEVER,  INFECTION,  AND  RENAL 
INJURY   ON. 

A  series  of  experiments  were  under- 
iaken  by  the  authors  to  throw  light  on 
the  still  very  obscure  conditions  con- 
trolling the  excretion  of  glucose  by  dia- 
betes, in  fever,  during  the  conrse  of  in- 
tercurrent infections,  'etc.  Rabbits 
were  used  as  experiment  animals,  and 
the  glycosuria  produced  by  suprarenii] 
injections  was  studied  after  the  tem- 
perature had  been  artificially  raised  by 
injury  to  the  corpus  striatum,  after  can- 
tharadin  or   streptococcus   bouillon   in- 


jections, and  temporary  ligation  of  the 
renal  arteries.  The  results  showed  that 
the  effect  of  the  artificially  produced 
fever  on  the  sugar  excretion  is  variable 
and  docs  not  as  yet  permit  of  satisfac- 
tory conclusions.  Bacterial  infection 
causes  diminution  of  the  glycosuria  only 
when  the  suprarenin  is  injected  shortly 
before  death,  perhaps  owing  to  accom- 
panying renal  lesions.  The  sugar  ex- 
cretion is  regularly  reduced  or  caused  to 
disappear  if  the  renal  functions  are  in- 
terfered with,  as,  for  example,  by  the 
temporary  ligation  of  the  renal  arteries. 
Neither  these  results  nor  those  obtained 
on  dogs  having  experimental  pancreatic 
diabetes  can  be  directly  transferred  to 
human  pathology,  but  they  indicate  the 
importance  of  observations  on  sugar  re- 
tention in  diabetics  with  diseased  kid- 
neys, and  it  is  to  be  hoped  that 
clinicians  will  interest  themselves  in 
this  field.  Ellinger  and  Seelig  (Miinch- 
ener  medicinische  Wochenschrif  t,  March 
11,  1905). 

SYPHILIS  AND  LONGEVITY. 

Syphilis,  like  unmodified  variola  and 
tuberculosis,  may  destroy  life.  In  its 
gravest  expression,  when  not  destructive 
of  life,  it  may  disfigure  and  mutilate 
the  human  body  to  a  formidable  extent. 
The  disease  should  be  counted  among 
the  dangerous  scourges  of  the  human 
family.  Once  in  the  presence  of  infec- 
tion,  neither  physician  nor  patient  can 
afford  to  neglect  skillful,  energetic,  and 
prolonged  treatment,  with  a  view  to  set- 
ting aside  the  possibilities  of  future 
danger. 

In  the  case  of  inherited  syphilis,  the 
fatality,  working  destruction  alike  of 
ovum,  foetus,  and  infant,  varies  between 
80  and  90  per  cent,  of-  the  infected.  The 
mortality,  exceding  that  resulting  from 
any  of  the  great  plagues  of  the  human 


SYPHILIS  AND  LONGEVITY. 


275 


race,  is  due  to  the  unprotected  condition 
of  the  embryo. 

By  reason  of  the  absence  of  trust- 
worthy statistics,  the  percentage  of  fa- 
tality in  acquired  syphilis,  where  the 
germ  of  the  disease  is  implanted  upon  a 
previously  sound  organism,  cannot  he 
accurately  determined.  Estimates  based 
upon  clinical  records  furnished  in  the 
larger  cities  of  the  United  States, 
coupled  with  the  facts  detailed  in  the 
volumes  of  vital  statistics  published  by 
the  United  States  Census  Bureau,  make 
it  appear  probable  that  the  fatality  in 
such  acquired  disease  is  represented  by 
less  than  2  per  cent. 

The  fatality  in  acquired  syphilis  re- 
sults less  often  from  the  active  invasion 
of  the  disease  than  from  an  entailed  loss 
of  resistance,  by  reason  of  which  com- 
mon agencies  of  disease  produce  serious 
effects,  especially  in  the  nervous  system. 

The  efficient  factors  in  the  production 
of  these  effects  are  fairly  well  under- 
stood. They  include  chronic  alcohol- 
ism, long-continued  tobacco  narcosis,  ex- 
treme fatigue,  severe  affliction,  the  mal- 
nutrition that  may  result  from  poverty, 
and  the  stress  and  strain  endured  by  the 
nervous  centers  in  the  anxieties  of  busi- 
ness. In  the  absence  of  these  efficient 
factors  in  the  production  of  the  grave 
conditions  which  may  follow  syphilis, 
the  skillful  management  of  that  disease, 
may  terminate  with  brilliant  results  in 
from  75  to  SO  per  cent,  of  acquired 
cases. 

The  damage  wrought  by  syphilis  is 
not  to  be  measured  solely  by  its  lethal 
issues,  though  these  are  of  chief  concern 
to  the  life  insurance-actuary.  The  low- 
ering of  the  standard  of  average  health 
wrought  by  the  inroads  of  Hie  malady, 
often  appreciable  in  the  skin,  hones. 
testes,  liver,  and  other  organs,  and  the 
moral  results  of  the  acquisition  of  the 


disease  popularly  described  as  "loath- 
some," may  jeopard  the  best  play  of  the 
body  functions,  pave  the  way  for  the  in- 
roads of  other  toxins,  and  possibly  lay 
the  foundation  for  mental  degeneration, 
alienation,  and  even  suicide. 

The  expectation  of  life  after  acquisi- 
tion of  syphilis  is  based  in  part  only 
upon  the  tendencies  of  the  morbid 
process.  Such  expectation  is  in  large 
measure  affected  by  the  inherited  ten- 
dencies, the  habits  of  life,  and  the  en- 
vironment of  the  individual.  The  lon- 
gevity prospects  are  unquestionably  bet- 
ter for  women  than  for  men,  by  reason 
of  the  relative  placidity  of  existence  of 
the  former. 

Briefly,  the  medical  examiner,  con- 
fronted with  a  history  of  syphilis  in  an 
applicant  for  life  insurance,  should  be 
influenced  in  acceptance  or  rejection  of 
the  risk  not  merely  by  the  historical 
facts  of  the  case,  including  the  character 
of  the  symptoms  exhibited,  and  the  du- 
ration of  time  since  the  last  objective 
manifestations  of  the  disorder  were  re- 
corded, but  especially  by  the  reasons 
which  would  lead  to  his  acceptance  or 
rejection  of  applicants  giving  a  history 
of  other  enfeebling  maladies. 

The  ideal  applicant  for  life  insurance 
who  has  suffered  from  syphilis  should 
have  had  active  and  unmistakable  symp- 
toms of  that  disease  early  in  life  ;  should 
have  had,  after  efficient  treatment, 
several  years  of  exemption  from  all  evi- 
dence of  infection;  should  have  an  ex- 
cellent family  history,  free  in  particular 
from  instances  of  nervous  diseases  af- 
fecting immediate  relatives:  and  should 
be  leading,  and  have  led,  a  life  relatively 
free  from  strain,  stress,  and  excess  of 
all  kinds,  including  indulgence  in  alco- 
hol, tobacco,  or  other  of  the  narcotico- 
stimulants.  J.  N.  Hyde  (Medicine, 
April,  1905). 


276 


TAPEWORM,  TREATMENT  OF. 


TETANUS  AND  QUININE. 


TAPEWORM,  TREATMENT  OE. 

The  author  slights  the  preliminary- 
preparation  of  the  patient  and  uses  a 
much  smaller  close  of  the  vermifuge 
than  some  consider  necessary.  He  gives 
from  5  to  8  grams  of  extract  of  male 
fern  in  the  morning,  fasting.  Six  hours 
later — not  before — he  gives  the  purga- 
tive, preferring  a  "bitter  water"  for  the 
purpose.  Otl  is  liable  to  promote  the 
absorption  of  the  fern  extract,  and  calo- 
mel is  unreliable  in  these  cases.  Several 
instances  are  related  to  show  the  success 
of  this  simple  technique  after  the  fail- 
ure of  ten  or  more  previous  "tapeworm 
treatments."  When  the  patient  vomits 
easily,  he  pours  the  extract  into  the 
stomach  in  the  form  of  a  thin  gum 
arabic  emulsion.  In  one  instance  mor- 
phine was  injected  at  the  Same  time.  I. 
Boas  (Therapeutische  Monatshefte,  vol. 
xviii,  No.  12;  Journal  of  the  American 
Medical  Association,  April  22,  1905). 

TENDON  TRANSPLANTATION. 

Tendon  transplantation,  alone  or  com- 
bined with  arthrodesis  or  other  bone 
operations,  offers  prospects  of  materially 
adding  to  the  comfort,  convenience,  and 
usefulness  of  a  very  large  class  of  pa- 
tients otherwise  more  or  less  dependent 
upon  forms  of  mechanical  apparatus. 
The  frequently  observed  improvement 
in  the  action  of  muscles  that  previous  to 
operation  gave  evidence  of  being  para- 
lyzed or  atrophied  from  disuse  shows  the 
capabilities  of  restoration  when  the  of- 
fending abnormalities  have  been  re- 
moved. It  is  impossible  to  estimate 
properly  what  the  future  development 
in  a  given  case  will  be.  The  cooper- 
ative, intelligent  care  of  the  patient 
must  be  depended  upon  in  securing  the 
best  permanent  results. 

Museles  cannot  develop  when  they  are 
used   to  excess  or  are  under  constant 


strain.  The  atrophy  from  disuse, 
whether  caused  by  tension  or  relaxation, 
often  presents  all  of  the  appearances  of 
paralysis.  The  avoidance  of  overstrain 
upon  incapable  muscles  is  often  de- 
manded so  that  the  minimum  muscle 
force  may  accomplish  the  maximum  of 
action. 

The  after-treatment  is  fully  as  im- 
portant as  the  surgical  procedure,  and 
must  be  given  prolonged  consideration 
in  order  to  accomplish  the  best  ultimate 
results.  Arthrodesis  alone  possesses 
advantages  in  cases  incapable  of  benefit 
from"  tendon  transplantation.  Various 
forms  of  osteotomy,  osteoclasis,  and 
other  bone  operations  are  available  for 
the  removal  of  deformity  and  for  the 
prevention  of  undue  strain  upon  the 
soft  parts  around  a  joint.  H.  A.  Wil- 
son (American  Medicine,  April  8,  1905). 

TETANUS  AND  QUININE. 

The  writer's  attention  was  attracted 
to  the  number  of  cases  that  have  been 
reported  in  which  tetanus  followed  an 
injection  of  quinine  under  aseptic  pre- 
cautions. He  has  been  experimenting 
and  reports  that  quinine  injected  into 
rabbits  at  the  same  time  or  following 
inoculation  with  tetanus  germs,  had  an 
unmistakable  action  in  favoring  the  de- 
velopment of  the  tetanus.  This  action 
was  both  local  and  general.  As  an  in- 
stance he  mentions  that  inoculation  with 
tetanus  on  the  other  side  of  the  body 
from  an  injection  of  quinine,  was  fol- 
lowed by  symptoms  of  tetanus,  and  the 
germs  were  found  congregated,  not  at 
the  point. of  inoculation,  but  at  the  point 
where  the  quinine  had  been  injected,  on 
the  other  side  of  the  body.  This  favor- 
able action  occurs  apparently  only  when 
the  quinine  is  injected  subcutaneously. 
The  facts  related  suggest  that  when  an 
injection  of  quinine  is  to  be  made  in  a 


THIERSCH'S  SKIN  GRAFTING. 


TOURNIQUET,  DANGERS  OF. 


277 


person  who  has  any  sores  or  excoriations 
liable  to  shelter  or  allow  the  entrance 
of  the  tetanus  bacillus,  it  would  be  wise 
to  inject  antitetanus  serum  at  the  same 
time.  E.  Vincent  (Annales  de  lTnsti- 
tut  Pasteur,  vol.  xviii,  No.  12;  Journal 
of  the  American  Medical  Association, 
May  20,  1905). 

THIERSCH'S  SKIN  GRAFTING,  MODIFICA- 
TION OF. 

While  fully  recognizing  the  superior- 
ity of  Thiersch's  method  of  skin  graft- 
ing over  the  older  methods  of  Reverden, 
the  writer  holds  that  in  cases  of  old  and 
healing  wounds  it  is  quite  unnecessary 
and,  indeed,  disadvantageous,  to  carry 
out  the  former  surgeon's  practice  of 
scraping  away  the  granulations,  and  of 
applying  the  large  and  thin  flaps  of  skin 
to  a  raw  and  bleeding  surface.  In  the 
course  of  the  last  eight  years  the  writer 
has  applied  Thiersch's  skin  flaps  di- 
rectly to  intact  granulating  surfaces, 
with  result  that  could  not  possibly  have 
been  improved'  had  he  removed  the 
granulations.  The  condition  for  suc- 
cess in  such  practice  are  a  easeful  and 
prolonged  aseptic  dressing  of  the  wound 
and  surrounding  skin  and  a  healthy  con- 
dition of  the  open  surface,  indicated  by 
small,  ruddy,  and  firm  granulations. 
The  author  insists  on  the  importance  of 
keeping  the  flaps  of  skin  in  position  by 
gauze  attached  to  the  surrounding  parts, 
of  collodion,  and  of  frequent  application 
over  the  gauze  of  boric-acid  fomenta- 
tions. After  the  eighth  day,  when  the 
transplanted  flaps  have  usually  become 
attached,  the  dry  and  covered  wound  is 
powdered  with  euphorin,  and  protected 
by  layers  of  dry  gauze  and  cotton  wool. 
The  objections  to  Thiersch's  practice  of 
removing  granulations  are  the  pain 
caused  by  this  part  of  the  operation, 
the  loss  of  time  in  stopping  the  haemor- 


rhage, and  the  delay,  due  to  exudation, 
in  the  establishing  of  vascular  connec- 
tions between  the  raw  surface  and  the 
flaps  of  skin.  Isnardi  (Zentralblatt  fiir 
Chirurgie,  No.  14,  1905;  British  Medi- 
cal Journal,  May  6,  1905). 

THYROID    GLAND;     INFLUENCE   OF   DIET 
ON  ITS  STRUCTURE  AND  FUNCTION. 

The  writer's  object  is  to  show  that 
different  diets  may  cause  histological 
changes  in  various  organs  and  alteration 
in  their  functional  activity;  this  being 
especially  true  of  the  thyroid  gland. 
Two  series  of  experiments  were  per- 
formed, one  on  fowls,  the  other  on  rats. 
The  conclusions  which  were  reached 
were:  (1)  An  excessive  meat  dietary 
induces  distinct  structural  changes  in 
the  thyroid  gland;  (2)  these  changes 
must  be  associated  with  a  modification 
of  the  functional  activity  of  the  gland. 
As  to  the  nature  of  the  modification  this 
diet  may  cause :  (1)  Excessive  activity 
of  the  gland  followed  by  diminished  ac- 
tivity, or  even  exhaustion,  of  its  func- 
tion; (2)  diminished  activity  from  the 
outset;  (3)  alteration  in  the  quality  of 
the  secretion,  a  persistent  secretion. 
The  clinical  application  of  these  data  to 
the  English  people,  with  whom  the 
quantity  of  meat  consumed  per  capita 
has  increased  greatly  since  1875,  is  that 
as  a  result  of  an  excessive  meal  dietary 
there  lias  been  established  in  many  in- 
dividuals a  change  in  the  character  of 
the  thyroid  secretion.  When  this 
change  takes  the  form  of  a  simple  defi- 
ciency of  the  thyroid  secretions  the  de- 
fect can  be  remedied  by  administration 
of  thyroid  extract.  Watson  (Archives 
of  the  Roentgen  Kay,  April,  1905). 

TOURNIQUET,  DANGERS  OF  THE. 

Three  instances  of  serious  injury  re- 
sulting from  the  application  of  the  Es- 


278 


TUBERCULOSIS,  ADAPTATION  AND. 


inarch  bandage  to  arrest  haemorrhage 
after  an  accident  are  related  hy  the 
writer.  In  one  case  the  tourniquet  had 
been  applied  very  tightly  and  left  for  a 
day  and  a  half  above  the  severed 
brachial  artery.  There  had  been  con- 
siderable haemorrhage,  and  the  patient, 
a  robust  young  man,  soon  succumbed. 
The  fatality  may  have  been  due  to  the 
acute  anaemia  alone,  but  there  is  a  pos- 
sibility that  the  products  of  decomposi- 
tion after  ligation  of  the  artery  may 
have  induced  intoxication  of  the  organ- 
ism, already  enfeebled  by  the  anaemia, 
when  the  constriction  was  removed. 
The  tourniquet  should  never  be  left  long, 
but  should  be  removed  at  the  earliest 
possible  moment.  It  should  be  applied 
as  close  to  the  wound  as  possible.  In 
two  of  his  cases  the  limb  had  to  be  am- 
putated at  a  much  higher  point  than 
would  have  been  required  by  the  trauma 
alone.  It  should  be  mo/»e  generally  em- 
phasized that  all  the  parts  below  a  tour- 
niquet left  for  more  than  three  hours, 
are  exposed  to  the  great  danger  of  tissue 
death.  Another  important  point  to  be 
borne  in  mind  is  that  the  injured  part 
should  have  all  the  cleansing  manipula- 
tions done  before  the  tourniquet  is  re- 
moved. It  prevents  foreign  matter  and 
fluid  from  being  sucked  into  the  circu- 
lation, and  consequently  they  should  all 
be  cleaned  off  before  the  circulation 
through  the  parts  is  restored.  A.  Ahl- 
berg  (Nordisches  medicinisches  Archiv, 
Stockholm,  vol.  xxxvii,  Surgery,  No.  1; 
Journal  of  the  American  Medical  Asso- 
ciation, April  8,  1905). 

TUBERCULOSIS,  ADAPTATION  AND. 

The  writer  emphasizes  the  fact  that 
in  infectious  diseases  in  general,  while 
the  bacteria  grow  more  particularly  in 
one  organ  or  tissue  the  successful  coun- 
teraction of  the  disease  is  not  a  local 


matter.  In  fact,  the  tissues  of  the  in- 
fected organ  are  so  injured  that  they 
cannot  themselves  play  any  very  active 
part.  The  counteraction  is  by  the  rest 
of  the  organism;  in  part  by  the  leu- 
cocytes developed  in  the  bone  marrow 
and  elsewhere ;  in  part  by  other  tissues, 
which  discharge  into  the  blood  diffusi- 
ble antitoxic  and  bactericidal  sub- 
stances. Particular  attention  is  called 
to  the  recent  observations  of  Wright  and 
Douglas  that  the  phagocytic  activity  of 
the  leucocytes  is  not  called  into  play  to 
any  extent  unless  the  blood  serum  con- 
tains certain  substances  which  activate 
the  leucocytes.  These  substances  ap- 
pear to  be  developed  apart  from  the  leu- 
cocytes, that  is  to  say,  by  other  tissues 
of  the  body.  Applying  these  considera- 
tions to  tuberculosis,  it  is  pointed  out 
that  when  the  tubercle  bacilli  grow  lo- 
cally there  is  a  slow  diffusion  out  of 
their  toxins ;  and  it  is  by  the  adaptation 
of  the  rest  of  the  tissues  to  these  toxins 
that  the  leucocytes  and  these  other 
tissues  become  accustomed  to  produce 
diffusible  antibacterial  substances.  In 
favorable  cases  these  are  present  in 
amounts  so  considerable  that  the  local 
growth  of  the  tubercle  bacilli  is  arrested 
and  healing  tends  to  ensue.  Post- 
mortem observations  show  that  this  ar- 
rest is  the  rule  rather  than  the  excep- 
tion. 

Applying  these  considerations  to  the 
treatment  of  tuberculosis,  it  is  first 
shown  that  the  tuberculin  treatment  is 
but  an  attempt  to  carry  out  the  natural 
process;  that  tuberculin  is  merely  a 
concentrated  extract  of  the  toxins  of  the 
bacilH,  and  these  now  are  injected  into 
the  organism  at  a  distance  from  the  site 
of  local  growth  of  the  bacilli.  Their 
action  must  be  to -stimulate  the  cells  of 
the  rest  of  the  organism,  and  to  produce 
increased  amounts  of  antibacterial  sub- 


TUBERCULOSIS,  RAW  MEAT  IN. 


TUBERCULOSIS,  STOMACH  IN.        279 


stances.     The  cells,  however,  may  be  in 
a  state  of  low  vitality  so  that  they  do 
not  react,  and  hence  this  treatment  is 
by    no    means    constantly     successful. 
Modern  treatment  similarly  is  a  carry- 
ing forward  of  the  same  idea.     The  dis- 
ease as  such  is  left  severely  alone,  every 
attempt  is  made  to  improve  the  general 
tone  of  the  organism  by  rest,  good  food, 
and  fresh  air.      The  cells  gain  improved 
tone  and  respond  to  the  toxins,  produc- 
ing increased  quantities  of  the  antitoxic 
and    antibacterial    substances.      Here, 
again,  it  is  the  body  as  a  whole  and  not 
the  local  reaction  that  brings  about  ar- 
rest of  the  tuberculous  process.      The 
adaptive  processes  on   the  part  of  the 
bacilli  are  next  considered.     These  also 
are  capable  of  being  modified  according 
to  alterations  in  their  environment,  so 
that  by  passage  they  are  found  to  adapt 
themselves  more  and  more  to  the  organ- 
ism of  any  particular  species.      By  pas- 
sage   through    the    organism    of    one 
species    the    bacilli    become    more    and 
more  virulent  for  that  species,  and  thus 
may  become  less  adapted  to  growing  the 
organism  of  another  species.      The  au- 
thor is  of  the  opinion  that  this  is  the 
ease  in  general,  and  with  tubercle  bacilli 
grown  in  the  human  or  bovine  organ- 
isms  respectively  in  particular.      J.  G. 
Adami   (American   Medicine,  April  20, 
1905). 

TUBERCULOSIS,    EFFECT    OF    RAW    MEAT 
ON  NITROGEN  METABOLISM  IN. 

The  experiments  conducted  by  the  au- 
thor tend  to  show  that  cooking  mate- 
rially affects  both  the  absorption  and  re- 
tention of  nitrogen,  in  the  physiologic 
as  well  as  in  the  tuberculous  subject. 
While  the  total  quantity  of  nitrogen 
present  in  the  fasces  on  a  diet  of  raw 
meat  is  increased,  that  increase  is  due 


entirely  to  the  presence  of  collogen ;  the 
soluble  and  digestible  nitrogen  is  ac- 
tually diminished.  Galatin  has  been 
shown  to  be  by  itself  incapable  of  sus- 
taining nitrogen  equilibrium.  The  chief 
points  of  interest  are  that  raw  meat 
causes  an  increased  retention  of  nitro- 
gen, even  with  a  diminished  intake,  and 
it  also  causes  an  improvement  in  intes- 
tinal metabolism,  manifesting  itself  in 
the  form  of  a  diminution  of  the  nitro- 
gen in  the  fa>ces.  Digestive  leucocytosis 
is  invariably  larger  on  a  diet  of  raw 
meat  than  on  a  diet  of  cooked  meat. 
This  may  be  correlated  with  the  in- 
creased nitrogen  retention,  on  the  sup- 
position that  the  digestive  leucocytosis 
is  the  evidence  of  a  functional  activity 
on  the  part  of  the  leucocyte,  the  object 
of  the  activity  being  the  secretion  of  a 
body  to  link  the  absorbed  nitrogen  on 
to  the  tissue  cells.  J.  J.  Galbraith 
(Practitioner,  February,  1905). 

TUBERCULOSIS,  STOMACH  FUNCTION  IN. 

As  a  result  of  the  examination  of  the 
stomach  function  in  26  cases  of  pulmon- 
ary tuberculosis,  the  author  has  found 
a    marked     tendency     to     hypoacidity, 
which   is    frequently   transformed    into 
anachlorhydria.      The  motor  power  is 
undisturbed.      The  first  group  examined 
included   10  eases  early  in  the  disease, 
the  duration  not  exceeding  nine  months. 
In  8  cases  (here  was  a  history  of  stom- 
ach symptoms,  which  in  some  cases  ante- 
dated the  lung  condition  and   in  others 
introduced   or   accompanied    it.       In   -1 
cases     hydrochloric    acid     was    always 
found,  in  1  it  was  always  absent,  in  5 
it.  wa.s  variable.       Peptic   digestion  ami 
tin'  motor  power  seemed  unchanged.    In 
a  second  group  of  11  cases  of  intermedi- 
ate severity  (be  duration  of  the  disease 
was  from  five  months  to  two  years.    Hy- 


280 


TUBERCULOSIS  DEPOSITS  IN  TONSILS. 


TYPHOID  FEVER. 


drochloric  acid  was  present  in  6  cases, 
absent  in  3,  variable  in  1,  and  doubtful 
in  1.  Peptic  digestion  was  undimin- 
ished. In  5  cases  of  advanced  tubercu- 
losis the  qualitative  test  for  free  hydro- 
chloric acid  was  present  once,  absent 
twice,  and  at  times  was  found  in  the  re- 
maining 2  cases.  Peptic  digestion  was 
usually  decreased.  The  acidity  in  the 
first  group  was  about  normal,  but  in  the 
other  two  groups  it  was  markedly  di- 
minished. It  may  be  assumed,  in  cases 
where  previous  dyspepsias  can  be  elimi- 
nated, that  the  digestive  disturbances 
which  introduce  or.  accompany  the  tu- 
berculous process  are  manifestations  of 
the  reaction  of  the  system  to  toxic  pro- 
ducts; a  reaction  analogous,  perhaps,  to 
the  rise  of  temperature  following  the 
administration  of  tuberculin.  J.  E. 
Munson  (New  York  Medical  Journal  and 
Philadelphia  Medical  Journal,  March 
18,  1905). 

TUBERCULOUS    DEPOSITS    IN    THE    TON- 
SILS, SIGNIFICANCE  OF. 

The  tonsillar  tissue  of  the  throat,  be- 
cause of  its  peculiar  anatomic  construc- 
tion and  its  topographical  relations,  is 
more  liable  to  become  infected  by  tuber- 
culosis than  any  other  part  of  the  upper 
respiratory  tract.  In  nearly  all  cases 
of  advanced  pulmonary  phthisis  the 
faucial  tonsils  become  inoculated.  In 
about  5  per  cent,  of  hypertrophied  phar- 
yngeal tonsils  some  form  of  primary  tu- 
berculosis will  be  found.  Primary  in- 
fection of  the  faucial  tonsil  is  a  rare 
condition. 

Tuberculous  adenitis  in  the  cervical 
lymphatics  develops  in  Ihc  majority  of 
cases  from  infection  originating  some- 
times in  the  faucial  tonsils,  but  more 
frequently  in  the  pharyngeal  tonsil. 
The  tubercle  bacillus  is  probably  unable 
to  pass  through  the  tonsils  without  hav- 


ing first  overcome  the  vital  resistance  of 
the  tonsillar  tissue. 

The  danger  of  systemic  or  pulmonic 
infection  resulting  from  a  tuberculous 
lesion  in  the  tonsillar  tissues  of  the 
throat  is  about  equal  to  that  of  tubercu- 
losis of  the  cervical  lymphatics.  The 
lesion  to  be  expected  as  a  resultant  in- 
fection from  the  broken-down  glands  of 
the  neck  is  a  miliary  tuberculosis  of  the 
lungs.  Further  than  this  possibility, 
tuberculosis  of  the  lymph  glands  of  the 
neck  is  no  more  dangerous  than  a  local- 
ized tuberculous  lesion  in  any  other  por- 
tion of  the  body. 

The  tonsils  are  more  resistant  to  the 
action  of  bacterial  toxins  than  ordinary 
lymphoid  tissue.  G.  B.  Wood  (Journal 
of  the  American  Medical  Association, 
May  6,  1905). 

TYPHOID  FEVER,  PERFORATION  IN. 

Perforation  of  the  bowel  in  typhoid 
fever  is  more  common  than  is  generally 
supposed,  occurring  once  and  a  trifle 
over  in  every  three  deaths.  The  most 
common  time  of  perforation  is  between 
the  fourteenth  and  twenty-first  days. 
In  92  per  cent,  of  the  cases  in  this  series 
the  perforation  occurred  between  the 
second  and  fifth  week  inclusive.  The 
earlier  cases  are  probably  perforation  in 
a  relapse;  now  and  then  perforation 
may  occur  without  evidence  of  previous 
illness. 

Perforation  occurs  in  cases  of  all 
grades  of  severity,  from  the  ambulatory 
to  the  hamiorrhagic  type.  It  is  most 
common  in  those  with  moderate  (25  per 
cent.)  and  severe  (50  per  cent.)  infec- 
tion (75  per  cent.).  It  is  not  more  com- 
mon in  the  hamiorrhagic  than  in  the 
mild  cases  (8  per  cent.  each). 

The  ileum  is  the  common  site  of  per- 
foration (8G  per  cent.);  the  majority 
occur  within  twelve  inches  of  the  ileo- 


ULCERATIVE  PROCESS,  CHLOROBROMIDE  OF  SODIUM  IN. 


281 


ca?eal  valve;  the  appendix  and  colon 
respectively  are  the  next  most  frequent 
sites  of  perforation  in  this  series  of 
cases. 

Pain  of  some  kind  is  present  in  75  per 
cent,  of  all  cases.  In  50  per  cent,  of 
the  cases  the  onset  is  sudden  and  severe 
and  of  increasing  intensity,  localizing 
itself  to  a  special  zone.  In  20  per  cent, 
of  the  cases  the  pain  is  of  slow  onset, 
not  localized,  with  general  distribution. 
In  some  cases  (12  per  cent,  of  this 
series)  no  pain  is  complained  of,  and  the 
usual  symptoms  of  perforation  are  ab- 
sent. 

Tenderness  and  rigidity  are  present  in 
from  65  to  75  per  cent,  respectively  of 
all  cases,  and  are  usually  combined;  in 
some  cases  either  one  or  the  other  may 
be  wanting;  rigidity  especially  may  be 
absent  in  cases  with  rather  a  pendulous 
and  relaxed  abdominal  wall. 

When  perforation  is  suspected  the 
temperature  should  be  taken  every 
hour;  only  by  this  means  can  the  im- 
mediate rise  and  slow  fall  to  normal  or 
subnormal,  which  often  occurs,  be  de- 
tected; in  some  cases,  and  especially 
those  of  extreme  toxicity,  no  note- 
worthy change  at  all  in  the  pulse,  tem- 
perature, or  respiration  can  be  detected 
when  perforation  occurs.  Diagnosis  is 
then  only  an  interference. 

Distention  (if  absent  during  the 
course  of  the  disease  and  at  the  time  of 
suspected  perforation)  is  a  late  symptom 
of  perforation.  The  obliteration  of 
liver  dullness  is  not  a  reliable  sign  of 
perforation.  The  study  of  the  leu- 
cocytes is  of  little  aid.  In  a  few  cases 
their  increase  is  such  as  to  assure  you  of 
your  diagnosis.  In  a  considerable  num- 
ber of  cases  there  is  a  decided  reduction 
in  leucocytes  after  symptoms  of  perfor- 
ation. Differential  counting  is  not  of 
practical  use. 


Before  being  assured  of  the  diagnosis 
right-sided  pleurisy,  pneumonia  (es- 
pecially in  the  young),  cholecystitis, 
acute  gastro-intestinal  indigestion,  fem- 
oral and  iliac  thrombosis,  appendicitis, 
peritonitis  without  perforation,  cystitis, 
rupture  of  a  mesenteric  gland,  or  even 
hgemorrhagic  exudation  into  the  ab- 
dominal muscles  (Zenker's  degenera- 
tion) should  be  considered.  Even  then 
mistakes  in  diagnosis  will  be  made. 

While  nature  will  infrequently  close 
one,  two,  or  even  three  perforations,  the 
only  rational  procedure  when  perfora- 
tion occurs  is  operative  interference. 
No  case  is  too  desperate  for  the  at- 
tempt. Not  infrequently  the  so-called 
mild  cases  succumb,  while  very  ill  ones 
recover.  The  diagnosis  made,  time  for 
operation  has  arrived;  its  important 
point  is  rapidity.  Closure  of  the  per- 
foration and  drainage  is  all  that  is 
needed;  fifteen  to  twenty  minutes 
should  suffice.  J.  A.  Scott  (University 
of  Pennsylvania  Medical  Bulletin,  May, 
1905). 

ULCERATIVE      PROCESSES,      CHLOROBRO- 
MIDE OF  SODIUM  IN. 

The  author  advocates  a  solution  of 
chlorobromidc  of  sodium  prepared  as 
follows,  in  the  treatment  of  ulcerative 
processes:  To  a  convenient  quantity  of 
water  add  3  per  cent,  sodium  chloride, 
0.1  per  cent,  bromine  and  0.5  per  cent. 
hydrochloric  acid  (C.  P.).  Subject  this 
mixture  to  the  action  of  an  electrical 
current  until  such  chemical  action  has 
taken  place  within  the  mixture  as  to 
convert  all  free  bromine  into  a  com- 
pound with  the  other  elements  present. 
The  resulting  fluid  is  pale  amber  in 
color,  with  a  strong  odor  of  chlorine,  a 
slightly  arid  taste,  and  a  specific  gravity 
of   1022.      It  must  be  kept   in  amber- 


282 


UTERINE  MYOMA. 


WATER  CURES,  ERRORS  IN. 


colored   bottles,   in   a   cool   place,   and 
tightly  corked. 

The  writer  has  used  this  solution  lo- 
cally with  very  satisfactory  results  in 
chronic  ulcers  of  the  leg,  regarded  as 
hopeless,  suppurative  Ira  bos  which  had 
resisted  all  other  methods  of  treatment, 
and  ulcerative  cervical  endometritis.  It 
has  also  been  administered  by  the  mouth 
in  pulmonary  tuberculosis.  It  seems  to 
have  the  power  to  check  ulcerative  proc- 
esses in  the  lung  and,  if  the  disease  is 
not  too  far  advanced,  ultimately  to  ef- 
fect a  cure.  It  must  be  given  in  free 
doses  for  a  considerable  period  of  time, 
from  1  to  1 1/2  ounces,  four  times  daily, 
before  each  meal  and  at  bedtime,  on  a 
stomach  which  is  completely  empty. 
One  hundred  cases  were  treated  in  this 
way  and  the  results  were  satisfactory. 
H.  W.  Mitchell  (Medical  Record,  April 
1,  1905). 

UTERINE  MYOMA. 

In  fibroid  tumors  complicating  preg- 
nancy, from  the  fact  that  from  70  to  80 
per  cent,  go  through  pregnancy  undis- 
turbed and  that  the  mortality  rate  in 
84  cases  was  3.6  per  cent.;  that  in  one 
series  of  23  cases,  G,  or  25  per  cent., 
were  operated  upon,  it  would  seem  that 
while  the  operation  itself  is  attended 
with  little  danger,  the  conservative  plan 
would  be  to  operate  during  pregnancy 
only  upon  those  tumors  that  interfere 
with  the  normal  development  of  the 
uterus  and  its  functions,  either  previous 
to  the  fourth  month,  if  the  uterus  is 
prevented  from  rising  out  of  the  pelvis, 
or  for  pernicious  or  incontrollable  vom- 
iting, or  if  it  is  discovered  that  the 
junior  will  in  any  way  interfere  with  the 
normal  expulsion  of  the  Eoetus  at  term. 

Little  authentic  work  lias  been  done 
in  describing  fibroid  tumors  and  heart 


disease.  One  series  of  70  cases  shows 
45  with  objective  symptoms  of  heart 
trouble.  Pinard  describes  post-mortems 
on  cases  dying  with  fibroid  tumors  that 
had  fibrous  myocarditis.  The  cause  of 
the  myocarditis  is  not  known. 

Studying  fibroid  tumors  and  malig- 
nancy there  is  a  larger  field  of  literature 
to  draw  from.  Noble's  collection  of 
statistics  of  988  cases  shows  that  over 
one-third  of  the  women  would  have  died 
had  the  tumor  not  been  removed.  Cul- 
len  estimates  malignancy  at  from  1/z  to 
2  per  cent. ;  Bland  Sutton  at  5  per  cent. 
This  evidence  is  incontrovertible  itself 
in  favor  of  surgical  treatment  of  all 
fibroids.  W.  M.  Thompson  (Chicago 
Medical  Recorder,  May  15,  1905). 

WATER  CURES,  ERRORS  IN. 

The  most  common  mistake  is  made 
"  with  reference  to  the  temperature.  The 
more  different  the  temperature  of  the 
water,  under  conditions  otherwise  the 
same,  which  comes  into  contact  with  the' 
body,  the  stronger  is  the  resistance  of 
the  organism  toward  the  loss  or  gain  of 
heat.  Another  mistake  lies  in  the 
choice  of  the  mechanical  stimulant  used. 
When  water  is  used  for  defervescent 
purposes,  it  is  wrong  to  begin  with  too 
low  a  temperature,  to  use  too  little  me- 
chanical irritation  (friction),  and  to  em- 
ploy the  bath  for  too  short  a  time.  In 
severe  acute  infectious  diseases,  the 
action  of  the  water  cannot  be  judged 
exclusively  by  its  effect  upon  the  tem- 
perature. In  cases  of  collapse  with 
cardiac  weakness,  the  trunk  should  have 
cold  compresses  placed  about  it,  while 
the  extremities  must  be  energetically 
heated.  It  is  a  blunder  to  use  water  at 
too  high  a  temperature  in  the  treatment 
of  the  anaemic,  the  chlorotic,  and  the 
convalescent.     In  giving'sitz  baths,  loss 


X-RAYS,  METHOD  OF  MEASURING. 


YELLOW  FEVER. 


283 


of  heat  from  that  part  of  the  body  which 
is  not  in  the  water,  can  be  avoided  by 
thoroughly  wrapping  it  in  blankets. 
Winternitz  (Berliner  klinische  Woehen- 
schrift,  April  10,  1905). 

X-RAYS,  METHOD  OF  MEASURING. 

The  writer  proposes  a  method  which 
is  based  on  the  power  of  the  x-rays  to 
ionize  the  gases  through  which  they 
travel.  The  method,  excepting  for 
necessary  modifications,  to  make  it  con- 
form with  the  special  requirements  of 
the  x-rays,  is  substantially  analogous  to 
that  now  commonly  employed  to  meas- 
ure the  radioactivity  of  the  radioactive 
substances.  Air  is  rendered  a  con- 
ductor of  electricity  by  the  ionizing 
agent,  and  measurement  of  the  amount 
of  current  flowing  through  it  under 
given  conditions  gives  an  absolute  index 
of  the  activity  of  the  radiation.  The 
instrument  used,  the  electroscope,  is 
charged  by  having  brought  into  contact 
with  the  knob  a  rod  of  vulcanite  which 
has  been  electrified  by  friction.  The 
knob  is  brought  into  communication 
with  a  filament  while  the  vulcanite  is  in 
contact  and  is  released  as  soon  as  the 
filament  has  assumed  a  horizontal  posi- 
tion. The  electroscope  is  brought  to 
the  same  distance  from  the  tube  as  the 
patient  or  plate  (in  any  position)  and 
while  the  tube  is  running  the  shutter  is 
open,  and  the  lime  in  seconds  occupied 
by  the  filament  in  transit  is  noted.  The 
number  of  seconds  is  the  exact  coefficient 
of  energy  of  the  rays,  and  when  compared 
with  any  other  reading  made,  under  any 
circumstances  whatever,  with  similar  in- 
strument, the  ratio  of  energy  of  the  two 
radiations  will  equal  that  of  the  two 
times.  M.  Franklin  (New  York  Medi- 
cal Journal  and  Philadelphia  Medical 
Journal,  April  22,  1905).  , 


YELLOW  FEVER,  TREATMENT  OF. 

The  great  desideratum  in  the  treat- 
ment of  yellow  fever  is  not  to  disturb 
the  stomach  and  to  relieve  the  con- 
gestion of  the  kidneys.  The  hot  mus- 
tard foot-bath  relieves  cerebral  con- 
gestion and  headache  and  often  induces 
free  perspiration  followed  by  sleep.  Ap- 
plications of  ice  or  cold  water  to  the 
head,  face,  hands,  or  back  during  the 
febrile  stage  are  dangerous,  because 
they  produce  a  sudden  cooling  of  the 
body  surface  and  increase  the  existing 
congestion  of  the  viscera.  Sinapisms 
over  the  epigastrium  relieve  pain  in  the 
stomach  as  well  as  visceral  congestion. 
Diaphoresis  and  diuresis  should  be 
promoted  by  means  of  large  draughts  of 
lemonade  made  with  Seltzer  water,  hot 
decoctions  of  orange  leaves,  Vichy  or 
soda  water,  or  by  rectal  injections  of 
fresh  water.  Opium  in  whatever  form, 
should  never  be  given.  Neither  are 
stimulants  indicated,  except  in  some 
cases  in  which  the  patient  has  been  in 
the  habit  of  using  them.  Iced  cham- 
pagne is  best.  When  the  pulsations  of 
the  heart  fall  to  50  or  60  a  minute,  digi- 
talis should  be  given.  Proper  alimenta- 
tion is  of  prime  importance.  During 
the  onset  of  the  attack  no  food  should 
be  given,  and  until  convalescence  is  fully 
and  completely  established  no  solid 
food  should  be  given  to  the  patient. 
Absolute  rest  in  bed  in  a  ventilated 
room  without  draughts  of  air,  or  even 
temperature,  is  very  important  to  the 
successful  treatment  of  yellow  fever. 
More  essential  than  that  is  a  calm  and 
hopeful  state  of  the  mind  and  spirit  of 
the  patient.  A.  M.  Fernandez  de 
Ybarra  (Therapeutic  Gazette,  April  15, 
1905). 


Correspondence. 


WORKS  AND  NOT  WORDS. 

An  Appeal  from  Mr.  Bok  to  the  Mbdical  Profession. 

Philadelphia,  May  15,  1905. 

To  the  Editor:— During  the  last  year  I  have  received  hundreds  of  letters  from  physicians 
in  every  part  of  the  United  States  commending  the  attitude  of  the  Ladies'  Home  Journal  in 
its  efforts  to  awaken  the  public  to  an  understanding  of  the  patent  medicine  curse.  Scores  of 
commendatory  resolutions  from  medical  associations  have  likewise  come  to  our  company. 
All  these  have  been  gladly  received  and  appreciated,  and  our  acknowledgments  in  each  case 
have  tried  to  express  this  fullest  feeling  of  satisfaction.  It  is,  therefore,  with  no  lack  of 
appreciation  that  I  say  that,  while  these  individual  and  association  commendations  have  been 
pleasant,  I  could  wish  the  sentiments  therein  expressed  might  have  resulted  in  some  effective 
cooperative  work. 

What  I  mean  is  this :  Dnring  the  past  winter  there  was  introduced  into  the  Legislatures 
of  not  less  than  fourteen  Skates  bills  which  had  for  their  object  the  regulation  of  the  sales 
of  injurious  patent  medicines,  or  the  compulsory  printing  of  the  ingredients  of  these 
medicines,  on  the  label  of  each  bottle,  under  penalty  of  fine  or  conviction.  Committee 
hearings  were  given  on  these  bills  in  each  State.  The  proprietors  of  some  of  the  patent  medi- 
cines were  exceedingly  active — and  effectively  so — in  their  opposition  to  these  bills.  Asso- 
ciations interested  in  the  patent  medicine  traffic  worked  with  unceasing  vigil  to  defeat  the 
bills—  which  they  succeeded  in  doing.  The  newspapers  in  these  States  carrying  the  advertise- 
ments of  patent  medicines  were  notified  that  this  legislation  was  not  desirable.  Skillful  law- 
yers appeared  before  these  committees  in  opposition  to  the  bills.  Every  effort,  in  short,  was 
made  to  defeat  these  measures,  and  in  all  save  one  State  the  bills  were  "killed." 

Now,  who  appeared  in  favor  of  the  bills  at  these  hearings?  Generally,  members  of  the 
Woman's  Christian  Temperance  Union  whose  zeal  usually  exceeded  their  discretion  and 
judgment — well-intentioned  but  ineffective.  In  one  or  two  cases,  representatives  of  some 
liquor  dealers'  association  appeared  in  behalf  of  the  bills.  But  not  in  a  single  instance,  and 
I  speak  by  authority  of  personal  representation  at  each  of  these  hearings,  did  there  appear  a 
single  physician  or  the  representative  of  a  single  State,  sounty,  or  city  medical  association. 
There  was  net  the  slightest  active  interest  taken  by  physicians  in  these  hearings,  and  yet 
scores  of  physicians  wrote  me  irate  letters  after  the  bills  were  defeated,  deploring  the  corrup- 
tion (?)  of  the  Legislatures  in  their  States! 

These  hearings  were  usually  of  the  most  perfunctory  order,  and,  from  the  side  of  any 
advocacy  of  the  bills,  absolutely  without  interest,  since  scarcely  anyone  appeared  to  give 
intelligent  or  convincing  reasons  why  the  bills  should  become  laws.  Now,  I  ask  the  physicians 
and  medical  associations  of  this  country:  how  are  we  ever  to  secure  effective  legislation 
against  patent  medicines  until  some  intelligent  reasons  are  presented  by  intelligent  people 
having  the  respect  of  a  community,  why  such  legislation  should  exist? 

It  is  not  only  likely,  but  probable,  that  during  the  next  fall  and  winter  terms  there  will 
be  introduced  into  the  Legislature  of  nearly  every  State  in  the  Union,  a  regulative  patent 
medicine  measure — bills  which  have  a  vital  interest  to  every  physician  in  the  United  States; 
and  my  objeet  in  this  letter  is  to  draw  to  the  attention  of  every  physician,  and  particularly 
every  medical  association,  not  only  the  need,  but  the  necessity,  for  their  cooperation  in  this 
legislative  work. 

It  is  not  meeting  this  question  for  physicians  and  associations  to  contend  that  their 
appearance  and  arguments  before  these  committees  would  be  deemed  as  emanating  from  inter- 
ested motives,  and  thus  have  no  Aveight.  Surely,  the  other  side  does  not  argue  thus,  and  their 
appearance  and  arguments  before  these  committees  are  certainly  from  "interested  motives." 

(284) 


BOOK  REVIEWS.  285 

The  statements  and  arguments  of  reputable  physicians  of  the  communities  concerned  would 
have  the  greatest  possible  weight  before  these  committees.  In  fact,  in  several  cases  members 
of  these  committees  have  asked  and  desired  that  some  physicians  of  standing  should  appear 
at  the  hearings,  and  marveled  at  their  uniform  and  consistent  absence. 

Here  is  not  only  direct  work  for  every  medical  association  in  America,  but  an  actual 
crying  need  for  such  work,  and,  if  I  may  speak  a  little  frankly,  a  clear  case  of  shirking  respon- 
sibility where  such  work  is  not  forthcoming. 

I  shall  be  in  a  position  to  know  of  the  introduction  of  these  legislative  measures  in  any 
State  where  they  are  presented,  and  if  in  each  State  the  leading  medical  association  would 
appoint  a  committee,  and  a  similar  committee  appointed  by  county  and  city  associations,  and 
the  full  name  and  address  of  the  chairman  of  each  committee  can  be  forwarded  to  me,  between 
now  and  October  1  next,  it  will  afford  me  pleasure  to  communicate  with  such  party  immediately 
on  the  introduction  of  such  a  measure  in  the  Legislature  of  his  State  and  supply  him  with 
printed  material,  now  being  prepared,  containing  arguments  for  the  regulation  of  the  patent 
medicine  traffic  in  America  and  showing  what  has  been  done  by  other  nations. 

But  the  fact  cannot  be  too  strongly  urged  that  the  most  representative  physicians  in  the 
State,  city  or  county,  the  men  occupying  the  highest  positions  in  their  professions  and  having 
the  unquestioned  respect  of  their  communities  should  be  members  of  such  appearing  com- 
mittees. The  greatest  weight  should  be  given  to  the  arguments  presented,  ensuring  the  most 
effective  influence. 

It  should  not  be  necessary  to  add— but  still  I  will  do  so,  in  case  of  the  exceptionally 
suspicious  mind  that  is  always  with  us:  that  no  advertising  element,  so  far  as  the  magazine 
of  which  I  am  editor  is  concerned,  enters  into  these  desires  on  our  part  or  into  the  material 
being  prepared.  The  publishers  of  the  Ladies'  Home  Journal  have  no  desire  that  their  periodi- 
cal shall  enter  into  these  hearings  as  a  periodical,  mentioned,  quoted,  or  commended;  they  do 
not  crave  such  advertising;  the  magazine  does  not  need  it.  The  periodical  entered  on  its 
editorial  treatment  of  the  patent  medicine  curse  from  principle  and  from  no  other  motive. 
Its  only  interest  is  the  interest  of  the  great  public  at  large:  not  the  commendation  either  of 
it  or  its  editor.  Both  have  received  that  at  the  hands  of  the  medical  profession.  It  now  asks 
at  the  hands  of  that  profession  works,  not  words. 

Edward  Bok, 
Editor  of  the  Ladies'  Home  Journal. 


3ook  Reviews. 


The  Roentgen  Rays  in  Therapeutics  and  Diagnosis.  By  William  A.  Posey,  A.M.,  M.D., 
and  Eugene  W.  Caldwell,  B.S.  Second  Edition,  Thoroughly  Revised  and  Enlarged.  090 
Pages,  with  195  Illustrations,  Including  Colored  Plates.  Price,  $5.00,  net.  W.  B. 
Saunders  &  Co.,  1904. 

That  a  second  edition  of  this  book  on  the  therapeutics  of  the  x-rays  should  be  called  for 
so  soon  should  be  both  a  matter  of  congratulation  to  its  authors  and  an  encouraging  sign  to 
workers  that  the  general  medical  public  of  this  country  is  taking  an  increasing  interest  in  this 
subject.  This  edition,  like  the  former,  should  be  of  great  value,  both  to  beginners  in  the 
practice  of  the  use  of  the  Roentgen  rays,  and  to  those  more  accustomed  to  their  application. 

The  first  half  of  the  book  by  Caldwell  dealing  with  the  subjects  of  apparatus  and 
radiography  is  quite  unchanged.  About  one  hunderd  pages  have  been  added  to  the  second  half 
of  the  work,  dealing  with  the  therapeutic  side  of  the  subject.  Dr.  Posey  has  gone  somewhat 
more  exhaustively  into  the  subjed  in  this  edition,  but  we  would  like  to  see  him  lay  more  stress 
on  the  question  of  burns  among  x-ray  workers  and  the  means  of  avoiding  them. 

The  section  on  cutaneous  carcinoma  and  carcinoma  of  the  breast  and  thorax  has  been 
enlarged  by  some  thirty-five  pages  of  interesting  material.      Many  cases  are  added  and  the 


286 


BOOK  EEVIEWS. 


histories  of  several  instructive  cases  reported  in  the  first  edition  are  brought  up  to  date.  A 
group  of  69  cases  of  cutaneous  carcinoma  is  reported  in  tabular  form,  giving  results  down 
to  January,  1904,  and  in  the  section  on  carcinoma  of  the  breast  and  thorax  he  gives  a  summary 
of  a  group  of  31  consecutive  cases  of  breast  carcinoma. 

There  are  a  few  new  illustrations  of  clinical  subjects,  and  these,  together  with  those  that 
appeared  in  the  first  edition,  are  of  special  interest  in  that  they  seem  to  be  quite  true  to  life 
and  not  overmuch  touched  up  by  the  photographer. 

Altogether  tbe  book  maintains  throughout  a  high  standard  of  excellence,  and  cannot  fail 
to  be  of  the  greatest  use  to  anyone  interested  in  this  subject  either  as  a  text  book  or  refer- 
ence work. — H.  H.  R. 

Diet  in   Health  and  Disease.      By  Julius  Friedenwald,   M.D.,   and   John   Ruhrah,   M.D. 
Published  by  W.  B.  Saunders  &  Co.,  Philadelphia.     Price,  $4.00. 

It  is  satisfactory  to  review  a  book  which  is  at  the  same  time  so  comprehensive,  scholarly, 
and  judicious.  The  subject  of  diet  has  received  immense  attention  of  late,  but  many 
strange  and  irreconcilable  views  are  recorded,  causing  readers  to  doubt  the  finding  on  a 
subject  whereon  such  diversity  of  opinion  can  exist.  Fortunately,  two  gentlemen  have  com- 
bined to  produce  a  book  which  shall  become  an  authority,  and  stand  as  the  basis  of  thought 
and  action. 

While  the  volume  is  not  large,  nevertheless  there  is  nothing  omitted  that  demands  atten- 
tion. It  is  possible  that  more  might  be  said,  more  details  given,  and  this  no  doubt  the 
authors  will  from  time  to  time  furnish.  Meanwhile  certain  points  stand  out  clear.  .There  is 
nothing  supererogatory.  The  statements  are  direct,  with  details  sufficient  where  they  are 
needed.  It  is  adapted  to  the  needs  of  the  clinician,  the  student,  and  particularly  the  trained 
nurse.  Rectal  feeding,  which  is  so  difficult  to  teach,  and  on  which  so  much  contradictory 
data  exists,  is  made  plain,  simple,  and  comprehensible.  The  subject  of  infant  feeding  alone  is 
so  carefully  presented  as  to  render  the  book  necessary  for  all  those  who  deal  with  the  ailments 
of  one-third  of  humanity.  The  diet,  not  only  for  infants,  is  thoroughly  discussed,  but  also 
for  those  after  the  first  year.  Numerous  excellent  receipts  are  given  in  the  chapter  on 
"Diseases  of  the  Stomach  and  Intestines,"  along  with  an  ample  amount  of  special  diets.  The 
article  on  diabetes,  gout,  obesity,  and  nephritis  is  admirable,  and  presents  the  views  of  the 
most  eminent  authorities.  Hospitals  and  institutions  will  find  this  book  necessary.  Regular 
and  special  dietaries  are  given  with  hints  as  to  most  practical  variants,  and  of  ample  scope, 
both  from  the  standpoint  of  economics  as  well  as  acceptability. 

The  surgeons  will  find  this  book  of  much  use  as  a  guide  to  feeding  after  anaesthesia  and 
operations,  especially  the  methods  of  feeding  after  gastro-intestinal  operations. 

Diet  is  considered  in  its  relation  to  various  conditions  of  age,  occupation,  domestic  and 
social  planes. — J.  M.  T. 

Nuksing   in  Eve,  Ear,  Nose,  and  Throat  Diseases.      By  A.  Edward  Davis,  M.D.,  and 

Beamon    Douglass,   M.D.      32   Illustrations.       Philadelphia:    F.  A.  Davis  Company,  1905. 

Price,  $1.25. 

This  little  book  purports  to  be  written  for  nurses.  It  is  so  complete  and  includes  so 
much  that  is  interesting  to  tbe  general  practitioner  as  to  be  well  adapted  for  use  far  beyond 
the  range  of  its  original  intent.  Of  especial  value  may  be  mentioned  the  clear  illuminating 
chapter  on  anatomy  and  physiology  of  Die  different  organs  mentioned  which  precedes  the 
other  chapters  relating  to  the  diseases  and  methods  of  treatment. 

Under  the  heading  of  treatment  also  there  is  much  that  no  one  except  the  specialist  is 
likely  to  know.  Many  of  the  procedures  important  to  employ  could  only  be  understood  by  a 
specialist  of  considerable  experience,  and  inasmuch  as  the  directions  to  the  carrying  out  of 
these  is  meant  for  nurses,  the  clarity  of  them  would  enable  any  practitioner  to  apply  them 
himself  in  the  absence  of  specialists.  Altogether,  it  is  an  excellent  little  book,  and  would  prove 
most  useful  for  practitioners  who  may  not  be  in  immediate  touch  with  specialists,  and  who  are 
compelled  to  make  use  of  such  measures  as  are  recommended  themselves. — J.  M.  T. 


BOOKS  AND  MONOGRAPHS  RECEIVED.  287 

Practical  Pediatrics:  A  Manual  of  the  Medical  and  Surgical  Diseases  of 
Infancy  and  Childhood.  By  Dr.  E.  Graetzer.  Authorized  Translation,  with  Numerous 
Additions  ami  Notes,  by  Herman  B.  Sheffield,  M.D.  Philadelphia:  E.  A.  Davis  Company, 
1905.     Price,  $3.00. 

Dr.  E.  Graetzer  was  a  pupil  of  Henoch,  as  he  states  in  the  preface,  and  leans  toward  his 
teachings.  The  scope  of  this  little  book  of  540  pages  is  that  of  a  compend,  but  an  exceedingly 
full  one,  standing  between  the  compend  and  the  manual.  The  translator  calls  the  book  a 
miniature  encyclopaedia  of  the  medical  and  surgical  diseases  of  infancy  and  childhood,  and 
he  claims  that  no  book  on  Pediatrics  presents  in  so  small  a  space  such  an  abundance  of 
practical  and  clinical  material,  pathological  and  bacteriological  data,  and  details  of  etiology 
and  diagnosis  as  the  volume  in  question. 

A  careful  review  of  the  book  makes  clear  that  a  vast  lot  of  superfluous  material  commonly 
exhibited  in  books  of  this  description  is  omitted — unnecessary  illustrations,  etc.;  indeel, 
there  are  none  in  the  book,  nor  diet  lists,  or  cooking  receipts.  The  subjects  are  presented 
clearly  and  succinctly,  yet  with  reasonable  fullness,  omitting  much  of  the  usual  description 
of  the  typical  courses  of  disease.  He  has  rather  laid  emphasis  upon  the  numerous  deviations 
from  type,  which  so  often  baffle  the  practitioner.  Altogether,  the  book  is  an  excellent  one 
which  can  be  safely  recommended  to  supplement  the  larger  text-book,  both  for  student  and 
clinician. — J.  M.  T. 


5©ol<s  and  /Monographs  Received. 


The  Editor   begs   to   acknowledge,   with   thanks,   the   receipt   of   the   following  books   and 
monographs:  — 

"Reports  of  Two  Cases  of  Cured  Graves's  Disease."      By  G.  B.  Webb,  Colorado  Springs. 

Colo.,   1905. "Glioma  of  the  Nose:      Report  of  Two  Congenital  Cases."      By  J.  P.  Clark, 

Boston,  Mass.,  1905. "The  Precise  Measurement  of  the  Primary  and  Secondary  Deviation  in 

Paralysis;    With  Remarks  on  the  Regular  Occurrence  of  Secondary  Deviation  in   Congenital 

Paralysis.''      By  Alexander  Duane,  New  York,  1904. "Congenital  Deficiency  of  Abduction. 

Associated  with  Impairment  of  Adduction,  Retraction  Movements.  Contraction  of  the  Palpebral 

Fissure,  and  Oblique  Movements  of  the  Eye."      By  Alexander  Duane,  New  York,   1905. 

"Prism  Exercises — Their  Indications  and  Technique."      By  Alexander  Duane.  New  York,  IDOL 

"Personal  Observations  on  the  Advantages  <>t'  Certain  Arctic  Localities  in  the  Treatment 

of  Tuberculosis."      Frederick   Sohon,   Washington,  D.   C,   1904. -"The   Applicability   of  the 

Greenland    Fjords    to    the    Treatment   of   Tuberculosis."       By    Frederick    Sohon,    Washington, 

D.  C,  1904. -The  Differentiation  and  Treatment  of  Lye  Diseases  Most  Commonly  Seen  by 

the  General  Practitioner."      By  L.  F.  Love,  Philadelphia,  1905. "Three  Cases  of  Poisoning 

by  Potassium  Cyanide."     By  J.   I.  McKelway,  Kin-'.-,  Park,   Long  Island,  1905. "Lentigo: 

Unilateral  Distribution;    Report  of  a  Case."     By  J.  I.  McKelway,  Binghampton,  N.  Y.,  1905. 

"Pernicious  Vomiting  of  Seven  Sears'  Duration  Cured  by  Suspension  of  the  Kidney."     By 

,;-  !•■  Shoemaker,  Philadelphia. "Bocetos  Populares  Sobre  Historia,  Literatura  j   Ciencias: 

'Democrito,'    'llipatia/    'Miguel    Servet.' ''       Por    le    Dr.    David    Cerna,    Monclova,    Coahuila, 
-Mexico,  1904-1905. 

The   following  monographs   have  been   received   from  the   United  States   Department   of 

Agriculture,   Washington,  D.  C:  — 

Information  Concerning  the  Milch  Goats.      By  G.  F.  Thompson,  1905.-  —Imports  of  Farm 
and  Forest  Products,  1901-1903,  by  Countries  from  which  Consigned.     Compiled  by  the  Divis- 


288 


BOOKS  AND  MONOGRAPHS  RECEIVED. 


ion  of  Foreign  Markets,  1905. Exports  of  Farm  and  Forest  Products,  1901-1903,  by  Countries 

to  which  Consigned.      Compiled  by  the  Division  of  Foreign  Markets,  1905. The  External 

Parasites  of  Hogs.     By  E.  C.  Stevenson,  1905. Alfalfa  Growing.     By  A.  S.  Hitchcock,  1905. 

Lessons  from  the  Grain-Rust  Epidemic  of  1904.     By  M.  A.  Carleton,  1905. Raspberries. 

By  L.  C.  Corbett,  1905.— — Fungous  Diseases  of  the  Cranberry.      By  C.  L.  Shear,   1905. 

The   Corn  Root-Worms.     By   F.   H.   Chittenden,    1905. The   Milk   Supply   of   Twenty-nine 

Southern  Cities.      By  C.  F.  Doane,  1905. Trade  with  Noncontiguous  Possessions  in  Farm 

and  Forest  Products,  1901-1903,  1905. The  Camembert  Type  of  Soft  Cheese  in  the  United 

States.     By  H.  W.  Conn,  Charles  Thorn,  A.  W.  Bosworth,  W.  A.  Stocking,  Jr.,  and  T.  W.  Issa- 

jeff,   1905. Coyotes  in  Their  Enonomic  Relations.      By  D.  E.  Lantz,   1905. The  School 

Garden.      By  L.  C.  Corbett,  1905. Report  on  the  Gypsy  Moth  and  the  Brown-Tail  Moth, 

July,    1904-1905. The    Imported    Cabbage    Worm.      1905. Experiment    Station    Work, 

XXVIII.      1905. Recommendations  of  State  Game  Commissioners  and  Wardens  for  1905. 


EDITORIAL    STAFF. 
Sajous's  Analytical  Cyclopaedia  of  Practical  Medicine. 


J.  GEORGE  ADAMI.  M.D., 

MONTREAL,  P.  Q. 

LEWIS  H.  ADLER,  M.D., 

PHILADELPHIA. 

JAMES  M.  ANDERS,  M.D.,  LL.D., 

PHILADELPHIA. 

THOMAS  G.  ASHTON,  M.D., 

PHILADELPHIA. 

A.  D.  BLACKADER.  M.D., 

MONTREAL,  P.  Q. 

E.  D.  BONDURANT,  M.D., 

MOBILE,  ALA. 

OAVID  BOVAIRD,  M.D., 

NEW  TORE  CITY. 

WILLIAM  BROWNING,  M.D., 

BROOKLYN,  N.  T. 

WILLIAM  T.  BULL,  M.D., 

NEW  TORE  CITT. 

CHARLES  W.  BURR,  M.D., 

PHILADELPHIA. 

HENRY  T.  BYFORD,  M.D., 

CHICAGO,  ILL. 

HENRY  W.  CATTELL,  M.D., 

PHILADELPHIA. 

WILLIAM  B.  COLEY,  M.D., 

NSW  TORE  CITT. 

FLOYD  M.  ORANDALL,  M.D., 

HEW  TORE  CITT. 

ANDREW  F.  CURRIER,  M.D., 

NEW  TORE  CITT. 

ERNEST  W.  CUSHING,  M.D., 

BOSTON,  MASS. 

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PHILADELPHIA. 

N.  S.  DAVIS,  M.D.. 

CHICAGO.  ILL 

AUGUSTUS  A.  ESHNER,  M.D., 

PHILADELPHIA. 

SIMON  FLEXNER.  M.D., 

PHILADELPHIA. 

LEONARD  FREEMAN,  M.D., 

DENVER,  COL. 

8.  O.  GANT,  M.D., 

NSW  TORE  CITT. 

J.  MoFADDEN  GASTON,  Sr..  M.D.. 

ATLANTA.  GA. 

J.  McFADDEN  GASTON,  Jr.,  M.D.. 

ATLANTA,  GA. 

E.  B.  GLEASON,  M.D., 

PHILADELPHIA.. 

EGBERT  H.  GRAN  DIN,  M.D.. 

MBW  TORE  OITT. 


ASSOCIATE.    EDITORS. 

J.  P.  CROZER  GRIFFITH,  M.D., 

PHILADELPHIA. 

C.  M.  HAY,  M.D., 

PHILADELPHIA. 

FREDERICK  P.  HENRY,  M.D., 

PHILADELPHIA. 

L.  EMMETT  HOLT,  M.D., 

NEW  TORE  CITT. 

EDWARD  JACKSON,  M.D., 

DENVER,  COL. 

W.  W.  KEEN,  M.D., 

PHILADELPHIA. 

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COPENHAGEN,  DENMARK. 

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CHICAGO,  ILL. 

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8TRACCSE,  N.  T. 
SIMON  MARX.  M.D., 

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THE    MONTHLY   CYCLOPEDIA 

OF 

PRACTICAL   MEDICINE 

(Published  the  Last  of  Each  Month) 


Vol.  XVIII. 
Old  Series. 


PHILADELPHIA,  JULY,  1905. 


Vol.  VIII,  No.  7. 
New  Series. 


PAGE 

EDITORIALS 

TH£  FEASIBILITY  AND 
VALUE  OF  ACCURATE  METH- 
ODS IN  CLINICAL  INVESTI- 
GATIONS.    B.  Onuf 289 

THE  INTERNAL  USE  OF  THYROID 
EXTRACT  TO  INCREASE  THE 
COAGULABILITY  OF  THE 
BLOOD.     William  J.  Taylor 2. "8 

SOME  FACTS  ABOUT  ARTIFICIAL 
DRUMHEADS  AND  OTHER 
AIDS  OF  HEARING.  B.  Alex. 
Randall 301 

HYPOTHESIS  ON  THE  ETIOLOGY 
OF  SCOLIOSIS  IN  CHILDREN. 
J.  Madison  Taylor „ .103 

CYCLOPEDIA    OF   CURRENT 
LITERATURE 

ACETANILID     POISONING.        D.    D. 

Stewart 306 

ALCOHOL,  ACTION    OF,   UPON   THE 

CIRCULATION.     D.  M.  Hoyt 306 

ANGI0S0LER0SI8  OF  THE  EXTREM- 
ITIES. INTERMITTENT  CLAU- 
DICATION DDE  TO.  J  Ramsay 
Hunt 307 

APPENDICITIS,  CHANGES  OF  VIEW 

ON.     R.  T.  Morris 307 

APPENDICITIS    IN   CHILDREN.      R. 

C.  Dun 308 

ASTHMA,  THE  RELATION  OF  ETH 
MO  I  DAL  INFLAMMATION 
TO.    II.  coggeshall 30S 

BATHS  AND  ELECTRICITY, 
EFFECTS  OF,  ON  METABO- 
LISM, BLOOD  AND  BLOOD- 
PRESSURE.  Bain  and  Frank- 
lin   308 

BONE    CAVITIES,    TREATMENT    OF 

J.  E.  Moore 309 

BRONCHIAL  ASTHMA,  VASOMOTOR 

ORIGIN  OF.     F.  Galdi 310 

BRONCHO-PNEUMONIA  IN  CHIL- 
DREN, TREATMENT  OF.  T. 
Zangger 310 

BURNS    OF    THE     THIRD     DEGREE. 

A.  M.  Fauntleroy 310 

CONSTIPATION  AS  A  CAUSE  OF 
INTRAUTERINE  INFECTION. 
Capaldi 311 


TABLE  OF  CONTENTS. 

page 
COPPER,     BACTERICIDAL    ACTION 
OF,    ON     ORGANISMS     IN 

WATER.     N.  Gildersleeve 311 

DIGESTIVE  DI8TURBANCE8  IN 
EARLY  INFANCY.  F.  Kermau- 
ner 311 

ELECTRIC  SHOCKS.     Wallbaum 312 

EXOPHTHALMIC  GOITER  RELUCED 

BY  RADIUM.     R.  Abbe 313 

FATTY    DEGENERATION,     NATURE 

OF.     M.  Luhlein 313 

GALL-8T0NE8     AND     CARCINOMA. 

G.  R.  Slade 313 

GASTRIC      PAIN,     LEFT-SIDES. 

Riedel 3U 

GASTRIC  ULCER,  ETIOLOGY  AND 
PATHOLOGY  OF.  Joseph  Mc- 
Farland 314 

GASTRIC     ULCER,     RE8T     IN     THE 

TREATMENT  OF.     F   D.  Boyd...  315 

G  A  8  T  R  O  -  ENTEROSTOMY.      W.  H. 

Wathen 315 

HAEMORRHAGE,  SODIUM  BICAR- 
BONATE IN.     P.  M.  Dawson : -.16 

HTPODERMOCLTSIS.  W.  Page  Mc- 
intosh   ; 317 

INFANT  FEEDING.  F.  8.  Churchill...  320 
INFANTILE   TUBERCULOSA.     R. 6. 

Freeman „ 321 

INGROWING     NAIL,     MEDICAL 

TREATMENT  OF.  A.  Gasparini  321 
INTESTINAL    ANTISEPSIS,  EFFECT 

OF,    ON    EXCRETION    OF    HIP- 

PORIC    ACID    IN   THE   URINE. 

J.  B.  Prager 3.2 

KNEE  INJURIES.  DeForest  Willard..  322 
LABOR,    BIMANUAL     DILATATION 

OF    THE     CERVIX    IN.       S.    G. 

Krashevski 322 

LEG    ULCER,    TREATMENT   OF.     11. 

Voerner 322 

MEASLES,      KOPLIKS      SPOTS      IN 

DIAGNO8I8  OF.  H.  Bruening..  323 
MENINGITIS    EPIDEMIC   OEREBRO- 

8PINAL,     TREATMENT     OF. 

Ruhemann 323 

NITROGLYCERINE,    TOLERANCE 

TO.     D.  D.  Stewart 32-1 

CEDEMA,    TREATMENT    OF.       J.    D. 

Mann 324 


OTITIS  MEDIA,  ACUTE  SUPPURA- 
TIVE.    C.  R.  Elwood 325 

OTITIS    MEDIA,     TREATMENT     OF. 

A.  E.  Bulson  325 

PARATYPHOID  FEVER.     J.  N.  Henry  326 

POTT'S  DISEASE.     A.  Campini 326 

PULMONARY       HEMORRHAGE 

TREATMENT  OF.  W.  A.  Dickey  327 
ROENTGEN  RAY  THERAPY  IN  DER- 

MATOLOUY.     J.  H.  Comroe 327 

SCARLATINA,  COMPLICATIONS  OF. 

J.  H.  W    Rhein 328 

SHOCK  IN    SURGERY.     G    W.  Crile...  328 

SPLEEN.     E.  T.  Williams 329 

STOMACH  CONTENTS^  MICROSCO- 
PICAL EXAMINATION  DUR- 
ING FASTING,  AND  ITS 
DIAGNOSTIC  VALUE.  W. 
Ackerman  and  D.  M.  Gompertz  ...  329 

STRUMA    AND     CATARACT.       A. 

Vossius 329 

8UGAR    IN   URINE,   DETECTION    OF 

E.  L.  McEwen 329 

TABE8,  CURABILITY  OF.     Fanre 330 

THYMECTOMY.  DIMINISHED  RE- 
SISTANCE TO  INFECTION 
AFTER.     G.  A.  Pari 331 

THYROID  GLAND,  ELIMINATION 
OF  IODINE  AND  ITS  RELA- 
TION TO  THE.     A.  Kocher 331 

TUBERCULOSI8,  EARLY  DIAGNOSIS 
OF.     A.  C.  Klebs,  J.  H.  Mnsser, 

F.  Billings,  J.  C.  Wilson,    II.  R. 
M.  Landis 332 

TUBERCULOSIS,  HEART  AND  CIR- 
CULATION IN  PROGNOSIS 
AND  MANAGEMENT  OF.  Von 
Ruck 332 

TUBERCULOSI8,  X-RAY  IN  DEEP- 
SEATED.     II.  K.  P.ncoast 333 

VACCINATION  DURING  SMALL- 
POX.    J.  C.  Hibbert 333 

WIDAL  REACTION.      E.  Andrade 333 

BOOK    REVIEWS 334 

BOOKS  AND  MONOGRAPHS  RE- 
CEIVED   335 

8TAFF   LIST 336 


Editorials. 


DEPARTMENT   IN  CHARGE  OF 
J.  MADISON  TAYLOR,  A.M.,  M.D. 


THE  FEASIBILITY  AND  VALUE  OF  ACCUKATE  METHODS  IN 

CLINICAL  INVESTIGATIONS. 
The  lack  of  accuracy  in  methods  has  often  proven  a  stumbling-block  in  clinical 
investigations:    i.e.,  often  the  investigator  has  found  great  difficulty  in  convincing 
his  readers  of  the  correctness  of  views  brought  forth,  or  of  observations  reported  by 

(289) 


290  ACCURATE  METHODS  IN  CLINICAL  INVESTIGATIONS. 

him,  for  a  lack  of  exact  figures.  How  difficult  is  it,  for  instance,  to  record  a 
gradual  diminution  of  the  knee-jerk  by  such  vague  terms  as  "subnormal,"  "weak," 
"almost  absent,"  etc. !  How  difficult  is  it,  therefore,  for  the  investigator,  not  only 
to  convince  the  reader,  but  even  to  convince  himself,  that  such  a  diminution  is  in 
progress,  if  he  has  no  definite  figures  on  which  to  base  his  observations ! 

The  feeling  of  dissatisfaction  with  such  vague  methods  shows  itself  clearly  in 
the  manifold  attempts  at  providing  accurate  means  of  registration.  Not  always 
have  such  attempts  been  successful.  The  attempts,  for  instance,  of  devising  an 
instrument  for  reliable  registration  of  the  knee-jerk,  allowing  trustworthy  com- 
parisons in  the  same  individual  and  in  different  individuals,  have,  to  the  writer's 
knowledge,  met  with  very  serious  obstacles.  In  other  fields,  however,  such  attempts 
have  proven  successful  and  gratifying.  Such  a  field,  for  instance,  is  ophthalmology. 
Here  the  mathematical  accuracy  with  which  vision,  visual  fields,  range  of  accom- 
modation, errors  of  refraction,  etc.,  can  be  measured  and  registered,  allow  us  to 
easily  note  and  record  the  slightest  fluctuations  in  function. 

Undoubtedly  even  here  sometimes  when  complicated  conditions  are  present, 
these  exact  methods  will  fail  us.  The  presence,  for  instance,  of  a  cataract  in  a 
given  eye  will  make  it  difficult  to  follow  and  correctly  interpret  diminution  of 
vision  occurring  in  that  eye,  if  at  the  same  time  it  presents  an  optic  atrophy.  But 
the  fact  that  such  complications  deprive  us  of  the  proper  use  of  such  exact  methods, 
does  not  gainsay  their  value.  The  conclusion  remains  that  where  such  accurate 
methods  are  feasible  they  should  be  applied. 

The  writer  on  taking  up  Dr.  Spratling's  suggestion,  to  make  investigations  of 
a  physio-chemic  nature  in  epileptics,  was  first  confronted  with  the  significance  of 
the  fact  just  mentioned.  Physio-chemical  investigations  may  perhaps  not  be  called 
clinical  in  the  strict  sense  of  the  word,  but  are  often  closely  allied  to,  and  inter- 
woven with,  clinical  problems,  and  often  pave  the  way  to  the  latter.  This  is  true 
also  for  the  investigations  to  be  discussed  here,  and  the  title  selected  for  this  edi- 
torial will  therefore  appear  permissible. 

The  particular  field  first  selected  by  the  writer  was  "the  gastric  functions  of 
the  epileptic."  While  it  was  and  still  is  the  writer's  intention  to  take  up  this 
chemico-clinical  problem  as  a  whole,  the  chemical  or  chemico-physiologic  side  first 
presented  itself. 

It  soon  became  apparent  that  only  by  accurate  methods  and  critical  discrimi- 
nation could  deviations  from  the  normal  be  definitely  recognized  and  eventually 
correctly  interpreted.  In  investigating  the  gastric  functions  oj  epileptics  the  prob- 
lem, therefore,  first  came  up  how  to  obtain  reliable  data  on  the  composition  and 
digestive  power  of  the  gastric  juice  in  general.  It  is  the  result  of  this  forestudy 
that  shall  here  be  presented  to  the  readers. 


ACCURATE  METHODS  IN  CLINICAL  INVESTIGATIONS.  291 

To  simply  study  the  gastric  acidity,  and  to  infer  from  the  degree  of  acidity 
the  amount  of  pepsin  present  in  the  juiee,  as  is  so  often  done,  seemed  unscientific. 
Direct  tests  of  the  digestive  power  of  the  juice  appeared,  therefore,  imperative,  and 
it  seemed  desirable  to  extend  such  tests  to  different  foodstuffs — starch,  casein,  etc. 

For  testing  the  digestion  of  albumin  Mett  has  recommended  glass  tubes  of  an 
inner  caliber  of  from  1  to  2  millimeters  diameter,  into  which  the  white  of  an  egg 
is  drawn  up  and  then  coagulated  by  heat.  The  digestive  power  of  the  juice  to  be 
tested  is  calculated  by  the  length  of  the  albumin  column  digested  off  in  a  given 
time.  This  method  promised  to  give  accurate  results,  provided  the  albumin  was 
of  even  composition  and  density  throughout  the  tube;  that  it  was  evenly  coagu- 
lated and  contained  no  air  bubbles;  provided,  furthermore,  that  the  albumin  col- 
umn, digested  under  normal  circumstances,  was  long  enough  to  easily  note  or 
record  deviations  from  the  normal. 

The  chief  difficulty  was  encountered  in  the  last-mentioned  requirement,  namely, 
of  obtaining  a  sufficiently  long  column  of  digested  albumin. 

Pawlow  and  his  pupils,  whose  inspiring  work  has  shed  so  much  light  on  the 
physiology  and  chemism  of  digestion  by  the  accuracy,  ingeniousness,  and  planful- 
ness  of  methods,  used  Mett's  tubes  with  great  success,  and  evidently  did  not  encoun- 
ter the  difficulty  last  mentioned.  But  we  must  not  forget  that  their  digestion  tests 
were  made  with  pure  juice,  not  with  a  juice  strongly  diluted  by  a  test  meal,  as  is 
the  case  in  clinical  tests.  While,  therefore,  owing  to  the  high  concentration  of  the 
juice,  the  digested  column  in  their  experiments  was  long,  reaching  in  some  instances 
the  length  of  8  y2  millimeters  in  ten  hours  at  body  temperature,  the  figures  obtained 
by  the  writer  with  human  gastric  juice  within  twenty-four  hours,  also  at  body  tem- 
perature, were  4  to  5  millimeters  only,  or  thereabouts.  With  such  small  figures  it 
seemed  hopeless  to  obtain  accurate  comparisons,  and  imperative  to  dilute  the  albu- 
min to  such  a  degree  that  the  figures  would  be  large  enough  to  easily  show  devia- 
tions from  the  normal.  However,  there  was  not  much  hope  that  a  strongly 
diluted  albumin  would  coagulate  in  a  continuous  column,  or  at  least  would  not 
shrink  away  from  the  wall  of  the  tube.  In  order  to  reach  the  desired  results, 
the  idea  therefore  suggested  itself  of  evenly  distributing  the  albumin  over  a  "vehi- 
cle'"' or  "carrier/1  and  coagulating  it  within  the  tube.  Such  a  method  eventually 
could  be  applied  also  to  the  digestion  of  casein,  starch,  etc. 

The  requirements  of  such  a  vehicle  were  that  it  allow  free  penetration,  that  it 
would  not  be  digested,  or  slowly  digested,  much  slower  than  the  test  material  carried 
by  it,  and  that  in  such  ease  the  rate  of  its  digestion  be  exactly  known.  A  full 
knowledge  of  the  laws  of  penetration  and  of  digestion  became  thus  necessary.  Only 
by  such  knowledge  could  the  results  obtainable  with  such  vehicles  be  properly 
utilized. 

Penetration  Laws. — After  having  first  selected  a  substance  which  seemed  suit- 


292  ACCURATE  METHODS  IN  CLINICAL  INVESTIGATIONS. 

able  for  a  vehicle,  penetration  experiments  were  made  with  this  substance 
without  at  first  using  it  as  a  carrier  for  material  that  was  to  be  digested.  The 
choice  fell  on  agar  as  a  medium  to  be  penetrated,  but  coagulated  albumin  was  used 
also  m  the  same  role  for  some  of  the  experiments.  The  "penetrating"  fluid  selected 
as  a  first  choice  was  hydrochloric  acid,  in  view  of  its  being  a  normal  constituent  of 
the  gastric  juice. 

The  results  obtained  and  their  relative  rapidity  were  gratifying;  and  the  most 
satisfactory  feature  was  that  the  more  minutely  all  details  were  observed,  the  more 
accurate  became  the  results,  confirming  more  and  more  precisely  the  laws  formu- 
lated from  the  preliminary  experiments. 

I  shall  first  enumerate  the  laws  so  far  established  for  the  penetration  of 
hydrochloric  acid  with  relation  to  agar  at  37°  C.  To  what  extent  they  may  prove 
applicable  also  to  other  media  to  be  penetrated,  I  am  not  prepared  to  say.  But  in 
a  number  of  experiments  the  first  named  law  was  found  to  apply  also  to  the  penetra- 
tion of  hydrochloric  acid1  through  homogeneous  coagulated  egg  albumin. 

1.  The  velocity  of  penetration  is  in  direct  proportion  to  the  square  of  the  distances 
penetrated.  (This  law  may  eventually  find  its  limitation  in  high  or  very  low  con- 
centrations of  the  acid,  perhaps  also  of  the  agar.  It  was  found  to  hold  true  for 
concentrations  of  from  %  per  mille  to  8  per  mille  of  the  acid  and  of  from  y2  to 
2  per  cent,  of  the  agar.) 

■  2.  The  concentration- of  the  agar  within  the  limits  so  far  investigated  has  no 
influence  on  the  velocity  of  penetration  of  the  acid.  A  2  per  cent,  agar  is  as  quickly 
penetrated  as  1/2  per  cent.  agar. 

3.  Within  certain  limits2  ths  square  roots  of  the  concentrations  of  the  penetrat- 
ing hydrochloric  acid  (also  of  other  acids  ( ?) )  are  in  direct  proportion  to  the  squares 
of  the  distances  penetrated  by  them  in  the  same  time.  To  concentrations  above  about 
4  per  mille  the  law  does  not  apply. 

Methods  by  Which  the  Penetration  Laws  were  Established. — It  may  be  of  some 
interest  to  give  the  evolution  of  the  methods  which  led  to  the  discovery  of  the  laws 
above  defined. 

First,  the  fundamental  fact  had  to  be  established  whether  the  fluids  penetrated 
to  any  depth,  and  in  a  reasonable  time,  the  medium  to  be  penetrated.  For  this  pur- 
pose one  of  the  reactions  used  for  the  determination' of  hydrochloric  acid  iu  gastric 
analysis  was  utilized,  namely,  the  dimethyl-amido-azo-beuzol.  Solutions  of  this 
compound,  if  made  acid  by  hydrochloric  acid,  assume  a  deep  pink  color;  if  neutral 
or  alkaline,  a  canary  yellow  or  orange3  color.  The  following  experiment  was  first 
made: — 


1  2  per  mille. 

2 Of  concentration,  not  definitely  established  yet. 

3  If  stronger  solutions  of  the  dimethyl-aniido-azo-benzol  are  used. 


ACCURATE  METHODS  IN  CLINICAL  INVESTIGATIONS.  •       293 

A  small  grain  of  dimethyl-amido-azo-bcnzol  powder  was  dipped  into  a  thick 
celloidine  solution,  and  then  fished  out  again  with  the  cellpidine  surrounding  it. 
This  celloidine  coating  was  allowed  to  dry,  and  the  "pearl"  thus  formed  was  dipped 
into  a  weak  solution  of  hydrochloric  acid.  The  orange  colored  coating  at  once 
turned  pink.  A  new  "pearl"  was  then  made  and  inserted  into  a  glass  tube  3  cen- 
timeters long  and  of  an  inner  diameter  of  2  millimeters.  This  glass  tube  was  then 
put  into  a  dish  filled  with  melted  agar  (2  per  cent.),  allowing  the  latter  to  stream 
in,  taking  care  to  leave  the  "pearl"  in  position  about  the  middle  of  the  tube.  Sub- 
sequently the  agar  was  allowed  to  cool  until  solid,  and  the  glass  tube  cut  out  of 
the  solid  agar  mass  and  put  into  a  solution  of  hydrochloric  acid  of  about  the  con- 
centration in  which  it  is  present  in  the  normal  gastric  juice  after  an  Ewald-Boas 
test  meal,  namely,  approximately,  2  pro  mille.  After  about  an  hour  the  hitherto 
orange  yellow  coating  of  the  "pearl"  turned  pink.  The  experiment  was  very  in- 
structive and  convincing,  but  its  inadequacy  for  finer  measurements  was  apparent. 
It  was  therefore  modified  as  follows: — 

A  few  grains  of  dimethyl-amido-azo-benzol  were  dissolved  in  thick  celloidine 
in  a  mortar,  giving  the  celloidine  an  orange  color.  A  glass  rod  was  then  dipped 
into  this  mass  of  molasses-like  consistency,  and  by  taking  it  out  again,  a  celloidine 
thread  was  drawn.  The  rod  was  kept  quiet  until  the  thread  was  dry,  and  the  latter 
was  then  severed  and  cut  into  minute  chips.  These  chips  when  put  into  hydro- 
chloric acid  solution  gave  the  dimethyl-amido-azo-benzol  reaction  in  a  striking 
manner.  The  penetration  experiment  was  then  repeated.  Instead  of  the  "pearl," 
two  chips  were  used,  one  being  placed  near  the  center  of  the  agar-filled  glass  tube, 
the  other  about  midway  between  it  and  the  end.  The  reaction  was  seen  to  first 
appear  in  that  part  of  the  "distal"  chip  nearest  the  end  of  the  tube.  It  was  sharp 
enough  to  already  allow,  even  after  the  second  or  third  experiment,  the  formulation 
of  the  law  first  enumerated,  namely,  that  the  velocity  of  penetration  is  proportionate 
to  the  square  of  the  distances  penetrated.  But  the  figures  were  still  somewhat  in- 
accurate. Moreover,  the  method  had  the  great  inconvenience  that  one  had  to  sit 
by  and  watch  until  the  reaction  appeared,  and  was  unable  to  do  anything  else  in 
the  meantime.  Furthermore,  the  exact  moment  of  the  appearance  of  the  reaction 
was  hard  to  determine,  as  the  transition  from  orange  to  pink  was  not  sudden. 

Another  experiment  was  now  made.  Two  drops  of  a  1  per  cent,  aqueous 
alizarine  solution  as  used  for  the  determination  of  the  total  acidity  minus  com- 
bined hydrochloric  acid,  in  gastric  analysis,  were  added  to  LO  cubic  centimeters  of 
a  molted  %  per  cent,  of  agar  solution,  after  the  latter  had  been  made  slightly 
alkaline  by  5  drops  of  a  1/.2(t  solution  of  sodium  hydrate.  The  agar  assumed  now 
a  purple  color. 

Glass  tubes  of  an  inner  diameter  of  2  millimeters  of  different  length  were  then 

placed   in  the  agar  solution,  taking  care  to   let   them   till   up   without  air  bubbles. 
3 


294  ACCURATE  METHODS  IN  CLINICAL  INVESTIGATIONS. 

After  the  agar  mass  had  become  solid  by  cooling,  the  glass  tubes  were  cut  out  of 
it.  They  were  subsequently  placed  in  weak  hydrochloric  acid  solution,  the  penetra- 
tion of  which  showed  prettily  by  the  transformation  of  purple  into  a  yellow  color,  at 
the  ends.  The  yellow  columns  extended  further  and  further  toward  the  center,  until 
after  a  certain  time  they  met,  the  entire  agar  column  having  become  yellow.  The 
line  of  demarcation  between  the  purple  and  yellow  zones  was  very  sharp,  allowing 
measurements  even  of  1/8  millimeter  by  means  of  a  scale  divided  into  l/4  milli- 
meters which  bad  been  fixed  photographically  on  a  glass  plate  and  was  read  off  with 
a  dissection  microscope. 

These  alizarine  agar  tubes  made  the  experiment  much  easier  and  more  accu- 
rate, and  the  conditions  of  the  experiment  were  more  under  the  control  of  the 
experimenter.  It  was  made  possible  to  eliminate  the  influence  of  inequalities  of 
the  temperature  by  placing  all  tubes  in  the  incubator,  maintaining  an  even  tem- 
perature (37°  C.)  throughout  the  experiment.  The  tubes  could  be  taken  out  after 
definite  intervals,  and  the  distances  penetrated  measured.  The  more  minutely  all 
precautions  were  observed,  the  more  closely  did  the  actual  results  agree  with  the 
results  gained  by  calculation,  thus  confirming  more  and  more  strongly  the  law 
formulated. 

Here  is  an  example: — 

1st  distance  penetrated  :  9  millimeters  :  :  Time  required  for  penetration  :  12  )  minutes. 

2d  distance  penetrated   :  14  millimeters  ::  Time  required  for  penetration  :  :5<)0  minutes. 

In  substituting  X  for  the  time  required  to  penetrate  the  second  distance  (14 

millimeters),  and  calculating  it  according  to  the  formulated  law,  the  following 

equation  is  obtained: — 

Square  of  1st  Sqnar    of  2d  Penetration  Time  Penetration  Time 

distance.  distance.  for  1st  distance.  for  2d  distance. 

9  millimeters2      :       14  millimeteis2        ::         120  m.nutes  X 

14*  x  120  196jx  120 

X =    ■  =     290  minutes. 

A  92  81 

In  other  words,  the  actual  time  was   300  minutes,  the  calculated  time  290 

minutes;    i.e.,  an  error  no  greater  than  3  x/a  per  cent. 

Another  instance : — 

Square  of  1st  Square  of  2d  Penetration  time         Penetration  time 

distance  penetrated        distance  penetrated  of  1st  distance  of  2d  distance 

5  millimeters2        :         7  millimeters2  ::  4  minutes  :  X 

72  x  40  49  x  40  " 

v  ■     —     ■       —      =     .59.2  minutes. 

52  25 

The  actual  time  was  40  minutes;    therefore,  error  for  40  minutes  was  4/5  of 
a  minute,  or  2  per  cent. 

To  multiply  these  examples  would  be  useless. 


ACCURATE  METHODS  IN  CLINICAL  INVESTIGATIONS. 


295 


Here  is  an  instance  showing  the  validity  of  the  second  law,  namely,  that  the 
concentration1  of  the  agar  to  be  penetrated  has  no  influence  on  the  velocity  of 
penetration.  The  figures  are  given  for  both  ends  of  the  tubes,  showing  how  closely 
the  distances  at  each  end  tally  with  each  other: — 


Distance  Penetrated  Within  20  M.nutes. 

D. stance  Penetrated  Within  40  Minutes. 

At  One  End. 
Through  1   %   agar  7}  millimeters 

\%      "     7}          " 
"        \%      "     7} 

At  the  Other  End. 
74  millimeters 
7| 

74 

At  One  End. 
104,  millimeters 
10J 
10* 

At  the  Other  End. 
lOf  millimeters 
10f 
10| 

These  figures  speak  too  clearly  to  require  any  discussion.  Whatever  little  dif- 
ferences are  present  can  be  easily  explained  by  slight  faultiness  of  technique. 

Of  great  interest  and  eventual  practical  application  is  the  third  law:  the 
square  roots  of  the  concentrations  of  the  penetrating  hydrochloric  acid  are  within 
certain  limits2  in  direct  proportion  to  the  squares  of  the  distance  penetrated. 
Only  one  example  shall  be  adduced  to  show  its  validity. 


Fluid  I=Hydrochloric  acid  approximately  2  pro  mille  * 
Fluid  II=TV  strength  f  of  Fluid  I     .    .    .    .  ... 


Distance  Penetrated  After  215  Minutes. 


At  One  End.  At  the  Other  End. 

274  millimeters      27J  millimeters 

14  "  I    14  " 


Equation  : 

Square  root  of 

Concentration  of 

Fluid  I 


Square  root  of 

Concentration  of 

Fluid  II 


Square  of  Distance 

Penetrated  by 

Fluid  I 


1   :|  =  X2:142 

142  x  1  196 


X2 
X 


k 


X2 


19G  x  4  =  784 


Square  of  Distance 

Penetrated  by 

Fluid  II 

14  millimeters2 


V'784" 


=  28 


In  other  words,  calculated  penetrated  distance  =  28  millimeters ;  real  pene- 
trated distance  =  27  y2  millimeters,  or  an  error  of  1/2  against  28,  or  of  1.8  per 
cent. 

This  third  law,  governing  the  velocity  of  penetration  according  to  concentra- 
tion, may  find  a  practical  application.  The  distance  penetrated  in  a  given  time 
corresponds  always  to  a  definite  concentration  of  a  given  acid  (eventually  also  of 
other  fluids).  The  method  could  therefore  be  used  as  a  substitute  of  titration. 
For  this  purpose,  of  course,  a  table  would  first  have  to  be  compiled,  giving  for 

1  Wi  hin  the  limits  so  far  investigated,  i.  e.,  f.om  4  to  2  per  cut. 

2  Which  were  discussed  then  enumerating  the  'A  penetration  laws. 

*  Namely,  2%  hydrochloric  acid,  \  cubic  centimeter  ;  distilled  water,  5  cubic  centimeters, 
t  Diluted  with  enough  distilled  water  to  make  it  ,l0  the  strength  of  Fluid  I. 


296  ACCURATE  METHODS  IN  CLINICAL  INVESTIGATIONS. 

a  given  time  (say  two  hours)  on  one  side  all  the  distances  from  0  to  50  milli- 
meters; for  instance,  in  14  millimeters,  i.e.,  14,  l/2,  %,  1,  1 14,  1  l/2}  1  %,  2,  etc., 
millimeters;  on  the  other  side  the  concentrations  of  the  given  acid  corresponding 
to  these. 

The  details  of  this  method  cannot  be  given  here  for  lack  of  space.  Suffice  it 
to  show  how  some  very  simple  experiments,  if  accurately  conducted,  may  lead  to  the 
discovery  of  important  laws  which  may  find  practical  application.  No  doubt  here 
the  accuracy  of  methods  has  produced  gratifying  results. 

Albumin  Experiments. — Of  considerable  interest  are  some  of  the  observations 
made  with  egg  albumin.  As  homogeneousness  of  the  material  to  be  digested  was  a 
conditio  sine  qua  non  for  accurate  digestion  tests,  and  as  the  white  of  an  egg  is  not 
of  even  density  throughout,  the  following  procedure  was  adopted  to  fulfill  the 
requirements  of  reliable  tests: — 

The  white  of  the  eggs  was  dried,  pounded  to  a  fine  powder,  and  redissolved  in 
distilled  water  in  different  proportions.  Measurement  of  the  volume  of  the  un- 
altered — i.e.,  original — white  of  the  egg  and  weighing  of  the  same  after  drying, 
showed  that  the  white  of  the  egg  represents  a  solution  of  the  dry  albumin  of  about 
12  per  cent  strength,  and  therefore  some  of  the  solutions  were  made  up  of  this 
concentration.  Before  using  this  albumin  for  the  tests  it  was  centrifuged.  This 
process  freed  the  albumin  of  all  air  bubbles,  separating  the  mass  into  a  narrow, 
foamy,  upper  zone,  a  wide  zone  of  clear  fluid,  and  a  small  sediment  zone  about  one 
inch  long  at  the  bottom  of  the  tube.  The  middle  zone  of  clear  fluid  alone  was  used. 
This  "disorganized"  white  of  egg  had  interesting  physical  qualities.  On  being 
coagulated  by  heat,  it  assumed  a  beautiful  opalescence,  being  quite  transparent  in 
thin  layers. 

Some  other  interesting  features  were  observed  in  this  albumin.'  Test-tubes 
were  filled  with  it,  and  a  number  of  glass  tubes  of  an  inner  diameter  of  2  millime- 
ters put  in,  removing  all  air  bubbles  by  tapping.  The  test-tube  was  then  stoppered, 
put  into  and  left  in  boiling  water  until  the  albumin  was  coagulated.  The  tubes 
were  subsequently  cut  out  and  subjected  at  body  temperature  to  an  artificial  gastric 
juice  composed  as  follows: — 

Pepsin  (Merck)       ...  .    .  grs.  ij. 

Hydrochloric  acid,  2%    (this  concentration 

was  determined  by  titration)      ....      -J-  cc. 
Distilled  water 5  cc. 

A  narrow  white  line1  was  soon  seen  to  .appear  near  either  end  of  the  tube 

respectively,  moving  gradually  toward  the  middle  of  the  tube,  but  not  increasing 

in  its  width,  which  was  about  x/10  millimeter.     It  was  found  that  this  zone  moved 

with  a  velocity  corresponding  to  law  No.  1.     After  having  "reached  the  center  and 

amalgamated  with  its  antipode,  it  disappeared. 

1  Or,  more  correctly  speaking,  white  disc. 


ACCURATE  METHODS  IN  CLINICAL  INVESTIGATIONS. 


297 


To  find  out  to  which  of  the  constituents  of  the  artificial  juice  this  phenomenon 
was  due,  or  whether  it  was  due  to  both,  the  following  experiment  was  made: — 

One  tube  was  put  into  the  artificial  juice  above  described.     Another  tube  was 

put  into 

2%  hydrochloric  acid £  cc. 

Distilled  water 5  cc. 

or,  in  other  words,  into  the  same  fluid  minus  the  pepsin. 

Both  tubes  were  put  into  their  respective  fluids  at  the  same  time,  and  the 
effect  was  watched.  It  proved  that  both  tubes  showed  the  line,  and  that  it  moved 
with  exactly  the  same  velocity  in  both,  showing  thus  that  this  "demarcation  line" 
was  purely  due  to  the  influence  of  the  hydrochloric  acid,  since  I  may  add  that  dis- 
tilled water  alone  did  not  produce  such  a  line. 

Here  are  the  figures  illustrating  the  results : — 


Experiment  with  the  Fuld  Containing  the  Hydrochloric 
Acid  Plus  Pepsin. 


At  One  End. 

1.  After    31  minutes,  2§  millimeters 

2.  "         62         "        3J  " 

3.  "       124         "        51 


At  the  Other  End 
2|  millimeters 
3f 
5| 


Experiment  with  the  Fluid  C  nt  lining 
the  Hydrochloric  Acid  Alone. 


At  One  End.  At  the  Other  End. 

2f  millimeters  2|  millimeters 

3*           "  3| 

51             u  ea             (< 


In  testing  here  again  the  validity  of  the  first  penetration  law  by  calculating 
the  penetration  time  for  3,  from  the  penetration  distance  of  3  (5%  millimeters), 
from  the  penetration  time  of  2  (62  minutes),  and  from  the  penetration  distance 
(3%  millimeters)  of  2,  the  following  result  is  obtained : — 


Square  of  2d  distance 
penetrated. 

3J  millimeters  2 
of2  x  62 


X    = 


31* 


Square  of  3d  distance 
penetrated.         "" 

5|  millimeters  2 

28.89  x  62 
14.0(5 


Penetration  time 
for  2d  distance 

62  minutes 
1791.18 


Penetration  time 
for  3d  distance 

X 


14.06 


=        127  minutes. 


Instead  of  124  minutes  ;  ctu  il  time. 
Error  =  3  :  127,  or  2.28  per  cent. 

Food  for  interesting  speculation  is  given  by  the  results  of  the  second  penetra- 
tion law  if  the  penetration  velocities  through  agar  and  albumin  are  compared. 
While  density  of  one  and  the  same  homogeneous  medium  has  no  influence  on  the 
velocity  of  penetration,  the  difference  in  the  nature  of  the  homogeneous  medium 
plays  a  decided  role.  In  127  minutes  coagulated  albumin  had  been  penetrated  by 
a  hydrochloric  acid  solution  of  given  strength  (approximately  2  pro  mille)  fur  a 
distance  of  5  %  millimeters  only.  In  120  minutes  (that  is,  in  slightly  less  time) 
agar  had  been  penetrated  by  hydrochloric  acid  of  exactly  the  same  strength  lor  a 
distance  of  17  !/»  millimeters;  i.e.,  slightly  more  than  three  times  as  great  as  the 
albumin. 


298  THYROID  EXTRACT  AND  THE  COAGULATION  OF  BLOOD. 

What  is  it,  then,  that  causes  this  difference  between  two  media,  if  the  density 
of  one  and  the  same  medium  plays  no  role?  Is  it  a  matter  of  chemical  affinity,  or 
of  the  size  of  the  molecule,  or  what? 

Certainly  this  is  a  subject  of  interest,  even  though  reaching  out  of  the  field 
of  medicine.  It  must  be  admitted,  that  this  second  law  still  requires  further  veri- 
fication as  to  the  generality  of  its  application,  and  therefore  conclusions  must  be 
made  with  some  caution. 

Let  me  briefly  mention  another  fact  brought  out  by  the  tests  with  the  "disor- 
ganized" egg  albumin;  namely,  that  such  albumin  is  digested,  not  only  by  pepsin 
plus  hydrochloric  acid,  but  even  by  hydrochloric  acid  alone  in  concentrations  in 
which  the  latter  is  found  in  gastric  contents  after  test  meals — i.e.,  approximately  2 
pro  mille. 

We  see  thus  that  accuracy  of  method  has  within  a  comparatively  short  space 
of  time1  led  to  the  following  results : — 

1.  The  apparent2  discovery  of  three  physical  laws. 

2.  The  discovery  of  the  principle  for  a  new  method  of  quantitative  acid  deter- 
mination. 

While  the  facts  elucidated  have  as  yet  no  direct  bearing  to  the  subject  which 
it  was  intended  to  investigate- — namely,  the  gastric  function  of  ihe  epileptic — they 
seem  sufficiently  important  in  themselves,  and  moreover,  they  give  a  very  important 
preparatory  basis  for  such  investigations,  without  which  the  latter  could  not  be 
carried  out  with  any  degree  of  reliance. 

B.  Onuf  (Onufrowicz).* 


THE  INTERNAL  USE  OF  THYROID  EXTRACT  TO  INCREASE  THE 
COAGULABILITY  OF  THE  BLOOD. 

The  use  of  thyroid  extract  internally  to  increase  the  coagulability  of  the 
blood  and  thus  to  diminish  the  dangers  which  all  surgeons  fear  in  operating  upon 
"bleeders"  seems  well  worthy  of  an  extended  trial,  either  in  cases  of  true  haemo- 
philia or  where  the  coagulating  time  has  been  increased  by  disease.  The  pathology 
of  this  condition  is  as  yet  so  undecided,  and  so  many  causes  have  been  assigned  for 
its  occurrence,  that  until  this  matter  is  more  systematically  investigated  little  can 
be  said  concerning  it.  The  statement  has  been  made  that  the  coagulating  time  of 
the  blood  in  true  hemophilics  is  not  materially  increased,  but  nowhere  have  I  been 
able  to  find  any  account  of  accurate  blood-tests  to  determine  this  point.  I  hope 
that  it  may  soon  receive  the  attention  which  its  importance  deserves. 


*  Pathological  Laboratory  of  the  Craig  Colony  for  Fpileptics,  Sonyea,  N.  Y. 

1  About  three  months. 

2  I  have  not  studied  the  text-books  of  physics  yet  to  positively  state  that  theEe  laws  are 
yet  unknown. 


THYROID  EXTRACT  AND  THE  COAGULATION  OF  BLOOD.         ^99 

My  own  experience  of  the  past  few  months  in  the  administration  of  thyroid 
extract  has  heen  confined  to  three  cases,  a  short  account  of  which  I  give  here,  hut 
I  purpose  in  the  near  future  to  give  elsewhere  a  more  detailed  and  elaborate  state- 
ment. 

At  the  suggestion  of  Dr.  C.  E.  do  M.  Sajous,  whom  I  consulted,  3  grains  of 
the  dried  thyroid  extract  were  given  three  times  a  day  to  a  woman  of  38  years. 
She  was  a  bleeder  who  required  a  nephropexy  for  an  extremely  movable  kidney. 
The  symptoms  produced  by  the  kidney  were  most  pronounced,  with  crises  in  which 
there  was  suppression  of  urine  with  hydronephrosis  accompanied  by  evidences  of 
uraemic  intoxication.  The  urine  at  these  times  was  loaded  with  blond,  and  there 
were  evidences  of  intense  congestion.  This  condition  was  so  serious  that  an  opera- 
tion to  fix  the  kidney  in  place  was  urgently  demanded,  as  no  bandage  or  pad  was 
of  any  value.  For  many  years  she  had  bled  profusely  from  the  simplest  wound. 
A  slight  operation  performed  upon  her  nose  had  caused  such  furious  and  persistent 
haemorrhage  that  her  physician  was  then  alarmed  for  her  life.  About  two  years 
ago  she  had  bled  from  nearly  all  of  her  mucous  membranes  and  a  series  of  pur- 
puric spots  appeared  over  her  body.  As  is  usual  in  these  cases,  her  menstrual  flow 
was  not  abnormal.  When  she  came  under  my  care  a  test  of  the  blood  showed 
haemoglobin  TO  per  cent.,  erythrocytes  3,350,000,  leucocytes  5800,  while  the  coagu- 
lation time  was  eleven  and  one-half  minutes — the  normal  being  from  three  to 
five — and  the  needle-prick  of  the  finger  bled  for  hours  and  was  only  controlled  by 
pressure.  Under  careful  and  systematic  treatment  by  iron,  malt,  massage,  and 
feeding,  and  the  use  of  thyroid  extract,  the  coagulating  time  of  the  blood  dimin- 
ished from  eleven  and  one-half  minutes  to  three  minutes  and  four  seconds.  Oper- 
ation was  about  to  be  undertaken,  when,  for  causes  other  than  those  connected  with 
her  physical  condition,  it  was  necessary  for  a  postponement.  Six  weeks  later  thy- 
roid extract  was  given  for  four  days,  and  the  coagulating  time  was  now  found  to 
be  two  minutes  and  six  seconds.  The  next  day  she  was  given  ether  and  an  incision 
made  in  the  right  loin,  and  the  kidney  fixed  in  place  by  means  of  sutures  passed 
through  dense  adhesions  which  were  found  to  be  attached  to  the  kidney,  the  resull 
of  former  inflammation,  but  no  sutures  were  passed  through  the  kidney  structure. 
To  the  astonishment  of  all  present  the  wound  was  remarkably  dry,  there  being 
much  less  oozing  than  is  usually  seen  in  such  operations.  The  after-course  of  the 
wound  was  extremely  satisfactory,  as  she  made  a  prompt  and  normal  convalescence 
and  there  was  no  bleeding  or  oozing  from  the  wound  whatever. 

The  second  case  was  a  boy  18  years  old,  a  bleeder  of  a  family  of  bleeders,  who 
was  operated  upon  for  necrosis  of  the  fibula  following  an  osteomyelitis,  and  until 
after  the  operation  I  had  not  known  of  this  family  tendency.  The  wound  bled  for 
weeks,  the  dressing  being  saturated  continuously,  and   it  did  not  do  well,  as  it 


300  THYROID  EXTRACT  AND  THE  COAGULATION  OF  BLOOD. 

showed  no  disposition  to  heal  and  the  granulations  were  large,  intensely  congested, 
and  bled  on  the  slightest  touch.  He  lost  flesh  and  appetite,  his  color  was  poor, 
and  he  became  weak  and  mentally  dull  and  discouraged.  Various  forms  of  tonics 
were  tried  without  any  improvement,  until  finally  he  was  given  thyroid  extract. 
Almost  immediately  there  was  a  marked  change  for  the  better  in  his  condition, 
but  particularly  was  this  seen  in  the  wound.  After  he  had  been  taking  the  thyroid 
for  one  week  all  bleeding  from  the  granulations  in  the  wound'  had  ceased,  and  it 
began  to  heal  rapidly,  although  no  change  was  made  in  the  materials  used  in  the 
dressing,  nor  was  any  other  form  of  internal  medicine  employed.  It  is  to  be 
regretted  that  there  was  no  test  of  the  coagulation  time  of  the  blood  made  in  this 
case. 

The  third  case  was  that  of  a  woman  who  had  been  a  bleeder  all  her  life,  and 
who,  eight  years  before,  had  bled  from  the  gum  forty-eight  hours  alter  a  tooth  had 
been  pulled.  Several  slight  cuts  had  bled  most  profusely,  and  she  was  subjected 
to  violent  expistaxis  at  frequent  intervals.  She  was  given  thyroid  extract  for  two 
days,  and  then  two  teeth  were  extracted.  The  dentist  found  considerable  difficulty 
in  this,  as  the  teeth  broke  down  under  manipulations  and  the  gum  was  badly 
lacerated.  In  spite  of  the  great  amount  of  trauma  there  was  less  bleeding  than 
could  have  been  expected  in  an  ordinary  individual. 

These  three  cases  were  all  unmistakable  bleeders,  and  the  remarkable  results 
following  the  use  of  thyroid  extract  can  only  be  attributed  to  its  influence.  In  the 
first  and  third  instances  haemorrhage  would  have  been,  of  a  certainty,  a  dangerous 
complication,  and  in  the  second  the  remarkable  improvement  in  the  appearance 
of  the  wound  and  the  sudden  cessation  of  the  oozing  could  only  be  due  to  its  action. 
How  does  thyroid  extract  act  to  accomplish  these  remarkable  results? 

Dr.  Sajous  considers  that  by  administering  thyroid  extract  we  stimulate  the 
anterior  pituitary  body,  which  in  turn  excites  the  adrenals  to  greater  activity,  thus 
augmenting  the  proportion  of  fibrin  ferment  in  the  blood  and  consequently  its 
coagulating  power.  His  researches  go  to  show  that  the  secretion  of  the  adrenals 
on  reaching  the  lungs  becomes  converted  into  an  oxidizing  agent,  or,  as  he  expresses 
it,  the  albuminous  constituent  of  the  haemoglobin  molecule.  This  substance  he 
finds  to  be  identical  with  the  "oxidases"  of  the  French  chemists,  and  with  fibrin 
ferment  in  its  reactions.  Where  the  functional  activity  of  the  adrenals  is  enhanced 
the  volume  of  fibrin  ferment  in  the  blood  (which  ferment  by  uniting  with  fibrin- 
ogen endows  the  latter  with  its  coagulating  property)  is  increased.  He  contends 
that  the  governing  center  of  the  adrenal  is  the  anterior  lobe  of  the  pituitary  body, 
and  this  organ  is  kept  active  by  the  internal  secretion  of  the  thyroid. 

If  this  be  true  it  would  explain  the  action  of  thyroid  extract  in  diminishing 
haemorrhage  in  these  hemophilics,  and  if  the  practical  results  obtained  continue 


ARTIFICIAL  DRUMHEADS  AND  OTHER  AIDS  OF  HEARING.  301 

in  other  cases  to  be  as  satisfactory  as  in  the  three  instances  which  I  have  just 
related,  its  value  to  the  surgeon  will  prove  to  be  tremendous.  This  explanation  of 
Dr.  Sajous  is  the  only  adequate  one  that  I  have  yet  seen  concerning  it. 

There  are  a  number  of  reported  cases  in  which  thyroid  extract  has  been  used 
in  hemophilics  with  prompt  and  satisfactory  results,  and  it  is  well  worthy  of  an 
exhaustive  trial  in  all  of  such  cases,  and  particularly  as  a  preparatory  method  of 
treatment  whenever  surgical  operation  must  be  undertaken  upon  these  unfortunate 
persons. 

This  preliminary  statement  is  made  in  the  hope  that  a  much  wider  use  may 
be  made  of  this  valuable  remedy. 

William  J.  Taylor.* 


SOME   FACTS   ABOUT   ARTIFICIAL.   DRUMHEADS   AND   OTHER 

AIDS  OF  HEARING. 

Much  has  been  written  about  the  perversion  of  medical  practice  in  the  hands 
of  opticians,  who  undertake  to  prescribe  not  only  for  refraction-defects,  but  for 
many  ©ther  ocular  affections;  but  too  little  has  been  said  of  a  kindred  subject — 
the  vending  of  artificial  drumheads  and  such  apparatus,  with  the  booming  of  which 
the  advertising  pages  of  medical  and  lay  magazines  arc  full.  Much  more  wide- 
spread than  the  feeling  that  anybody  who  can  repair  jewelry  can  fit  lenses  precisely 
to  the  eyes,  is  an  impression  among  medical  and  laymen  alike  that  there  is  nothing 
to  be  done  for  deafness  except  employ  some  apparatus  or  other  aid.  Conspicuous 
and  annoying  as  trumpets  arc,  there  is  a  great  search  for  invisible  yet  potent  helps; 
and  the  hundreds  of  thousands  spent  in  advertising  such  devices  give  strong  testi- 
mony to  the  far  greater  sums  that  must  constantly  pass  into  the  hands  of  those 
who  offer  new  patented  helps.  Were  the  advertisements  as  approximately  truthful 
as  those  of  the  circus-poster  there  would  be  less  reason  to  condemn  them  ;  but  their 
claims  are  so  flagrant  and  beyond  all  possibility  of  performance  and  their  methods 
so  often  highly  reprehensible  that  a  word  on  the  subject  seems  decidedly  called  for. 
Some  years  since  the  proprietors  of  an  alleged  incomparable  restorer  of  hearing 
secured  an  advertisement  page  in  the  University  Medical  Magazine  and  have  not 
since  ceased  to  quote  under  the  caption  "what  the  official  organ  of  the  University 

Medical  Department  has  to  say  in  praise  of  the  artificial  drumhead,"  as 

though  the  words  were  something  else  than  their  own  paid  advertisement.  Boomed 
in  such  consciousless  fashion  it  is  small  wonder  that  the  many  having  defects  of 
hearing  (Troltsch  showed  us  fifty  years  ago  that  one  adult  in  three  is  deaf  in  one 
or  both  ears)  should  turn  toward  these  wonder-compelling  appliances,  "guaranteed 
*  Surgeon  to  the  Orthopedic  Hospital  of  Philadelphia,  etc. 


302  ARTIFICIAL  DRUMHEADS  AND  OTHER  AIDS  OF  HEARING. 

to  be  original  and  valuable  by  the  granting  of  letters  patent  by  the  United  States," 
and  to  waste  their  earnings  upon  one  after  another  of  these  devices  which  frequently 
promise  not  merely  aid,  but  cure  and  restoration  of  hearing.  For  the  great  ma- 
jority of  cases  such  devices  are  utterly  useless  and  generally  far  from  harmless. 
Foreign  bodies  in  the  ear  are  rarely  dangerous  if  let  alone ;  but  few  of  these  artificial 
drumheads  are  so  unirritating  that  they  can  long  remain  present  without  real  detri- 
ment to  ears  which  can  ill  afford  any  further  impairment.  For  the  suppurating 
cases  they  can  easily  become  serious  obstacles  to  proper  cleansing  and  may  give  rise 
to  dangerous  or  fatal  extension  of  the  disease. 

This  is  an  electric  age;  so  many  of  the  devices  claim  marvelous  aid  from  mag- 
netism or  electricity  either  for  the  cure  or  improvement  of  hearing.  A  tiny  coil 
of  magnetized  wire  or  other  form  of  magnet  is  stated  to  be  capable  of  doing  more 
for  the  magnification  of  sounds  than  the  most  practical  and  elaborate  microphone 
has  as  yet  secured.  It  is  said  that  the  inventor  of  the  microphone,  almost  hopelessly 
deaf,  has  not  been  able  to  devise  an  instrument  which  will  aid  his  own  hearing ;  and 
expert  study  from  the  medical  side  has  shown  that  the  microphone  is  valueless  and 
offers  practically  no  promise  in  aid  of  the  deaf.  Yet  enormous  claims  are  put  forth 
by  rival  microphone  constructors — neither  of  whom  can  sufficiently  blackguard  the 
other — as  to  their  ability  to  aid  the  deaf  and  give  hearing  to  the  deaf-mute.  The 
public  prints  are  used  to  laud  the  brilliant  results  achieved  and  to  catalogue  the 
medical  men  who,  seeking  to  investigate  the  subject,  are  at  once  set  forth  as  ardent 
advocates  of  the  apparatus.  Such  appliances  are  able  to  help  those  whose  defect  is 
only  i'ci  regard  to  low  tones,  but  who  hear  through  the  telephone  the  voice  trans- 
posed to  a  higher  register,  when  they  are  unable  to  hear  it  unaided.  Whether  any 
of  them  are  better  than  the  simplest  magnetic  telephone  is  doubtful.  Certainly  the 
more  electric  current  that  is  used  the  louder,  more  disturbing,  and  less  articulate 
and  clear  is  the  sound  heard  through  such  instruments. 

Any  device  which  brings  the  voice  audibly  to  the  impaired  ear  can  be  of  some 
benefit  and  possibly  can  work  a  slow  improvement;  but  it  is  very  different  with  the 
measures  of  electric  vibration  employed  to  stimulate  the  nerve  or  to  benumb  its 
sensitiveness  to  harassing  subjective  sounds.  The  success  such  apparatus  sometimes 
achieves  in  exhausting  the  nerve-force  and  so  making  the  ear  insensitive  to  tinnitus 
should  be  sufficient  warning  as  to  the  damage  which  it  can  do  to  any  useful 
remnant  of  hearing.  Certainly  they  rarely  fail  to  injure  rather  than  help  those  who 
seek  the  benefit  which  they  arc  assured  can  be  expected  from  them. 

An  "International  Specialist"  writes  from  the  West  to  a  patient  of  mine: 
"Your  answers  to  the  questions  in  my  diagnosis-blank  are  so  clear  and  complete 
that  I  am  certain  you  can  be  cured  by  my  treatment.  Never  before  in  the  history 
of  the  world's  medical  science  could  you  have  been  cured.     Deafness  was  never 


HYPOTHESIS  ON  ETIOLOGY  OF  SCOLIOSIS  IN  CHILDREN.  303 

cured  by  any  treatment  within  my  knowledge  until  I  perfected  my  Electro-Vibra- 
tory treatment  less  than  three  years  ago.  I  offer  you  the  only  rational,  complete, 
and  genuine  cure  which,  in  the  crucible  of  trial,  stands  the  test  of  curing  completely 
and  permanently;"  and  continues  with  two  thousand  words  of  laudation  of  this 
apparatus,  which  is  simply  a  vibrator  of  variable  rapidity  with  tubes  conveying 
the  sounds  of  the  current-breaker  to  the  ears.  Two  minutes  of  such  treatment  and 
two  of  application  of  the  current  itself  through  tiny  electrodes  inserted  in  the  cars, 
is  the  infallible  method  offered,  irrespective  of  the  fact  that  the  current  is  faradic 
not  galvanic,  and  with  no  account  taken  of  the  poles  of  the  battery,  or  whether 
cathode-opening  or  anode  closure  may  not  greatly  increase  instead  of  lessen  any 
tinnitus  present.  The  device  is  electric — that  is  all  the  patient  knows,  and  appa- 
rently all  that  the  inventor  knows  or  cares  except  as  to  its  price  and  the  payment, 
as  to  which  his  directions  are  much  more  explicit. 

It  is  probably  hopeless  to  try  to  stem  the  tide  of  unfortunates  which  sets 
toward  such  charlatans.  Whatever  the  possibilities  of  their  cases  under  rational 
treatment,  there  are  many  who  prefer  to  try  irregular  practitioners,  and  only  a 
few  who  will  ask  medical  advice  as  to  these  aids  which  are  offered  under  such 
glowing  encomiums.  But  it  does  seem  right  that  the  profession  should  be  some- 
what aroused  not  only  as  to  the  ethics  of  the  case,  but  warned  of  the  serious  detri- 
ment to  their  friends  and  patients  which  lurks  in  many  of  these  "patented"  devices. 
There  is  no  more  sense  or  propriety  in  recommending  patients  to  try  these  "patent 
eardrums"  than  there  would  be  in  sending  them  for  other  ailments  to  a  non-medical 
patent-medicine  man  whose  advertisement  assures  them  that  "'there  is  hope.** 

B.  Alex  Randall.* 


HYPOTHESIS  ON  THE  ETIOLOGY  OF  SCOLIOSIS  IN  CHILDREN. 

Oub  knowledge  of  the  causes  conditioning  lateral  curvature  still  leaves  much 
to  be  desired.  Many  etiologic  factors  are  recognized  which  on  inspection  prove 
to  he,  in  essence,  contributory  rather  than  fundamental.  A  study  of  a  relatively 
new  principle  of  applied  physiology,  utilized  in 'both  diagnosis  and  treatment, 
lias  suggested  to  me  that  herein  we  may  find  an  explanation,  capable  of  fur- 
nishing the  key  to  a  large  proportion  at  least,  of  those  instances  of  lateral 
curvature  arising  in  the  very  young.  The  only  way  by  which  this  postulate 
can  he  verified  or  set  aside;  is  by  a  broad  cooperation  among  clinicians,  espe- 
cially family  physicians,  who  alone  are  able  to  note  the  causes  ami  effects,  herein- 
after outlined,  in  their  incipiency.  Orthopedists  can  do  much  if  they  will  take 
the  trouble  to  amplify  their  case  histories  by  searching  into  the  data  of  earlier 
illnesses,  noting  the  time  of  occurrence,  the  extent  of   involvement,   what   lesions 


*  Professor  of  Otology — University  of  Pennsylvania. 


304  HYPOTHESIS  ON  ETIOLOGY  OF  SCOLIOSIS  IN  CHILDREN. 

persist,  and  to  what  degree  they  depress  vitality.  Already  my  own  observations 
lead  me  to  note  many  remarkable  coincidences.  How  far  these  factors  will  reach, 
to  what  degree  they  may  impress  a  skeptic,  time  and  the  aggregation  of  further 
statistics  alone  can  determine.  If,  however,  my  hypothesis  be  not  entirely  correct, 
at  least  I  feel  confident  that  it  must  be  along  some  such  line  of  research  that  we 
shall  find  the  earliest  prephenomena  and  omens  of  this  disability.  I  particularly 
request  that  the  suggestion  may  receive  such  attention  as  at  least  the  gravity  of 
the  subject  undoubtedly  warrants,  and  that  observers  will  record  frankly  the  striking 
coincidences  which  must  come  to  their  attention  and  which,  to  my  mind,  closely 
resemble  causes  and  effects.  I  may  be  permitted  to  make  some  quotations  from  a 
paper  by  myself  on  "Diagnosis  in  Diseases  of  Children."1  Few  or  no  pathologic 
processes  can  exist  in  the  body  without  manifesting  themselves  by  disturbances  in 
ihc  nervous  mechanisms  of  the  area  or  parts  involved.  These  are  brought  about 
by  changes  in  the  circulation  of  the  central  nervous  system.  A  large  part,  by  far 
the  largest  part,  of  the  nervous  mechanisms  of  the  body  are  located  in  the  spinal 
cord.  Disturbances  of  the  circulation  in  the  spinal  cord  have  been  shown  to  be 
expressed  externally  by  alterations  in  the  conditions  of  those  tissues  supplied  by 
the  posterior  primary  divisions  of  the  spinal  nerves,  as  well  as  in  the  peripheral 
parts  diseased. 

There  is  found  to  be  a  correlationship  between  the  blood  supply  of  organs  and 
their  functional  processes,  and  this  involves  the  status  of  the  blood  supply  in  those 
segments  of  the  cord  in  which  the  cell  bodies  reside  and  from  which  the  viscera, 
etc.,  are  innervated. 

•Explanations  of  viscero-motor  and  other  activities  must  be  sought  through  a 
practical  knowledge  of  vasomotor  mechanisms  and  functions  of  the  spinal  segments 
through  which  the  viscus  is  controlled. 

Effects  upon  the  blood  supply  of  all  parts  of  the  body  can  be  induced  by 
stimulating  the  centers  in  the  spinal  cord  more  directly  and  forcefully,  and  through 
them  exerted  upon  the  sympathetic  centers  and  ganglia,  than  from  measures  directed 
immediately  to  the  organs  disturbed.2  Conversely,  disturbances  in  the  various 
organs,  systems,  and  tissues,  being  due  to  circulatory  changes  induced  reflexly 
through  the  central  nervous  system,  the  major  portion  of  the  nervous  mechanisms 
being  located  in  the  spinal  cord,  disturbance  of  the  circulation  in  the  cord  is 
expressed  by  alterations  in  the  structures  of  those  parts  supplied  by  the  posterior 
primary  divisions  of  the  spinal  nerves,  as  well  as  of  -the  parts  affected.  During 
the  continuance  of  diseased  states,  or  even  lesser  disturbances,  pronounced  altera- 


1  Published  consentaneously  in  the  British  Journal  of  Children's  Diseases,  January  1,  1905, 
and  the  New  York  Medical  News,  December  17,  1904. 

2  See  Lander  Brunton's  explanation  of  the  effects  of  a  mustard  plaster.     Lectures  on  Phar- 
macology, etc. 


HYPOTHESIS  ON  ETIOLOGY  OF  SCOLIOSIS  IN  CHILDREN.  305 

tions  are  to  be  observed  in  those  tissues  immediately  innervated  by  fibers  arising 
in  the  spinal  segments  whose  integrity  is  thus  affected  by  derangements  in  func- 
tion of  organs  and  areas  dependent  upon  those  segments.  In  brief  there  is  both 
a  sensory  and  nutritive  reaction  exhibited  upon  the  erector  spina}  muscles,  and 
allied  structures,  ligaments,  etc.,  caused  by  the  disturbed  circulatory  equilibrium  in 
areas  depending  for  control  upon  certain  groups  of  segments  of  the  cord. 

There  is,  as  has  been  said,  a  compensatory  relationship  existing  between,  first, 
Hie  surface  muscles  and  ligaments,  skin,  etc.,  supplied  by  the  posterior  primary 
divisions  of  the  spinal  nerves;  and  second,  the  blood  vessels  of  the  cord  and  the 
deep  structures,  organs,  and  remoter  parts,  innervated  by  fibers  whose  cell  bodies 
arise  in  the  corresponding  region  of  the  cord. 

Any  agent  or  irritant,  mechanical,  electric,  infective,  toxic,  or  other,  which 
causes  vascular  constriction  in  the  tissues  of  the  back  contiguous  to  the  spinal 
column  will  produce,  conversely,  dilation  of  the  vessels  in  the  cord  and  of  the  organs 
and  beyond  parts,  in  the  line  of  innervation. 

I  have  been  scrutinizing  the  conditions  of  the  back  with  these  possibilities  in 
view  for  three  years  at  my  clinic  at  the  Children's  Hospital  and  in  my  service  at 
the  Children's  Hospital  at  the  Philadelphia  Hospital,  and  am  increasingly  impressed 
with  the  many  significant  conditions  observed.  After  long  continued  disturbances 
in  the  lungs  there  is  almost  always  a  marked  derangement  in  the  alignment  of  the 
upper  dorsal  vertebrae.  Where  there  have  been  protracted  disorders  of  the  digestive 
organs  there  are  to  be  noted  similar  disorganizations  of  the  vertebrae  of  the  lower 
dorsal  and  upper  lumbar  regions.    To  continue  quoting  from  the  aforesaid  paper : — 

On  inspecting  the  back  of  one  who  is  and  always  has  been  perfectly  sound 
there  will  be  seen,  if  certain  attitudes  are  assumed  to  bring  them  into  prominence, 
the  spines  of  the  vertebrae  in  normal  alignment,  distance  apart,  and  degree  of  poste- 
rior projection.  If  there  has  been  a  history  of  long  continued  or  recurrent  disturb- 
ances of  the  internal  organs,  these  are  frequently  evidenced  by  alterations  in  the 
tonus  of  the  blood-vessels  of  those  muscles  and  other  tissues  innervated  by,  or  lying 
adjacent  to,  the  governing  segments  of  the  cord  from  which  the  organs  at  fault 
are  reflexly  controlled  through  their  vasomotor  connections.  The  change  of  form 
is  an  atrophy  of  some,  infiltration  and  thickening  of  others,  and,  if  long  continued, 
asymmetries  of  the  vertebrae,  the  spines  apparently  pointing  in  different  directions. 
If  the  lesions  have  become  chronic,  the  spines  arc  then  usually  found  separated 
owing  to  relaxation  of  the  posterior  ligaments,  until  between  two  or  more  appear, 
marked  depressions  or  several  are  depressed  below  the  normal  line  of  projection. 
These  disarrangements  of  the  vertebrae  are  more  apparent  than  real,  the  asym- 
metries being  due  to  loss  of  tone  and  relaxation  in  the  supporting  ligaments  and 
these  disappear  under  appropriate  treatment. 


306  ACETANILID  POISONING.  ALCOHOL  AND  THE  CIRCULATION. 

If  these  phenomena  are  observable,  they  undoubtedly  seem  to  be  constant  in 
transitory  states,  producing  these  demonstrable  alterations  in  the  morphology  of 
the  structures  of  the  vertebral  column  and  adjacent  tissues,  it  is  fair  to  assume  that 
a  persistence  of  these  may  result  in  permanent  lesions  and  deformities. 

If  further  studies  corroborate  the  postulate  and  we  find  that  a  large  proportion 
of  these  disabilities  end  in  lateral  curvatures,  it  is  obvious  that  we  have  here  a 
means  of  correcting  these  deformities  in  their  incipience. 

The  means  for  doing  this  are  two-fold :  first,  the  prompt,  thorough,  and  con- 
sistent correction  of  the  visceral  derangements,  pursuing  treatment  till  the  desired 
finality  is  reached,  and,  second,  by  manipulations  of  the  structures  exhibiting  the 
morphologic  and  sensory  alterations  by  measures  which  I  will  set  forth  on  a  later 
occasion. 

Already  I  have  had  under  constant  treatment  six  or  seven  cases  of  distinct 
lateral  curves,  seemingly  due  to  definite  visceral  disorders,  which  have  subsided. 

In  some  of  these  I  have  had  consultations  with  orthopedic  surgeons  to  verify 
my  findings  and  results. 

J.  Madison  Taylor,* 

Philadelphia. 

Cyclopedia  of  Current  biteratur*?. 


acetanilid  POISONING.  cyanosis.  Apart  from  the  usual  choco- 
The  writer  reports  a  considerable  late  hue  of  the  blood  so  noticeable  on 
number  of  cases  of  chronic  acetanilid  puncture,  the  blood-picture,  were  it  not 
poisoning.  Special  attention  is  given  for  an  almost  invariably  present  leuco- 
to  the  condition  of  the  blood  and  of  the  cytosis,  would  suggest  pernicious  anae- 
urine.  The  blood  picture  is  quite  char-  mia.  D.  D.  Stewart  (Journal  of  the 
acteristic.  The  haemoglobin  cannot  be  American  Medical  Association,  June  3, 
estimated,  on  account  of  the  presence  1905). 
of  methsemoglobin,  which  gives  the  char- 
acteristic chocolate,  color  to  the  blood,  alcohol,  action  of,  UPON  the  CIR- 
The   red    cells    are    usually    reduced    in  CULATION. 

number  and  are  more  or  less  deformed.  From  elaborate  animal  experiments, 
There  is  usually  leucocytosis.  the  writers  conclude  that  alcohol  does 
In  cases  of  severe  chronic  poisoning  not  seriously  affect  normal  animal  blood- 
by  acetanilid  and  related  coal-tar  prod-  pressure,  elevates  the  blood-pressure 
ucts,  the  symptoms  are  usually  very  after  vasomotor  paralysis  from  section 
similar  as  concerns  progressive  mental  of  the  cervical  cord,  increases  the  rate 
and  physical  debility,  which  later  often  of  the  blood  flow,  and  directly  stimu- 
reaches  a  high  grade.  There  is  cardiac  lates  the  heart.  Therefore,  the  general 
weakness,  with  more  or  less  pronounced  action  upon  the  circulation  of  the  mod- 


*  Physician  to  the  Philadelphia  Hospital,  Children's  Hospital. 


ANGIOSCLEROSIS  OF  EXTREMITIES. 


APPENDICITIS. 


307 


erate  dose  of  alcohol  is  cardiac  stimu- 
lation with  vascular  dilatation,  due  to 
depression  of  the  vasomotor  centers. 
Two  experiments  on  human  beings  with 
the  arm  plethysmograph  were  corrobora- 
tive of  tbe  results  with  animals.  In 
general,  the  studies  indicate  that  the  in- 
creased cerebral  excitement  and  activity 
following  ingestion  of  alcohol  are  not 
due  to  direct  action  of  the  drug  upon 
the  brain,  but  to  the  increased  amount 
of  blood  in  that  organ.  H.  C.  Wood  and 
D.  M.  Hoyt  (University  of  Pennsylva- 
nia Medical  Bulletin,  May,  1905). 

ANGIOSCLEROSIS  OF  THE  EXTREMITIES, 
INTERMITTENT  CLAUDICATION  DUE 
TO. 

Angiosclerosis  of  the  extremities  in 
its  gravest  form,  uncomplicated  by  a 
vasomotor  neurosis,  leads  to  spontane- 
ous gangrene.  If  the  angiosclerosis  oc- 
curs in  combination  with  a  vasomotor 
instability  and  a  tendency  to  vasomotor 
spasm,  the  syndrome  of  intermittent 
claudication  results.  This  is  character- 
ized by  the  development  of  sensory 
(pains  and  paresthesia),  and  motor 
(weakness  and  rigidity)  manifestations 
during  functional  activity  with  a  rapid 
and  permanent  restoration  to  the  nor- 
mal during  rest.  The  syndrome,  how- 
ever, has  a  wider  and  more  general  ap- 
plication to  the  whole  circulatory  mech- 
anism and  has  been  observed  in  relation 
to  various  organs  of  the  body  (heart, 
intestines,  brain,  kidney,  and  eyes).  J. 
Ramsay  Hunt  (Medical  Record,  May 
27,  1905). 

APPENDICITIS,  CHANGES  OF  VIEW  ON. 

Although  formerly  the  writer  used  to 
forbid  morphine  altogether,  his  views 
on  the  subject  have  changed,  and  he  now 
gives  it  cautiously  in  cases  in  which  there 


is  great  restlessness.  Both  gauze  pack- 
ing and  iodoform  gauze  have  been  aban- 
doned altogether,  as  well  as  the  use  of 
buried  sutures  of  silkworm  gut.  A 
standard  length  of  one  and  one-half 
inches  for  the  incision  has  been  adopted 
for  nearly  all  instances,  including  cases 
of  abscesses  and  peritonitis,  and  it  has 
been  found  safer  to  deal  with  adhesions 
by  touch  than  by  sight.  The  time  limit 
has  also  been  greatly  reduced,  and  now 
it  is  common  to  have  the  time  from  the 
first  incision  to  the  last  suture  occupy 
not  more  than  seven  or  eight  minutes. 
All  patients  operated  on,  even  if  mori- 
bund, a  preliminary  infusion  of  salt  so- 
lution being  given,  adhesions  are  freely 
separated  if  necessary,  but  not  otherwise, 
and  the  idea  of  flushing  out  the  abdomen 
has  been  dropped.  After  eliminating  the 
features  which  seemed  to  have  a  special 
death  rate  of  their  own,  viz.,  gauze  pack- 
ing, iodoform  gauze,  long  incisions,  and 
the  expenditure  of  time  in  unnecessary 
detail  of  work,  100  consecutive  opera- 
tions were  reported  with  a  2  per  cent, 
death  rate. 

The  author  does  not  favor  the  re- 
moval of  the  normal  appendix  in  the 
course  of  other  operative  work,  and  he 
now  uses  a  cigarette  drain  in  all  cases 
in  which  pus  and  septic  debris  have  been 
left  in  the  peritoneal  cavity.  Tbe  dic- 
tum of  operating  as  soon  as  the  diagnosis 
is  made  holds  good,  with  certain  excep- 
tions, but  it  is  still  a  question  what  to 
do  with  patients  who  are  convalescing 
from  the  attack.  In  interval  cases  it 
now  seems  best  to  operate  only  when,  on 
palpation,  the  appendix  is  found  to  be 
the  definite  scat  of  chronic  infection  or 
of  adhesions  which  cause  symptoms.  R. 
T.  Morris  (Medical  Record,  May  27, 
1905). 


308 


APPENDICITIS  IN  CHILDREN. 


BATHS  AND  ELECTRICITY. 


APPENDICITIS  IN  CHILDREN. 

Appendicitis  is  not  an  uncommon  dis- 
ease in  children.  It  does  not  at  first 
tend  to  be  of  a  more  serious  type  than 
in  adults,  but  the  slighter  cases  are  often 
difficult  to  diagnose,  and  are  therefore 
apt  to  be  overlooked.  The  author  would 
urge  a  closer  attention  to  recurrent  at- 
tacks of  colic,  and  points  out  the  fre- 
quency with  which  diarrhoea  and  blad- 
der irritation  are  associated  with  appen- 
dix inflammation  in  childhood.  When 
several  slight  attacks  of  appendicitis 
have  occurred,  the  removal  of  the  appen- 
dix is  the  best  and  safest  treatment. 
Where  localized  peritonitis  is  present, 
operation  should  be  delayed  until  the 
quiescent  period  is  reached,  but  pus 
formation  must  always  be  suspected  and 
carefully  watched  for  during  the  waiting 
period.  Should  abscess  formation  take 
place,  immediate  operation  is  demanded, 
but  undue  risks  should  not  be  run  in 
attempting  the  removal  of  a  firmly  ad- 
herent appendix  under  such  circum- 
stances. The  administration  of  purga- 
tives and  opium  is  not  without  risk,  and 
is,  the  writer  considers,  best  avoided. 
E.  C.  'Dun  (Glasgow  Medical  Journal, 
June,  1905). 

ASTHMA,  THE  RELATION  OF  ETHMOIDAL 
INFLAMMATION   TO. 

The  author  states  that  asthma  is  a 
name  given  to  paroxysmal  difficult 
breathing,  and  the  disease  is  an  inflam- 
mation of  the  mucous  membrane  of  the 
ethmoidal  cells.  An  irritation  of 
branches  of  the  trigeminus  or  olfactory 
nerves  causes  an  altered  activity  in  the 
medulla,  that  is  to  say,  in  the  center  of 
respiration.  The  result  in  the  bronchial 
tubes  is  a  vasomotor  disturbance  or  con- 
traction of  muscles,  or  both.  Chronic 
bronchitis,  or  emphysema,  or  a  dilated 
right  side  of  the  heart,  is  not  asthma. 


They  are  sequels  to  asthma  of  severity 
and  long  standing.  Other  varied  factors 
are  the  contributory  causes  of  asthma. 
Errors  of  nutrition,  errors  of  diet,  gout, 
obesity,  lymphatism,  impure  air,  and 
poor  circulation  are  such  causes.  To 
these  may  be  added  direct  irritants  to 
the  nasal  mucous  membrane,  such  as 
various  pollens,  emanations  from  ani- 
mals, dust,  smoke,  and  many  others  in 
the  cases  of  the  sufferers  from  periodic 
asthma.  H.  Coggeshall  (Medical  Eec- 
ord,  June  3,  1905). 

BATHS  AND  ELECTRICITY,  EFFECTS  OF, 
ON  METABOLISM,  BLOOD  AND  BLOOD- 
PRESSURE. 

The  physiologic  action  of  the  high- 
frequency  current  in  its  general  appli- 
cation tends  to  confirm  its  use  in  cases 
of  nutritional  disorders,  such  as  chronic 
gout,  chronic  rheumatism,  and  obesity, 
by  reason  of  the  changes  effected  in 
blood-pressure  and  the  stimulus  given 
to  metabolism,  as  shown  by  the  plus  heat 
production,  the  plus  excretion  of  urea, 
of  uric  acid,  and  of  C02  and  the  loss  of 
weight.  The  rise  produced  in  the  haemo- 
globin  value  of  the  corpuscle  points  to 
its  use  in  the  above  cases  when  anasmia 
is  a  prominent  symptom,  and  also  as  a 
useful  adjunct  in  cases  of  simple  anae- 
mia and  chlorosis.  The  distinct  con- 
traction of  unstriped  muscle  fiber  excited 
by  the  effleuve  indicates  a  trial  of  the 
method  in  cases  of  atony  of  the  hollow 
viscera,  and  may  also  account  for  the 
striking  results  sometimes  observed  in 
the  shrinking  and  disappearance  of 
haemorrhoids  after  repeated  applications. 
The  evidence  of  its  real  value  in  cases 
of  diabetes  and  phthisis  does  not  appear 
to  rest  on  a  sufficiently  large  number  of 
cases  to  carry  conviction  as  to  its  supe- 
riority over  other  modes  of  treatment. 
With  regard  to  its  action  in  local  affec- 


BONE  CAVITIES,  TREATMENT  OF. 


309 


tions  of  the  nerves  and  skin,  results  offer 
no  evidence  for  or  against. 

Electric  immersion  baths  are  used 
largely  to  induce  restoration  of  contrac- 
tile power  in  cases  of  muscular  weakness 
or  atrophy  resulting  from  nerve  lesions 
or  essential  muscular  dystrophy,  and  in 
cases  of  neurasthenia  and  the  latent 
form  of  hysteria.  They  are  also  useful 
as  a  general  tonic  measure  in  cases  pre- 
senting no  definite  disease,  but  suffering 
from  slackness  and  want  of  tone.  The 
results  obtained  on  metabolism  are  not 
sufficiently  striking  to  justify  the  fre- 
quent employment  of  these  baths  in 
cases  of  chronic  gout  unless  the  slight 
increase  in  elimination  of  urea  and  uric 
acid  which  followed  the  constant  cur- 
rent may  be  considered  an  indication  in 
this  direction. 

The  striking  results  obtained  on  the 
haemoglobin  value  of  the  blood  with  the 
light  and  ozone  bath  point  to  its  use  in 
cases  requiring  sweating  baths,  in  which 
anaemia  is  present,  and  further  tend  to 
show  that  the  daily  breathing,  for  a 
stated  time,  of  air  highly  charged  with 
ozone  may  be  a  useful  auxiliary  measure 
in  the  treatment  of  intractable  cases  of 
chlorosis  and  secondary  anaemia. 

Peat  baths  are  largely  used  in  cases 
of  chronic  pelvic  disorder  of  an  inflam- 
matory nature.  Their  action,  which  re- 
sembles that  of  a  widespread  poultice, 
materially  aids  in  the  absorption  of  ef- 
fused products.  They  are  also  used  for 
cases  of  chronic  intractable  rheumatism 
and  gout  and  in  local  manifestations  of 
these  disorders,  such  as  lumbago  or  sci- 
atica. The  results  obtained  are  not  con- 
clusive enough  to  indicate  strongly  in 
which  direction  they  are  likely  to  be  of 
service. 

Thermal  sulphur  baths  are  largely 
user!  at  Harrowgate  in  the  treatment  of 


gout,  rheumatism,  and  functional  de- 
rangements of  the  liver,  and  also  for 
their  local  action  on  the  skin  in  cases  of 
skin  diseases.  In  the  former,  as  well  as 
in  the  latter,  experience  shows  that  they 
are  of  undoubted  value,  though  their 
mode  of  action  is  by  no  means  clear. 
Apart  from  their  marked  effect  on  blood- 
pressure,  which  has  been  previously 
shown,  this  investigation  proved  noth- 
ing conclusive  as  to  their  influence  on 
metabolism.  Bain  and  Frankling  (Lan- 
cet, April  29,  1905). 

BONE   CAVITIES,   TREATMENT   OF. 

The  author  has  had  some  very  favor- 
able results  with  von  Mosetig's  bone 
plug.  Four  of  his  recent  cases  are  re- 
ported in  detail.  Briefly  the  method 
consists  in  completely  filling  bone  cavi- 
ties, resulting  from  operation,  with  a 
preparation  of  wax  and  iodoform.  For 
success  to  be  attained  the  following  con- 
ditions must  be  fulfilled :  The  cavity 
must  be  sterile;  it  must  be  dry;  all 
dead  and  diseased  bone  must  be  removed. 
The  material  for  plugging  consists  of  60 
parts  iodoform,  40  parts  spermaceti,  and 
40  parts  of  oleum  sesami.  These  ingre- 
dients are  slowly  heated  to  100°  C,  and 
when  allowed  to  cool  form  a  soft  solid 
which  remains  solid  at  the  temperature 
of  the  body.  For  use  it  is  heated  to  50° 
C,  being  constantly  stirred  to  keep  the 
iodoform  evenly  distributed.  At  this 
temperature  it  can  be  poured  into  the 
cavity,  where  it  immediately  solidifies. 
This  material  does  not  act  as  a  foreign 
body,  nor  does  it  act  as  a  culture  me- 
dium. It  posses.-es  the  inhibitory  and 
medicinal  properties  <>f  iodoform  with- 
out causing  iodoform  intoxication.  Its 
physical  properties  arc  such  that  it  is 
gradually  absorbed  and  replaced  by 
granulations   and    finally   by   new   bone. 


310 


BRONCHIAL  ASTHMA. 


BURNS  OF  THIRD  DEGREE. 


J.  E.  Moore  (Journal- of  the  American 
Medical  Association,  May  20,  1905). 

BRONCHIAL    ASTHMA,    VASOMOTOR    ORI- 
GIN OF. 

The  writer  supports  the  theory  of  the 
vasomotor  origin  of  bronchial  asthma, 
citing  an  interesting  case  in  which  a 
woman  had  suffered  for  years  from 
bronchial  asthma,  and  in  which  a  dis- 
tinct connection  between  the  attacks  of 
dyspnoea  and  other  vasomotor  phe- 
nomena could  be  traced.  Thus  this 
patient  was  subject  to  hyperidrosis,  to 
urticaria,  to  a  sense  of  prickling  in  the 
limbs,  oedema,  ptyalism,  swelling  of  the 
tongue,  and  diarrhoea.  These  signs  ap- 
peared usually  in  the  intervals  between 
the  attacks  and  disappeared  when  the 
attacks  set  in.  Another  noteworthy 
feature  in  this  case  was  the  relation  of 
the  paroxysms  of  bronchial  asthma  to 
menstruation.  When  menstruation  set 
in,  the  paroxysm  ceased.  On  the  other 
hand,  in  the  presence  of  severe  and  re- 
peated paroxysms  which  came  on  from 
time  to  time,  menstruation  became  ir- 
regular. The  treatment  consisted  in 
the  use  of  tepid  general  sulphur  baths, 
and  local  irritation  about  the  dorsal  re- 
gion of  the  spine,  to  stimulate  .the  vaso- 
moter  centers.  Tonics  were  also  ad- 
ministered. F.  Galdi  (Gazett'a  degli 
Ospedalie  e  delle  Clmiche,  March  5, 
1905;  New  York  Medical  Journal  and 
Philadelphia  Medical  Journal,  May  13, 
1905). 

BRONCHO-PNEUMONIA       IN       CHILDREN, 
TREATMENT    OF. 

Report  of  10  cases  of  broncho-pneu- 
monia in  children  three  months  to  11 
years  of  age  in  which  defervescence  was 
realized  in  one  to  four  days.  The  au- 
thor ascribes  this  favorable  result  to  his 
method  of  giving  the  little  patients  from 


one  to  seven  "half-baths"  of  four  to 
seven  minutes  each,  the  water  at  a  tem- 
perature of  from  30°  to  28°  C,  grad- 
ually reduced  to  26°  or  21°  C.  (8G°  to 
82°  P.,  reduced  to  78°  or  75°  F.).  The 
room  must  be  moderately  warm,  and  the 
child  must  be  placed  in  a  bath-tub  with 
only  enough  water  in  it  to  cover  the 
body,  leaving  the  breast  almost  uncov- 
ered with  water.  The  child  is  rubbed 
during  the  bath,  and  after  two  minutes 
cool  water  is  added  to  bring  the  water 
down  to  the  desired  temperature.  The 
child  is  then  rubbed  dry  with  warm  tow- 
els and  put  back  to  bed.  These  half- 
baths  are  given  night  and  morning;  a 
little  milk  is  given  to  the  child  before 
and  after  the  bath.  The  diet  should  be 
milk,  diluted  or  not,  and  cold  spring 
water  should  be  sipped  frequently.  The 
author's  experience  has  been  that  these 
baths  twice  a  day  raise  the  blood-pres- 
sure, strengthen  the  heart,  promote  ex- 
pectoration, and  soothe  the  nerves,  etc., 
much  better  than  any  other  measures. 
T.  Zangger  (Correspondenz-Blatt  fur 
Schweizer  Aerzte,  Bd.  xxxv,  No.  1 ; 
Journal  of  the  American  Medical  Asso- 
ciation, June  3,  1905). 

BURNS  OF  THE  THIRD  DEGREE. 

All  extensive  bums  should  be  treated, 
if  possible,  by  the  continuous  warm  bath. 
This  method  is  very  restful  to  the  pa- 
tient, relieves  the  existing  shock,  and 
attention  can  be  given  to  the  burned 
area  without  handling  the  patient  or  re- 
moving dressings,  both  of  which  opera- 
tions are  always  attended  by  more  or  less 
shock  and  no  little  pain. 

When  the  sloughs  have  begun  to  sepa- 
rate, some  form  of  more  active  contin- 
uous antiseptic  irrigation,  preferably 
aluminum  acetate,  is  indicated.  (The 
aluminum  acetate  could  not  be  obtained 


CONSTIPATION,  EXTRA-UTERINE  INFECTION.    DIGESTIVE  DISTURBANCES.      31 1 


for  the  case  reported,  and  corrosive  sub- 
limate was  used  instead.) 

While  food  is  essential,  it  should  be 
strictly  liquid,  and  given  in  small  but 
repeated  doses.  For  the  accumulation 
of  gas  in  the  intestines,  which  almost 
invariably  occurs  when  the  abdomen  is 
involved,  turpentine,  in  small  doses,  is 
strongly  recommended,  though  the  kid- 
neys may  be  slightly  diseased.  The  rec- 
tal tube  is,  of  course,  a  useful  adjunct. 

For  the  shock,  which  is  always  pres- 
ent in  extensive  burns,  besides  the  well- 
known  methods  for  combating  it,  the 
intravenous  infusion  of  normal  salt  so- 
lution will  give  oftentimes  miraculous 
results.  Extensive  burns,  of  even  over 
one-half  the  body  surface,  should  not  be 
despaired  of,  as  the  writer  is  of  the  opin- 
ion that  heretofore  the  profession  has 
been  too  prone  to  regard  as  hopeless  a 
burn  involving  extensive  areas.  As  a 
result  of  this,  some  of  the  methods  and 
technique  which,  at  least,  should  be  given 
a  fair  trial  when  it  is  possible  to  do  so, 
are  liable  to  be  neglected,  or  regarded  as 
useless.  A.  M.  Fauntleroy  (American 
Journal  of  the  Medical  Sciences,  June, 
1905). 

CONSTIPATION    AS    A    CAUSE    OF    INTRA- 
UTERINE  INFECTION. 

The  author  conducted  a  scries  of  ex- 
periments in  animals  in  order  to  deter- 
mine the  effect  of  coprostasis  on  uterine 
infection.  Complete  obstruction  was 
produced  by  suturing  the  anus.  Both 
pregnant  and  non-pregnant  guinea-pigs 
were  used.  Almost  without  exception 
colon  bacilli  were  found  in  the  uterus, 
amniotic  fluid  and  peritoneal  cavity 
after  death.  Although  these  experi- 
ments do  not  furnish  conclusive  evidence 
with  regard  to  the  effects  of  obstinate 
constipation  in  the  human  female,  the 


writer  believes  that  they  point  a  moral 
as  to  the  importance  of  careful  regula- 
tion of  the  bowels  in  the  non-gravid  as 
well  as  in  pregnant  women.  Capaldi 
(Arch,  di  Ost.  e  Gin.;  Zentralblatt  fiir 
Gynakologie,  No.  8,  1905). 

COPPER,   BACTERICIDAL   ACTION   OF,    ON 
ORGANISMS  IN  WATER. 

Dilute  solutions  of  copper  salts  have 
a  marked  destructive  action  on  many 
bacteria.  Of  these  salts  the  sulphate 
is  most  active.  This  is  probably  due  to 
the  fact  that  it  undergoes  electrolytic 
dissociation  more  readily  than  the 
ethers.  The  amount  of  sulphate  to  be 
used  in  the  water  should  be  from  1  part 
in  250,000  to  1  part  in  100,000,  depend- 
ing on  the  character  of  the  water. 

Colloidal  copper  will  quickly  destroy 
certain  bacteria;  should  copper  vessels 
or  plates  be  used  to  destroy  bacteria  in 
water  they  must  be  kept  highly  polished 
or  the  bactericidal  properties  will  be 
greatly  reduced.  The  author  has  been 
unable  to  find  evidence  of  copper,  in- 
gested in  small  quantities  for  long 
periods,  having  a  detrimental  action  on 
the  health  of  an  individual.  N.  Gilder- 
sleeve  (American  Journal  Medical  Sci- 
ences, May,  1905). 

DIGESTIVE     DISTURBANCES     IN     EARLY 
INFANCY. 

From  his  own  experience  and  that  of 
others,  the  writer  states  that  more  than 
2G  per  cent,  of  the  infants  who  succumb 
to  gastro-intestinal  disturbances  are  less 

than  a  month  old.  The  infection  must 
have  taken  place  during  the  first  days 
of  life.  If  infection  during  the.  first 
week  can  he  prevented,  the  child  then 
acquires  Btrength  and  produces  anti- 
bodies which,  to  a  certain  extent,  pro- 
tect it  against  infection  later.    It  is  not 


312 


ELECTRIC  SHOCKS. 


the  lack  of  proper  food  so  much  as  the 
lack  of  proper  care  otherwise  that  is  re- 
sponsible for  this  high  morbidity  dur- 
ing the  first  week.  Almost  all  the  in- 
fants in  his  charge  at  the  Heidelberg 
Maternity  showed  the  staphylococcus 
albus  in  their  stools.  This  infection  re- 
mained latent  or  induced  dyspepsia  ac- 
cordingly as  the  infants  were  kept  clean 
and  warm  or  were  allowed  to  become 
chilled.  The  attendants  are  required  to 
wash  their  hands  each  time  after  chang- 
ing the  napkin  of  an  infant.  Heubner 
even  goes  so  far  as  to  have  different  at- 
tendants take  care  of  the  upper  and  of 
the  lower  parts  of  the  body  of  the  in- 
fant. The  cotton  used  in  powdering  is 
thrown  away  and  a  fresh  piece  taken  for 
each  child.  The  infants  suck  through  a 
nipple  guard  to  prevent  infection  from 
this  source,  and  the  mothers  are  taught 
to  keep  the  nipple  clean  and  not  to  touch 
the  rubber  guard. 

The  low  temperature  of  the  new- 
born is  combated  by  wrapping  in  warm 
woolen  blankets  and  by  giving  the  first 
bath  at  a  temperature  of  40°  C.  (104° 
F.),  leaving  the  child  in  the  water  for 
fifteen  minutes,  and  keeping  it  warm 
afterward  with  hot-water  bottles  in  the 
crib.  Tp  avoid  exposing  the  infant,  the 
umbilical  cord  is  not  inspected  until  the 
fourth  day  after  it  is  dressed.  Cleanli- 
ness and  warmth  are  the  principal  aids 
in  tiding  the  infant  past  its  defenseless 
stage  and  in  preventing  the  latent  mi- 
crobism from  developing  gastrointes- 
tinal disturbances.  F.  Kerma-uner 
(Archiv  fur  Gynakologie,  Bd.  lxxv,  Nu. 
2;  Journal  of  the  American  Medical 
Association,  June  17,  1905). _ 

ELECTRIC   SHOCKS. 

The  injuries  received  by  telephone  op- 
erators in  the  course  of  their  work  has 


not  received  sufficient  attention.  It 
sometimes  happens  that  shocks  of  greater 
or  less  severity  are  received  and  the  au- 
thor gives  the  histories  of  several  such 
cases  in  which  the  consequences  were 
rather  serious.  According  to  the  nature 
of  the  accident  and  the  powers  of  re- 
sistance of  the  sufferer,  the  first  symp- 
toms comprise  fainting,  clonic  convul- 
sions, attacks  of  weeping,  swelling  of 
the  extremities,  especially  on  the  in- 
jured side,  and  disorders  of  sensation. 
Later  on,  severe  headaches  and  dizziness 
appear,  as  well  as  erratic  neuralgic  dis- 
turbances, which  are  most  prominent 
during  cold  or  stormy  weather.  Cramp- 
like abdominal  pain,  hemiplegia,  vaso- 
motor paresis,  and  other  evidences  of 
nervous  exhaustion  such  as  the  loss  of 
power  of  mental  concentration,  are  also 
observed.  One  important  symptom 
which  was  noticed  in  all  cases  was  car- 
diac weakness,  evidenced  by  irregularity 
of  the  pulse,  precordial  pain,  palpita- 
tion, etc.,  and  the  author  makes  this 
group  of  manifestations  responsible  for 
much  of  the  great  weakness  and  prostra- 
tion complained  of.  The  prognosis  is 
bad  as  regards  permanent  resumption 
of  telephonic  work,  for  although  great 
improvement  may  be  obtained,  the  shock 
to  the  nervous  system  is  too  great  to 
permit  of  complete  restoration. 

The  treatment  consists  mainly  in  sug- 
gestion, static  electricity,  massage,  and 
baths.  Faradic  electricity  and  bromides 
should  be  avoided.  The  author  recom- 
mends greater  care  in  selecting  young 
women  for  these  positions,  and  the  fam- 
ily history  should  be  carefuly  inquired 
into. "  Applicants  in  whose  families 
mental  disorders  or  nervous  diseases 
have  occurred  should  be  excluded,  and 
those  whose  parents  have  died  of  a  se- 
vere  chronic   malady   should   be   tested 


EXOPHTHALMIC  GOITER. 

with  especial  care  as  regards  the  nerv- 
ous and  vascular  systems.  Wallbaum 
(Deutsche  Medicinische  Wochenschrift, 
May  4,  1905;  Medical  Record,  May  27, 
1905). 

EXOPHTHALMIC     GOITER     REDUCED     BY 
RADIUM. 

The  writer  reports  the  first  case  in 
which  radium  has  been  applied.  On 
account  of  the  different  effect  of  Roent- 
gen rays  on  ulcerated  and  unbroken  skin 
surfaces,  it  occurred  to  him  that  while 
radium  outside  of  goiter  would  be  in- 
effective, inside  it  might  have  striking 
results.  Under  cocaine  anaesthesia  he 
made  a  small  media  incision,  dissecting 
down  to  the  isthmus  of  the  thyroid. 
Into  this  he  thrust  a  small  bistoury, 
making  a  deep  enough  incision  to  bury 
a  sterilized  tube  of  radium  at  right  an- 
gles to  the  skin  and  an  inch  deep.  It 
was  held  in  place  by  dressings  and  straps, 
the  patient  keeping  her  head  fairly  quiet 
for  twenty-four  hours.  The  glass  tube 
was  1/8  inch  in  diameter,  and  contained 
10  centigrams  of  Curie  radium.  At 
first  the  gland  seemed  a  little  more 
swollen.  In  four  months  it  was  only 
a  sixth  of  its  former  bulk.  All  unpleas- 
ant symptoms,  including  a  sense  of  suf- 
focation, severe  headaches,  inability  for 
exertion,  tremor,  etc.,  disappeared. 
Some  tachycardia  remained.  R.  Abbe 
(Archives  of  the  "Roentgen  Rays,  March, 
1905). 

FATTY  DEGENERATION,   NATURE   OF. 

Ever  since  the  days  of  Virchow  it  haa 
been  customary  to  look  upon  fatty  de- 
generation of  the  kidney  as  a  very  com- 
mon lesion  which  accompanies  almosi 
every  change  in  the  renal  (issue-.  Re- 
cently, however,  attention  has  been 
drawn  to  the  fact  that  the  chemical  ex- 


GALL-STONES  AND  CARCINOMA. 


313 


amination  of  kidneys  which  were  pro- 
nounced fatty  to  a  marked  degree  by 
microscopic  examination  frequently  did 
not  show  an  excess  but  rather  a  de- 
ficiency of  fat.  The  explanation  of- 
fered by  the  author  is  that  many  of  the 
highly  refractile  granules  seen  within 
the  epithelial  cells  of  the  renal  tubules 
are  not  really  fat  but  a  modified  proteid 
called  protagon.  This  protagon  reduces 
osmic  acid  like  fat  if  mixed  with  a 
small  amount  of  lecithin;  hence,  will 
pass  for  fat  in  specimens  hardened  in 
Fleming's  or  Herman's  fluid.  In  fresh 
specimens  one  may,  however,  distin- 
guish the  two  substances  with  ease,  since 
protagon  is  anisotropic,  but  fat  isotropic. 
The  author  has  examined  a  large  num- 
ber of  kidneys,  and  comes  to  the  follow- 
ing conclusions:  Fatty  infiltration  of 
the  kidney  is  an  accumulation  of  true 
fat  within  the  epithelial  cells  of  the  tu- 
bules. The  epithelial  cells  themselves 
do  not  suffer  by  this,  and  albuminuria 
does  not  occur.  Fatty  degeneration,  on 
the  other  hand,  is  due  to  a  less  pro- 
nounced accumulation  of  fat,  together 
with  a  crystallization  of  protagon  within 
the  epithelial  cells.  The  latter  are  con- 
siderably damaged,  and  albuminuria  is 
the  rule.#  An  instance  of  fatty  infiltra- 
tion of  the  severest  grade  is  phosphorus 
poisoning,  and  it  is  a  significant  fact 
that  albuminuria  is  often  absent,  at 
least  in  the  earlier  stages.  M.  Lohlein 
(Virchow's  Archiv,  Bd.  180,  Nu.  1; 
Mcdi.-al  News,  June  10,  1905). 

GAIL-STONES  AND  CARCINOMA. 

The  association  between  carcinoma  of 
the  gall-bladder  and  gall-stones  is  very 
close.  Gall-stones  may  be  looked  upon 
as  the  determining  cause  of  cancer  of 
the  gall-hladder.  Thickening  of  the 
wall  of  the  gall-bladder  is  presumptive 


314 


GASTRIC  PAIN,  LEFT-SIDED. 


GASTRIC  ULCER. 


evidence  of  carcinomatous  change. 
Cholecystectomy  should  be  performed 
whenever  possible  if  any  thickening  of 
the  wall  of  the  gall-bladder  be  found  at 
the  time  of  operation.  G.  E.  Slade 
(Lancet,  April  22,  1905). 

GASTRIC  PAIN,  LEFT-SIDED. 

The  author  points  out  that  gastric 
pain  occurring  reflexly  from  disease  of 
other  abdominal  viscera  is  most  often 
referred  to  the  right  side,  so  that  left- 
sided  gastric  pain,  in  the  great  major- 
ity of  cases,  signifies  an  affection  of  the 
stomach  itself.  The  only  two  excep- 
tions, fat  necrosis  of  the  pancreas  and 
splenic  abscess,  are  so  rare  that  they  can 
be  disregarded.  An  ulcer  situated  at 
the  pylorus  is  much  harder  to  diagnose 
than  one  in  the  body  of  the  stomach, 
since  the  former  gives  rise  to  pain  on 
the  right  side,  which  often  cannot  ba 
distinguished  from  the  pain  caused  by 
cholecystitis.  With  ulcers  of  the  antrum 
pylori,  the  pain  is  accurately  referred 
to  the  median  line  just  like  the  reflex 
abdominal  pain  caused  by  chronic  ap- 
pendicitis and  that  of  a  hernia  of  the 
linea  alba.  Tumefaction  is  exceedingly 
common  with  ulcers,  since  the  muscu- 
laris  and  serosa  will  thicken  and  adhe- 
sions will  readily  form  with  the  neigh- 
boring organs,  particularly  the  liver  and 
the  pancreas.  A  mass  may  thus  be  felt 
to  the  left  of  the  median  line,  if  the 
ulcer  is  situated  in  the  middle  portions 
of  the  stomach.  It  is  very  important  to 
diagnose  the  case  sufficiently  early,  since 
the  end  result  will  be  an  hour-cdass 
stomach,  which  can  only  be  treated  by 
means  of  an  operation.  The  history  is 
rather  characteristic:  At  first  there  is 
an  attack  of  left-sided  pain  directly 
after  eating,  lasting  Several  hours. 
Several  months  later  there  may  be  an- 
other attack,  the  stomach  having  been 


perfectly  normal  in  the  meantime.  In 
six  months  or  so  the  pain  comes  more 
often  and  lasts  as  long  as  twelve  hours, 
and  the  irritability  of  the  stomach  in- 
creases. Finally,  vomiting  sets  in  half 
an  hour  after  a  meal.  This  is  purely  re- 
flex, since  a  stenosis  has  not  yet  formed. 
The  pain  is  now  permanent  and  vomit- 
ing occurs  daily,  but  blood  is  found  in 
only  half  of  the  cases.  Operation  is  in- 
dicated, if  rest  in  bed  for  several  weeks 
with  hot  applications  and  fluid  diet  does 
not  result  in  a  cure.  Eiedel  (Miinch- 
ener  Medicinische  Wochenschrift,  April 
25,  1905;  Medical  News,  June  17, 
1905). 

GASTRIC     ULCER,     ETIOLOGY     AND     PA- 
THOLOGY OF. 

Gastric  ulcers  may  arise  from  numer- 
ous and  very  different  causes,  though  in 
all  probability  such  ulcers  are  not  iden- 
tical with  those  known  to  clinicians  as 
the  round  ulcer  or  peptic  ulcer. 

The  etiology  of  this  particular  lesion 
seems  to  require  the  co-operation  of  two 
factors:  (1)  the  corrosive  gastric  juice, 
.and  (2)  a  local  loss  of  resisting  power 
in  the  tissues  with  which  the  juice  comes 
in  contact.  (1)  The  gastric  juice, 
should  the  author's  assumption  regard- 
ing the  diminished  resisting  power  of 
the  tissue  be  correct,  need  have  no  ab- 
normal composition  and  need  not  be  ex- 
cessively acid,  so  that  it  can  be  dis- 
missed as  no  more  than  an  incidental 
factor  in  the  production  of  the  lesion. 
(2)  The  lost  resisting  power  of  the  tis- 
sue, therefore,  becomes  the  essential  fac- 
tor. This  cannot  be  common  to  the 
gastric  tissue, -else  the  lesion  could  not 
be  local.  It  must  be  focal,  and  there- 
fore, must  depend  upon  some  condition 
operating  upon  a  circumscribed  area  of 
the  tissue.  It  seems  very  improbable 
that   it  can  be  traumatic   since  experi- 


GASTRIC  ULCER,  REST  IN  TREATMENT. 


GASTROENTEROSTOMY. 


315 


mental,  operative,  and  accidental  lesions 
of  the  stomach  heal  so  kindly  in  most 
cases.  It  must,  therefore,  be  nutritional 
and  vascular,  whether  the  vascular  dis- 
turbance depends  upon  traumatic  in- 
juries of  minute  vessels  resulting  from 
ovcrdistention,  pressure,  embolism, 
thrombosis,  infection,  intoxication,  or 
defective  innervation  remains  to  be 
shown.  It  is  not  improbable  that  all 
of  these  have  to  do  with  particular  cases. 
The  nature  of  the  defective  tissue  re- 
sistance is  obscure  and  will  probably 
elude  our  efforts  to  discover  it,  as  the 
normal  immunity  of  tissue  so  long  has 
done.  In  the  light  of  modern  studies, 
the  immunity  of  the  gastric  mucosa  is 
no  longer  referred  to  the  alkaline  mucus 
that  covers  it  or  to  the  alkaline  blood 
circulating  in  its  capillaries.  It  is  sim- 
ply the  immunity  of  the  normal  living 
tissue  to  its  own  products.  So  soon  as 
the  vitality  of  the  tissue  is  disturbed, 
this  immunity  fails  in  part;  when  it  is 
lost  it  disappears.  If  the  immunity  of 
the  stomach  to  the  action  of  pepsin  is 
referred  to  the  alkalinization  of  the  hy- 
drochloric acid  by  the  blood  salts,  how 
shall  the  immunity  of  the  intestine  to 
trypsin  which  is  active  in  alkaline  media 
be  explained  ?  Both  are  due  to  the 
natural  immunity  of  the  respective  cells 
to  the  respective  enzymes,  and  the  nature 
of  this  natural  immunity  is  unknown. 
Joseph  McFarland  (Proceedings  of  the 
Philadelphia  County  Medical  Society, 
March  31,  1905). 

GASTRIC  ULCER,  REST  IN  THE  TREAT- 
MENT OF. 
The  writer  does  not  advise  rectal  ali- 
mentation  in  acute  gastric  ulcer,  since 
there  is  evidence  that  food  injected  into 
the  colon  finds  its  way  into  the  stomach 
thus  preventing  complete  gastric  rest. 
There  is  also  increased  intestinal  putre- 


faction, with  possible  autointoxication. 
The  author  siphons  into  the  bowel  every 
six  hours  a  pint  of  normal  saline  solu- 
tion, orders  an  antiseptic  mouth  wash, 
and  warns  the  patient  against  swallowing 
the  secretions  of  the  mouth.  No  food 
is  given  for  four  to  six  days,  and  after 
this,  milk  in  small  quantities.  Toward 
the  end  of  the  rest  period  the  complaint 
of  hunger  has  been  no  greater  than  when 
rectal  alimentation  was  given.  Most  pa- 
tients had  a  feeling  of  well-being  and 
an  absence  of  pain.  Lavage  of  the  stom- 
ach in  haemorrhage  is  advised,  the  water 
being  heated  to  104°  or  105°  F.  In 
chronic  ulcer  complete  rest  should  be 
persisted  in  as  long  as  the  general  nu- 
trition permits.  The  patient  should  be 
kept  in  bed  two  months  and  on  re- 
stricted diet  much  longer.  In  pyloric 
stenosis,  gastroenterostomy,  by  resting 
the  ulcer,  will  effect  a  cure.  If  there  is 
no  stenosis  and  the  ulcer  is  on  the  py- 
loric third  of  the  stomach,  gastroenter- 
ostomy may  cure  by  giving  the  ulcer 
rest,  but  according  to  present  experience 
it  will  not  do  so  if  the  ulcer  is  outside 
the  pyloric  third.  ■  In  such  cases  ex- 
cision may  result  in  benefit.  F.  D. 
Boyd  (Scottish  Medical  and  Surgical 
Journal,  March,  1905). 

GASTRO-ENTEROSTOMY. 

Some  cases  of  acute  and  subacute 
gastric  and  duodenal  ulcer,  and  many 
cases  of  chronic  and  duodenal  ulcer, 
should  be  treated  by  efficient  stomach 
drainage  into  the  duodenum  or  jejunum. 
Drainage  by  pyloric  divulsion,  and  by 
pyloroplasty  with  its  modifications,  has 
not  been  successful,  and  these  methods 
are  now  practically  obsolete. 

Gastro-duodenostomy,  a*  modified  by 
Kocher  and  Finney,  may  give  efficienl 
drainage  in  many  cases,  but  should  be 
limited    to    such    patients    as    cannot    be 


316 


HEMORRHAGE,  SODIUM  BICARBONATE  IN. 


operated  on  by  a  posterior  retrocolic  gas- 
troenterostomy with  the  anastomosis 
near  the  duodenojejunal  flexure.  Ante- 
rior anticolic  gastro-enterostomy  should 
not  be  an  operation  of  election,  but  an 
operation  of  expediency  and  necessity, 
to  give  temporary  relief,  or  to  meet  spe- 
cial abnormal  conditions  that  may  con- 
traindicate  the  posterior  attachment. 

The  ideal  operation  of  election  must 
be   the   posterior   retrocolic   attachment 
near  the  beginning  of  the  jejunum,  and 
tit  the  bottom  of  the  stomach  in  the  py- 
loric   end,    thus    eliminating   the    loop. 
This  gives  the  most  efficient  drainage, 
prevents  the  vicious  circle  and  regurgi- 
tant vomiting,  leaves  stomach  and  intes- 
tinein  nearly  normal  relation,  and  is  fol- 
lowed by  better  immediate  and  ultimate 
results.     The  intestinal  incision  should 
be  marie  longitudinally  and  not  less  than 
two   inches   long,   and   the   stomach   in- 
cision of  corresponding  length,  prefer- 
ably in  the  oblique  direction.     An  ellip- 
tical strip  of  mucosa  should  be  excised 
from   both    stomach    and    intestinal    in- 
cision.    The  anastomosis   is  best  made 
with  a  continuous  suture  (Pagenstecher 
or   silk),   using   a   full   curverl,   round- 
pointed  needle.     The  suture  should  be 
applied  in  double  layers,  the  inner  to  in- 
clude all  the  visceral  layers,  and  unite 
the  cut  edges  of  the  opening;  the  outer, 
one-fifth  inch  away,  to  include  the  serous 
and  sub-serous  layers. 

Entero-enterostomy,  or  closure  by 
suture  constriction  or  resection  of  the 
proximal  jejunum  or  the  pylorus  is  con- 
traindicated.  It  commits  an  unneces- 
sary traumatism  and  leaves  a  deformity 
that  may  cause  immediate  and  subse- 
quent bad  results.  W.  H.  Wathen  (Jour- 
nal of  the  American  Medical  Associa- 
tion, June  17,  1905). 


HEMORRHAGE,    SODIUM    BICARBONATE 
IN. 

Using  dogs  for  the  purpose  of  his  ex- 
periments, the  writer  has  investigated 
the  cardio-vascular  effects  of  intraven- 
ous infusion,  after  severe  haemorrhages, 
of     solutions     containing    sodium    bi- 
carbonate.     He  finds  that  whereas,  so- 
dium chloride  alone  has  the  immediate 
effect  of  raising  blood-pressure,  with  the 
addition  of  sodium  bicarbonate  to  the 
chloride  solution  the  rise  in  pressure  is 
markedly  increased.      The  author  sug- 
gests  that   in   some   extreme   cases    of 
shock  due  to  haemorrhage  the  addition 
of  from  x/2  to  1  per  cent,  of  the  bicar- 
bonate to  a  0.8  per  cent,  sodium  chloride 
solution  may  be  of  advantage  in  two  re- 
spects.    In  the  first  place,  the  rise  in  all 
the  pressures,  but  especially  in  the  dias- 
tolic pressure,  is  more  pronounced  than 
•when  the  pure  chloride  is  used;    and, 
secondly,  the  quantity  of  fluid  required 
is  smaller  than  is  the  case  with  the  pure 
chloride;    the  greater,  therefore,  is  the 
rapidity  with  which  the  solution  can  be 
hurried  into  the  circulation — a  matter 
which  may  be  of  importance  in  desper- 
ate cases. 

There  is,  however,  one  possibility 
which  ought  not  to  be  overlooked  in  the 
employment  of  bicarbonate — namely, 
the  danger  of  overworking  the  heart. 
From  experiments  not  yet  concluded 
the  author  finds  reason  to  believe  that 
very  strong  solutions  of  sodium  carbon- 
ate and  bicarbonate  act  very  powerfully 
as  cardiac  stimulants.  Before  employ- 
ing the  bicarbonate,  therefore,  in  cases 
of  haemorrhage  the  physician  ought  to 
decide  whether  a  cardiac  stimulant  is  or 
is  not  contraindicated.  P.  M.  Dawson 
(Journal  of  Experimental  Medicine,  vol. 
vii,  p.  1,  1905). 


HYPODERMOCLYSIS. 


317 


HYPODERMOCLYSIS. 

In  combating  disease  there  are  three 
ways  to  relieve  the  patient:  first,  by 
elimination,  removing  from  the  system 
the  deleterious  effects  of  disease;  sec- 
ond, the  stimulation  of  the  internal  se- 
cretions, increasing  phagocytosis  and 
the  formation  of  antibodies;  third,  the 
introduction  of  an  antitoxic  substance 
ready  formed. 

In  calling  attention  to  the  subject  of 
hypodermoclysis,  the  author  makes  no 
claim  to  have  discovered  something  new, 
but  only  to  have  done  considerable  work 
in  this  line,  and  believes  it  a  proceeding 
either  not  properly  understood  or  greatly 
neglected.  Hypodermoclysis  no  doubt 
acts  to  some  extent  by  increasing  the 
elimination  of  effete  and  toxic  materials, 
but  as  it  does  not  cause  a  large  increase 
in  the  substance  normally  excreted  by 
the  kidneys,  as  proved  by  the  normal  or 
diminished  amount  of  urea  found  in  the 
urine  after  its  use,  it  must  accomplish 
its  beneficient  effect  in  some  other  way 
than  by  flushing  out  the  system  and  di- 
luting the  toxins.  The  flushing  out  of 
the  whole  system  and  at  the  same  time 
diluting  and  removing  the  toxins  is  a 
theory  beautiful  to  contemplate  in  the 
abstract.  An  increase  in  the  percentage 
of  urea  was  expected  after  the  use  of 
Baline  solution,  but  in  no  case  did  this 
occur. 

A  study  of  the  blood  is  of  far  more 
importance.  There  is  a  decided  leuco- 
cytosis,  and  there  is  also  a  large  increase 
in  the  number  of  erythrocytes  produced 
by  hypodermoclysis.  The  leukocytosis 
has  a  direct  bearing  on  the  subject  in  the 
phagocytic  theory  of  Metchnikoff  and 
the  crythrocytosis  upon  the  oxygenation 
of  the  I  issues.  The  author  uses  Sajous's 
explanation  (Monthly  Cyclop. kih a  of 
Practical  Medicine,  December,  1904). 


The  "phagocytic  theory  of  Metchnikoff 
is  that  the  living  cells  seize  upon  and 
destroy  the  bacteria  in  the  blood,  the 
organisms  that  escape  from  one  cell  are 
seized  upon  by  others,  but  if  their  multi- 
plication is  excessive  they  overpower  the 
phagocytic  leucocytes,  and  invade  the 
blood-stream.  Various  observers,  Pfeif- 
fer,  Buchner,  and  others,  having  demon- 
strated that  the  blood-serum  and  other 
body  fluids  were  likewise  bactericidal, 
Metchnikoff  ascribed  this  fact  to  the  dis- 
integration of  the  phagocytes,  the  prop- 
erties of  these  cells  being  thus  imparted 
to  the  serum.  Bordet  and  other  French 
observers  showed  this  property  to  be  due 
to  two  constituents  of  the  plasma;  the 
one  (the  specific  immune  body)  circu- 
lates in  the  plasma  according  to  Metch- 
nikoff, and  resists  a  temperature  as  high 
as  100°  C.  The  other,  cytase,  thought 
to  be  derived  from  disintegrated  phago- 
cytes, is  destroyed  at  a  temperature  of 
56°  C.  Cytase  is  considered  by  Metch- 
nikoff as  belonging  to  the  category  of 
trypsins.  The  view  that  the  serum  is 
endowed  with  bactericidal  powers  has 
been  ably  defended  by  Pfeiffer,  Nuttall, 
and  others.  Buchner  and  Hankin  iso- 
lated substances  which  they  termed  alex- 
ins, and  to  these  bodies  they  ascribed  the 
power  to  confer  immunity.  They  were 
thought  by  Buchner  to  be  derived  from 
oxyphile  leucocytes  and  kindred  cells. 
Laschtscenka  having  isolated  them  from 
living  leucocytes,  the  bactericidal  action 
was  thought  by  Buchner  to  be  due  to  a 
proteolytic  enzyme  similar  to  the  ordi- 
nary digestive  ferments.  According  to 
Gruber  the  bacteria  cell  walls  were  first 
made  adhesive  by  the  blood  agglutinins 
and  thus  became  vulnerable  to  the  de- 
-i  ractive  ad  ion  of  the  alexins. 

"The  side  chain  theory   advanced  by 
Khrlichin  1897  aimed  to  harmonize  the 


318 


HYPODERMOCLYSIS. 


results  so  far  reached  in  the  study  of 
natural  and  artificial  immunity.  This 
theory  is  not  necessarily  a  complex  one, 
and  is  based  on  recognized  biological  and 
chemical  principles.  The  colonies  of 
body  cells  differ  from  each  other  in  their 
functional  attributes.  Nerve  cells,  mus- 
cle cells,  gland  cells,  etc.,  each  having  a 
special  affinity  for  certain  drugs :  the 
cerebro-spinal  cells  having  a  special 
affinity  for  strychnine,  the  cardiac  mus- 
cle cells  for  digitalis,  the  sweat  and  sali- 
vary gland  cells  for  jaborandi. 

"Now  as  toxins  differ  in  no  way  from 
remedies  in  this  particular,  they  are  also 
specific  owing  to  their  affinities,  toxin 
being  also  taken  up  by  specific  cells. 
This  specific  action  represents  the  found- 
ation of  Ehrlich's  theory.  The  theory 
itself  is  based  upon  the  mechanism  of 
cell  nutrition  in  its  mode  of  production 
of  specific  antitoxins,  or  bactericidal  and 
antitoxic  sera. 

"The  cellular  protoplasm  is  very  com- 
plex and  Ehrlich  assumes  that  each  cell 
contains  an  active  central  nucleus  and 
of  groups  of  molecules  or  side  chains; 
these  extranuclear  molecules  he  calls 
receptors.  Since  each  of  them  has  for 
its  function  the  receiving  of  food  mole- 
cules or  haptophores  (  am-eiu,  to  bring), 
a  cell's  nutrition  is  thus  carried  on 
through  the  affinity  its  receptors  have  for 
its  haptophores. 

"Unfortunately  the  receptors  do  not 
combine  with  nutritive  substances  only, 
but  have  an  affinity  for  substances  which 
may  be  their  chemical  analogues  and 
which  may  include  harmful  bodies ;  thus 
a  poison,  toxin,  or  venom  may  contain 
the  same  elements  and  the  same  num- 
ber of  them  as  a  nutrient  molecule  or 
haptophore,  the  atoms  only  being  ar- 
ranged differently  (isomerism).  Tur- 
pentine and  oil  of  lemon  each  have  the 


formula  C10H16,  though  their  properties 
are  quite  dissimilar.  Ethyl  formate  and 
methyl  acetate  have  the  same  molecular 
weight  74  and  the  formula  C3HG02.  It 
is  possible  then  for  a  cell  to  take  up  any 
number  of  isomeric  non-nutritive  bodies, 
and  when  one  of  these  happens  to  be 
toxic  it  is  called  a  toxiphore.  If  the 
toxin  is  not  sufficient  to  destroy  the  cell 
or  inhibit  its  functions,  the  latter  socks 
to  rid  itself  of  the  poison  and  to  pro- 
tect itself  from  any  further  aggression 
from  this  poison  or  its  isomers.  The 
toxic  group  of  the  haptophoric  molecules 
attaches  itself  to  the  receptors  and  then 
reacts  actively  upon  the  cell  proper;  the 
receptors  themselves  being  destroyed,  the 
cell  (in  keeping  with  Weigert's  theory  of 
overproduction)  not  only  reproduces 
them,  but  the  process  is  so  active  that 
many  more  receptors  are  created  than 
are  required  by  the  cell  itself,  and  thus 
accumulate  in  the  blood  and  lymph. 
These  receptors  still  preserve  their 
affinity  for  their  specific  haptophores 
and  their  isomeric  toxin ;  they  therefore 
become  cell  protectors,  capturing  and 
holding  the  toxin  before  it  reaches  the 
cell." 

HaffMne's  prophylactic  is  a  good  illus- 
tration of  this  action,  a  toxin  being  in- 
troduced, the  system  forms  its  own  anti- 
toxin. The  author  thinks  it  is  probable 
that  the  saline  solution  stimulates  the 
formation  of  receptors  and  thus  protects. 
It  is  said  by  good  observers  that  the 
arrow  poison  used  by  the  South  Sea  Isl- 
anders and  other  savage  tribes  is  not 
effective  against  people  who  partake 
freely  of  salt  in  their  food,  although 
deadly  -to  other  animals.  Lambinet 
(Bull.  Acad.  Eoy.  de  Med.  de  Belgiquc 
Beport  on  Anaemia.  in  Puerto  Bico)  found 
that  immersion  in  a  2  per  cent,  solution 
of  bichloride  of  mercury,  or  a  3  per  cent. 


HYPODERMOCLYSIS. 


319 


solution   of   lysol   for   one   hour,   would 
Dot  kill  ova  of  the  Uncinaria  Americana, 
while  a  strong  solution  of  salt  was  fatal. 
Again,  Metchnikoff  states  that  his  tryp- 
tic  cytase  acts  only  in  the  presence  of 
salts,  and  that  when  relieved  of  its  salts 
by  dialysis  the  serum  loses  its  haemolytic 
power,  but  when  the  salts  are  restored  to 
it   this   reappears.      In   pneumonia    the 
chlorides  disappear  from  the  urine  and 
accumulate  in  the  lungs,   as  shown  by 
Bcale  a  number  of  years  ago,  their  ac- 
tion in  the  lungs  being  no  doubt  to  in- 
crease the  efficiency  of  the  protective  ac- 
tion  of   the  pulmonary  fluids   (Sajous, 
ib.,     November,   1904).        Again,     the 
presence  of  proteolytic   enzymes   in  the 
scrum  has  been  recently  demonstrated  by 
Delezenna  and  Pozerski,  and  the  results 
confirmed  by  Hedin.    The  latter  investi- 
gator states  that  the  serum  of  the  ox 
contains     a    weak     proteolytic     enzyme 
which  acts  in  an  alkaline  medium.    The 
origin  of  this  enzyme  has  been  traced  as 
well  as  the  increased  alkalinity  and  the 
supply  of  salts  necessary  to  render  serum 
hemolytic. 

The  three  prominent  theories  of  im- 
munity have  several  features  in  com- 
mon; one  of  these  is  that  the  destruc- 
tion of  the  bacteria  in  the  blood  serum 
is  ascribable  to  a  substance  which  Metch- 
nikoff calls  cytase.  Buchner  calls  it 
alexin,  and  Ehrlich  complement.  An- 
other is  that  the  bactericidal  body  is 
derived  from  the  leucocytes.  Metchni- 
koff thinks  it  comes  from  the  phago- 
cytes. Buchner  traced  it  to  oxophylic 
leucocytes,  while  Ehrlich  is  inclined  to 
believe  that  his  bacteriolysins  are  de- 
rived  from  these  cells.  All  three  theo- 
ries concur  in  recognizing  that  the  blood 
destroys  pathogenic  organisms  by  means 
of  a  digestive  (ferment)  substance,  and 
that  this  substance  is  derived  from  the 


white  blood-cells.  This  proteolytic  fer- 
ment is  believed  by  Buchner,  Hankin, 
and  Sajous  to  be  supplied  to  the  leuco- 
cytes by  the  ductless  glands. 

The   sodium    chloride   solution   itself 
probably  has  the  action  of  a  digestive 
ferment  in  the  blood.     A.  Eobin  (Bull, 
de  l'Acad.  de  Med.,  December  6,  1904) 
announces  that  "a  solution  of  a  metal, 
in  a  proportion  of  .00009  to  .0002  gram 
to  the  cubic  centimeter,  has  a  most  re- 
markable   action    when    injected    subcu- 
taneously.      It   displays    a   physiological 
action,  like  that  of  a  true  ferment,  out 
of  all  proportion  to  the  minute  amount 
of  the  metal  employed.     The  injection 
is   followed   by   leucocytosis.      Fourteen 
cases  of  pneumonia  were  treated  and  the 
crisis   was   hastened   in   each    case,   the 
temperature  dropping  to  normal  before 
the  seventh   day.      The   metal   ferments 
evidently  stimulate  the  action  of  the  or- 
ganism,  reinforcing   the   natural   resist- 
ing powers  and  superposing  on  the  vital 
and  personal  reactions  a  parallel  activity 
revealed  by  the  more  rapid   disappear- 
ance of  the  correlative  symptoms  of  the 
infection.     The  therapeutical  use  of  the 
metal  ferments  is  an  attempt  to  apply 
in  the  clinic  the  new  data  furnished  by 
physics  and  chemistry  in  the  last  few 
years  in  regard  to  radioactivity,  ioniza- 
tion,  and   atomic   energy,   diastases,   zy- 
mases, minutely  divided  metals  of  cata- 
lytic phenomena."     At  this  time  when 
we  are  seeking  antitoxic  sera  for  all  in- 
fectious diseases,-  saline  solution    is  ex- 
tremely useful  and  should  be  used  in  all 
cases   when   a   specific   antitoxin   is   not 
obtainable,  as  it  acts  much  in  the  same 
way.  only  its  field  of  action  is  greater 
and  its  applicability  wider. 

From  experiments  and  observations 
made  by  the  writer,  he  believes  that  the 
use  of  saline  solutiou  by  hypodermoclysis 


320 


INFANT  FEEDING. 


causes  a  decided  increase  in  both  the 
erythrocytes  and  the  leucocytes.  It  is 
also  probable,  but  not  proved,  except  by 
the  leucocytosis,  that  it  stimulates  the 
ductless  glands  to  increased  activity. 

Certain  cases  were  studied  to  ascer- 
tain, if  possible,  the  mode  of  action  of 
hypodermoclysis.  The  urine  for  twenty- 
four  hours  was  saved  and  analyzed,  on 
the  day  before  the  hypodermoclysis  was 
used,  the  twenty-four  hours  reaching  up 
to  the  time  of  injection.  Just  before  the 
saline  solution  was  used,  a  count  of  the 
leucocytes  was  made  and  a  haemotocritic 
estimate  made  of  the  red  cells. 

The  writer  concludes  that  the  physio- 
logical effect  of  hypodermoclysis  is  prob- 
ably to  stimulate  the  ductless  glands, 
causing  an  increase  of  the  internal  secre- 
tions. Certainly  an  increase  of  the  leu- 
cocytes with  a  consequent  increase  of  the 
enzyme,  cytase,  or  alexin,  increased 
phagocytosis,  with  an  increase  of 
Ehrlich's  receptors;  a  very  decided 
addition  to  the  salts  of  the  serum  with 
an  increase  or  restoration  of  its  haemo- 
lytic  power;  an  increase  in  the  alkalin- 
ity of  the  serum  which,  as  has  been 
shown,  adds  greatly  to  the  bactericidal 
properties.  The  clinical  effects  of  hypo- 
dermoclysis are  to  raise  the  blood-pres- 
sure, and  to  strengthen  and  regulate  the 
pulse.  The  increase  of  the  erythrocytes 
enables  the  blood  to  carry  more  oxygen, 
and  the  respirations  are  deeper  and  less 
•rapid ;  the  blood  and  tissues  are  more 
thoroughly  oxygenated  ■;  the  skin  be- 
comes moist  (and  warm  if  cold  before). 
Diuresis  is  increased;  the  mind  becomes 
clearer,  sleep  is  promoted,  the  appetite  is 
improved,  the  patient  is  encouraged,  and 
there  is  a  feeling  of  well  being. 

Eypodermoclysis  is  not  a  remedy  for 
everything.  To  the  surgeon  the  author 
suggests  its  use  always  after  haemor- 
rhage, in  shock,  and  often  to  prevent 


shock;  it  will  be  found  his  best  friend; 
to  the  obstetrician,  in  eclampsia,  and 
after  post-partum  haemorrhage,  provided 
the  haemorrhage  is  well  under  control. 
To  the  physician  the  author  advises  its 
use  in  anaemia,  enteric  fever,  and  pneu- 
monia— in  all  of  these  it  will  help  him, 
and  in  the  last  two  mentioned  will  often 
save  a  previous  life  when  all  else  has 
failed.  W.  Page  Mcintosh  (New  York 
Medical  Journal  and  Philadelphia  Med- 
ical Journal,  June  10,  1905). 

INFANT   FEEDING. 

Cases  of  difficult  feeding  in  infancy 
are  cases  of  (a)  fat  indigestion,  (b) 
sugar  indigestion,  (c)  proteid  indiges- 
tion. Each  one  of  these  varieties  may 
exist  alone  or  in  combination  with  the 
others.  The  most  frequent  form  is  pro- 
teid indigestion,  but  cases  of  fat  indi- 
gestion are  also  common. 

Each  individual  infant  must  be  a  law 
unto  himself.  Babies  cannot  be  fed  by 
rule  of  thumb.  The  form  of  indigestion 
present,  if  possible,  must  be  determined 
and  appropriate  treatment  be  applied. 
The  treatment  is  almost  exclusively 
dietary.  The  fats  and  sugar  can  be  reg- 
ulated by  varying  the  amounts  of  cream 
and  sugar. 

The  composition  of  cow  proteid,  high 
caseinogen  and  low  lactalbumin,  must 
be  remembered  in  the  management  of 
proteid  cases.  The  caseinogen  must 
often  be  cut  to  a  low  point  or  even 
eliminated  altogether ;.  lactalbumin  must 
be  retained  in  the  food;  this  twofold 
object  is  attained  by  feeding  whey.  In- 
crease in  quality  and  quantity  of  the 
food  must  be  made  gradually.  It  is 
desirable  that  many  artificially  fed  ba- 
bies should  be  carefully  studied,  the 
symptoms  of  different  forms  of  indiges- 
tion noted,  and  the  data  published.  F. 
S.  Churchill  (Journal  of  the  -American 
Medical  Association,  May  27,  1905). 


INFANTILE  TUBERCULOSIS. 


INGROWING  NAIL. 


321 


INFANTILE   TUBERCULOSIS. 

Tuberculosis  in  infancy  arises  most 
often  from  an  infection  through  either 
the  respiratory  or  alimentary  tract;  the 
comparative  frequency  of  these  two 
modes  of  infection  has  not  yet  been 
definitely  determined. 

The  tuberculosis  of  early  life  is  most 
common  during  the  first  year,  when 
children  are  on  an  exclusive  milk  diet, 
and  much  milk  contains  tubercle  bacilli, 
and  bovine  tubercle  bacilli  are  patho- 
genic for  man.  At  this  period,  owing  to 
the  structure  of  the  intestinal  wall,  bac- 
teria can  probably  pass  through  it,  al- 
though it  is  uninjured.  Experiments 
on  animals  show  that  inhalation  tuber- 
culosis causes  usually  lesions  of  the 
bronchial  lymph  nodes  and  lungs  alone, 
while,  wherever  the  portal  of  entry, 
these  structures  become  very  early  in- 
volved. Inoculation  experiments  prove 
that  the  mesenteric  lymph  nodes  may  be 
tuberculous  within  the  presence  of  any 
gross  lesions  in  them. 

Twenty-six  and  one-half  per  cent,  of 
the  158  autopsies  on  tuberculous  cases 
at  the  Foundling  and  Nursery  and 
Child's  Hospital,  which  the  writer  has 
tabulated,  show  intestinal  or  mesenteric 
lesion  on  gross  examination. 

The  tuberculosis  of  infancy,  unlike 
that  of  later  life,  is  usually  an  acute, 
widely  disseminated,  general  disease, 
with  moderate  temperature  and  few 
symptoms  and  physical  signs  unless  the 
invasion  of  the  meninges  gives  rise  to 
symptoms. 

Tuberculosis  of  the  cervical  lymph- 
nodes  and  of  the  joints  is  rarely  seen 
under  (he  third  year.  The  power  to 
overcome  a  tuberculous  infection  that 
has  spread  from  the  lymphatics  and  in- 
vaded the  organs  apparently  docs  not 
exist  in  infancy. 


While  the  autopsies  tabulated  show  a 
very  wide  distribution  of  the  tubercu- 
lous disease  in  these  infants,  they  prob- 
ably indicate  a  much  less  general  dis- 
tribution than  really  existed,  for  the 
data  is  based  often  on  hurried  gross 
examination  without  microscopical  con- 
firmation. 

A  series  of  autopsies  in  the  same  in- 
stitutions, in  which  the  intestines  were 
carefully  examined  without  being  sepa- 
rated from  the  mesentery,  and  with  mi- 
croscopical examination  of  all  suspicious 
thickenings,  would  probably  show  a 
much  larger  proportion  of  intestinal  in- 
volvement and  a  still  greater  proportion 
could  be  found  by  animal  inoculations. 
E.  G.  Freeman  (Medical  News,  May  27, 
1905). 

INGROWING      NAIL,      MEDICAL      TREAT- 
MENT  OF. 

The  writer  has  found  that  copious  ap- 
plication of  dried  powdered  alum  is  suf- 
ficient to  cure  every  case  of  ingrowing 
nail  in  his  experience  in  about  five  days. 
The  applications  were  never  painful  in 
the  least,  and  the  destruction  of  the 
pathologic  tissue  resulted  in  the  forma- 
tion of  a  hard,  resistant  and  non-sensi- 
tive bed  for  the  nail,  a  perfect  cure  for 
the  ingrowing  tendency.  The  non-tox- 
icity  of  the  alum,  its  easy  application, 
and  the  fine  results  render  it  the  chosen 
treatment  for  cases  in  which  surgical 
intervention  is  not  contemplated.  The 
writer  applies  a  fomentation  of  soap  and 
water  for  twenty-four  hours  beforehand 
and  then  pours  the  alum  into  the  space 
between  the  nail  and  il^  bed,  tamponing 
with  cotton  to  keep  the  alum  in  place, 
and  repeating  the  application  daily.  The 
suppuration  rapidly  dries  up,  and  pain 
and  discomfort  are  relieved  almost  at 
once.     A.  Gasparini  (Gazzetta  Ospedali, 


322 


INTESTINAL  ANTISEPSIS. 


LABOR,  BIMANUAL  DILATATION. 


vol.  xxvi,  No.  10 ;  Journal  of  the  Amer- 
ican Medical  Association,  June  10, 
1905). 

INTESTINAL  ANTISEPSIS,  EFFECT  OF, 
ON  EXCRETION  OF  HIPPURIC  ACID 
IN  THE   URINE. 

The  feeding  of  gelatine  alone  in- 
creases the  excretion  of  hippuric  acid. 
When  putrefactive  changes  are  increased 
the  excretion  of  hippuric  acid  is  in- 
creased, and  vice  versa.  When  the  in- 
testinal, canal  was  made  antiseptic  with 
calomel  there  was  practically  no  hip- 
puric acid  excreted.  Intestinal  antisep- 
sis has  no  effect  whatever  on  the  excre- 
tion of  nitrogen.  No  matter  how  much 
gelatine  was  fed  it  was  completely 
burned  and  some  of  the  body's  proteid 
with  it.  Therefore,  gelatine  never  builds 
up  any  tissue,  although  it  may  to  a  cer- 
tain extent  protect  the  body's  proteid 
from  decomposition.  J.  B.  Prager 
(Medical  News,  June  3,  1905). 

KNEE   INJURIES. 

Apparently  slight  injuries  of  the  knee 
often  prove  more  lasting  and  annoying 
than  those  of  a  more  positive  nature,  as 
fracture  or  dislocation.  Every  injury 
of  the  knee  should  receive  careful  exam- 
ination, since  laceration  of  ligaments  or 
of  periarticulate  tissues,  or  displacement 
of  semilunar  cartilages,  or  of  loose  bod- 
ies, may  have  occurred.  •  Obscure  frac- 
tures, also,  are  not  uncommon. 

Every  injured  knee  requires  rest  dur- 
ing its  acute  inflammatory  stage;  rest 
in  bed,  fixed  dressings,  and  crutches  are 
needful.  Heat  and  cold  are  two  pow- 
erful agents  in  aborting  a  threatened  in- 
flammation. Adhesive  plaster  strapping 
is  of  great  value  in  securing  partial  re- 
straint of  a  knee  and  in  producing  ab- 
sorption of  effusion.  Eestricting  appa- 
ratus should  be  used  with  discrimina- 
tion.    Blood  clots  in  the  joints  should 


be  removed  by  incision  and  flushings. 
Effusions,  if  large,  should  be  removed 
by  aspiration,  or  incision  followed  by 
weak  iodine  injection.  Displaced  semi- 
lunar cartilages  should  be  stitched  in  po- 
sition, or  removed.  Loose  cartilaginous 
bodies  should  be  removed. 

Motion  is  the  normal  condition  of 
joints,  consequently  massage  and  volun- 
tary motions  should  be  instituted  as  soon 
as  the  inflammatory  stage  has  passed. 
Neglect  of  this  precaution  may  result  in 
a  neuromimetric  patient  and  a  chronic 
cripple.  Sensitive  neurotic  knees  should 
not  be  mistaken  for  diseased  ones.  Com- 
plete primary  rest  during  the  inflam- 
matory stage,  followed  by  massage,  vol- 
untary and  involuntary  movements, 
gymnastic  exercises,  hot-air  treatment, 
hot  and  cold  douchings,  etc.,  are  the  best 
means  at  our  command  for  preventing 
ankylosis.  Should  ankylosis  follow, 
forcible  straightenings,  tenotomies,  os- 
teotomies, etc.,  may  be  required.  De 
Forest  Willard  (American  Medicine, 
June  17,  1905). 

LABOR,  BIMANUAL  DILATATION  OF  THE 
CERVIX  IN. 

The  following  method  for  the  bi- 
manual dilatation  of  the  cervix  during 
labor  is  recommended  by  the  writer, 
when  the  narrow  and  unyielding  neck 
of  the  uterus  prevents  prompt  delivery: 
The  index  finger  of  the  right  hand  is 
passed  into  the  cervix,  and.  is  hooked 
under  the  upper  lip  thereof,  the  patient 
lying  on  her  back  and  the  operator 
standing  at  her  right  side.  Then,  if 
only  a  little  over  one  finger  can  be  in- 
troduced- into  the  os,  the  index  finger 
of  the  left  hand  is  passed  along  that  of 
the  right  hand  until  it  reaches  the  cer- 
vix, when  it  is  hooked  "over  the  posterior 
lip,  with  the  palmar  surface  downward. 
Then   traction   is   made  slowly.      It   is 


LEG  ULCER. 


MEASLES,  KOPLIK'S  SPOTS  IN  DIAGNOSIS  OF. 


323 


preferable  to  do  this  during  the  pains, 
as  the  manoeuvre  is  painful.  After  from 
five  to  eight  such  stretchings,  each  of 
which  should  take  about  a  minute  and 
a  half,  the  cervix  will  begin  to  yield  per- 
ceptibly. The  process  should  be  con- 
tinued until  the  womb  admits  about  four 
fingers,  when  the  whole  hand  can  usu- 
ally be  introduced,  or  the  forceps  ap- 
plied. In  14  cases  in  which  the  author 
used  this  method,  he  has  seen  neither 
hamiorrhage  nor  tears  of  the  cervix.  S. 
G.  Krashevski  (Eoussky  Vratch,  April 
9,  1905 ;  New  York  Medical  Journal 
and  Philadelphia  Medical  Journal,  June 
3,  1905). 

LEG    ULCER,    TREATMENT    OF. 

The  writer  has  employed  for  the  last 
two  years,  with  considerable  success,  the 
following  modification  from  the  usual 
methods  of  treatment:  The  medicinal 
substance  having  been  applied  to  the 
ulcer,  the  limb  is  bandaged  with  two 
thin,  firm,  long,  elastic  bandages,  one 
above  the  other,  beginning  as  near  as 
possible  to  the  big  toe.  Because  of  its 
increased  firmness,  this  is  superior  to  the 
single  bandage..  At  night  the  bandages 
are  taken  off  and  a  stimulating  dressing 
applied  until  morning.  When  an  im- 
movable dressing  is  required,  the  ulcer 
having  been  dressed,  one  bandage  is  ap- 
plied, and  a  lime  made  from  tragacanth, 
.05  per  cent. ;  gelatine,  10  per  cent. ; 
glycerine,  5  per  cent.;  boric  acid,  5  per 
cent.,  and  sodium  borate,  5  per  cent., 
smeared  over  it  after  heating  it:  the 
second  bandage  is  (hen  applied.  Tins 
produces  a  verv  firm  dressing  and  one 
which  is  easily  taken  off.  One  minute 
in  warm  water  will  dissolve  it  sufficiently 
to  take  it  off.  H.  Voerner  (Miinchener 
Medicinische  Wochenschrift,  Bd.  Hi,  \n. 
8,  1905;  American  Medicine,  June  10, 
1905). 


MEASLES,    KOPLIK'S    SPOTS    IN    DIAGNO- 
SIS   OF. 

Koplik's  spots,  the  size  of  a  pinhead, 
bluish-white  in  color,  and  surrounded  by 
a  red  areola,  occur  in  varying  numbers 
on  the  mucous  membrane  of  the  cheek, 
opposite  the  molar  teeth,  in  patients  suf- 
fering from  measles;  they  are  seen 
usually  several  days  before  the  exanthem 
appears,  and  fade  in  most  instances  with 
the  appearance  of  the  measly  eruption. 
Of  48  referred  to  the  author's  institu- 
tion with  the  diagnosis  and  eruption  of 
measles,  19  per  cent,  showed  the  Koplik 
spots;  of  52,  in  whom  the  disease  ap- 
peared while  in  the  institution,  50  were 
found  to  have  them.  The  patients  in- 
cluded children  of  all  ages.  It  was 
found  3  times  on  the  fifth  and  sixth  days 
before  the  eruption,  4  times  four  days 
before,  7  times  three  days  before,  11 
times  two  clays  before,  and  25  times  one 
day  before  the  eruption  came  out;  in 
only  17  did  they  persist  long  enough  to 
be  present  at  the  same  time  as  the  actual 
cutaneous  eruption,  and  in  only  2  in- 
stances did  they  last  as  long  as  the  erup- 
tion itself.  They  were  usually  small,  but 
easily  observed  as  soon  as  the  mouth  was 
opened,  diffuse  daylight  being  the  best 
light  for  their  observation.  In  some 
cases  they  were  scattered  over  lips, 
cheeks,  gums,  etc.,  but  usually  seen  op- 
posite Steno's  duct.  They  were  not  ob- 
served by  the  author  in  any  other  erup- 
tive fever,  such  as  rubeola,  scarlet  fever, 
serum  exanthemas,  so  that  he  considers 
them  absolutely  pathognomonic  for  mea- 
sles, advising  their  use  for  purposes  of 
diagnosis,  differential  diagnosis,  and 
prophylaxis.  II.  Bruening  (Deutsche 
medicinische  Wochenschrift,  vol.  xxxi, 
Nu.  10,  1905;  American  Medicine, 
June  17,  1905). 


324 


MENINGITIS,  EPIDEMIC,  TREATMENT. 


(EDEMA,  TREATMENT. 


MENINGITIS,  EPIDEMIC  CEREBRO-SPI- 
NAL,  TREATMENT  OF. 
The  author  warmly  urges  the  use  of 
sodium  iodide  in  this  condition  and  de- 
scribes an  apparently  hopeless  case  in 
which  its  administration  was  followed 
by  remarkably  prompt  curative  effects. 
The  sodium  salt  differs  from  potassium 
iodide  and  the  newer  iodine  combina- 
tions in  the  rapidity  with  which  it  gives 
up  in  the  body  its  iodine  in  the  nascent 
state  through  the  action  of  the  hydriodic 
acid  formed.  This  is  shown  by  the 
promptness  with  which  the  taste  of  io- 
dine becomes  perceptible  in  the  mouth 
after  injection  of  the  drug  beneath  the 
skin  of  the  forehead  or  neck.  The  au- 
thor has  on  other  occasions  called  atten- 
tion to  the  value  of  this  salt  in  certain 
diseases  of  the  cerebro-spinal  system, 
and  he  says  that  in  cerebro-spinal  men- 
ingitis it  will  do  bo  harm,  while  he  is 
convinced  that  it  will  be  of  service  and 
will  certainly  prevent  the  development 
of,  and  relieve  already  existing,  cerebral 
disturbances.  The  drug  may  be  admin- 
istered subcutaneously  or  by  mouth;  in 
the  former  case  the  addition  of  a  little 
eucaine  obviates  the  slight  pain  attend- 
ing injection.  The  writer  suggests  the 
use  of  a  1  to  20  solution  of  sodium  io- 
dide with  .3  gram  of  eucaine  to  each 
20  cubic  centimeters;  1  to  2  centigrams 
of  this  may  be  injected  in  the  neighbor- 
hood of  the  head,  two  or  three  times  a 
day.  If  lumbar  puncture  is  done,  3  to 
4  centigrams  might  be  injected.  Ruhe- 
mann  (Berliner  klinische  Wochenschrift. 
May  1,  1905;  Medical  Record,  May  27, 
1905). 

NITROGLYCERINE,  TOLERANCE  TO. 

An  excessive  tolerance  of  nitroglyc- 
erine can  be  readily  acquired  if  care  is 
not  takon  to  avoid  a  too  rapid  increase 
of  the  dose,  hence  the  drug,  though  in- 


telligently employed,  is  often  of  little 
service.  The  best  rule  for  giving  the 
drug  for  its  effects  on  blood-pressure  is, 
in  the  opinion  of  the  author,  to  admin- 
ister it  four  times  a  day  in  dose  just 
sufficient  to  produce  the  slightest  feel- 
ing of  fullness  in  the  head  or  slightly 
to  quicken  the  pulse.  If  more  than  this 
is  given,  an  undesirable  tolerance  is 
likely  to  be  established.  When  a  rather 
rapid  increase  seems  needed  to  keep  up 
a  constant  effect,  it  is  best  to  discontinue 
the  drug  for  two  or  more  days,  at  inter- 
vals, and  to  resume  its  use  with  a  smaller 
initial  dose.  By  so  doing  the  use  of 
very  large  doses  and  strong  solutions, 
which  are  not  exactly  safe  to  handle, 
will  be  avoided.  Nitroglycerine  has  not 
met  expectations  as  a  remedy  in  condi- 
tions of  persistent  high  tension,  merely 
endeavoring  at  first,  at  least,  to  relieve 
by  limiting  the  nitroglycerine  intake  and 
maintaining  free  action  of  the  skin  and 
bowels.  Aconite  is  often  substituted  for 
nitroglycerine  in  these  cases  with  advan- 
tage. D.  D.  Stewart  (Journal  of  the 
American  Medical  Association,  May  27, 
1905). 

CEDEMA,   TREATMENT   OF. 

In  cardiac  oedema,  when  the  heart 
alone  is  at  fault,  physiologic  rest  is  the 
most  potent  of  all  remedial  agents;  but 
in  most  cases  of  failure  of  cardiac  com- 
pensation, rest  alone  is  insufficient  to 
restore  it.  Of  drugs  the  author  prefers 
digitalis  to  strophanthus.  When  the  in- 
competent kidneys  fail  to  respond  to  the 
stimulus  of  diuretics,  hot-air  baths  and 
vapor  baths  must  be  resorted  to.  He  ad- 
vises against  allowing  the  patient  to 
drink  copiously  of  water  during  the  ad- 
ministration of  the  bath,  because  the 
water  thus  drunk  is_  added  to  that  which 
is  already  retained,  and,  therefore,  in 
proportion  to  its  amount,  it  neutralizes 


OTITIS  MEDIA,  SUPPURATIVE. 


OTITIS  MEDIA,  TREATMENT. 


325 


the  remedial  action  of  the  bath.  Regu- 
lation of  the  diet  is  also  of  importance. 
The  indications  are  to  avoid  excess  of 
proteids  and  of  such  dietetic  substance? 
as  are  likely  to  irritate  the  renal  epithe- 
lium or  to  increase  the  retention  of 
water.  The  quantity  of  liquid  allow.'. I 
to  dropsical  patients  with  Bright's  dis- 
ease should  be  determined  by  careful 
consideration  of  the  conditions  involved. 
The  plan  frequently  adopted  of  causing 
the  patient  to  drink  copiously  of  liquids 
in  order  to  promote  the  elimination 
of  end-products  is  fallacious  on  two 
grounds :  First,  the  kidneys  are  incom- 
petent to  excrete  urine  of  normal  molec- 
ular density,  consequently  it  is  poor  in 
solid  constituents;  second,  the  fact  that 
oedema  is  present  indicates  a  tendency 
to  retention  of  water  which  lays  under 
contribution  the  whole  of  the  liquid  im- 
bibed, leaving  but  a  small  proportion  of 
the  excess  to  act  as  the  vehicle  for  car- 
rying away  effete  products  in  the  urine, 
so  that  the  oedema  is  increased  in  pla?e 
of  the  tissues  being  flushed  out.  On  the 
other  hand,  undue  restriction  of  liquids 
impedes  the  output  of  a  certain  propor- 
tion of  solid  constituents  which  the  kid- 
neys are  still  competent  to  eliminate, 
provided  that  the  volume  of  urine  be 
not  arbitrarily  checked.  When  the  vol- 
ume of  urine  is  ample,  the  intake  of 
liquid  usually  needs  no  restriction  with 
scanty  urine,  the  intake  should  be  ad- 
justed by  comparing  daily  the  intake 
willi  the  weight  of  the  patient;  increase 
in  weighl  would  suggest  restriction  of 
intake.  It  is  better  to  aid  diuresis  by  9 
sufficiency  of  water  than  to  attempt  ro 
induce  it  by  copious  imbibation.  J.  D. 
Mann  (British  Medical  Journal,  May 
20,  1005). 

OTITIS    MEDIA,    ACUTE    SUPPURATIVE. 

Adenoid     vegetations,     especially     in 
children,  are  frequently  exciting  and  al- 


ways predisposing  causes  of  acute  sup- 
purative otitis  media  and  should  be  re- 
moved. When  pus  does  form  in  the 
tympanic  cavity  it  should  be  evacuated, 
the  sooner  the  better;  a  properly  per- 
formed paracentesis  being  preferable  in 
every  way  to  spontaneous  rupture.  To  > 
vigorous  after-treatment  is  to  be  dis- 
couraged. Most  cases  of  chronic  sup- 
purative otitis  media  are  the  result  of 
neglect  or  improper  treatment  during 
the  acute  stage. 

When  the  mastoid  symptoms  do  de- 
velop, energetic  treatment  is  indicated  ; 
operation  is  far  less  dangerous  than  dis- 
ease if  not  promptly  checked  by  less 
radical  measures.  C.  E.  Elwood  (Jour- 
nal of  the  Michigan  State  Medical  So- 
ciety, June,  1905). 

OTITIS    MEDIA,    TREATMENT    OF. 

The  patient  should  be  kept  quiet, 
preferably  in  bed,  and  the  more  active 
the  symptoms  the  more  necessary  for 
the  enforcement  of  this  measure.  A 
prompt  and  free  movement  of  the  bow- 
els should  be  secured  by  means  of  cal- 
omel and  salines.  Depletion  of  the  ves- 
sels of  the  membrana  tympani  and  the 
tympanic  cavity  should  be  secured  by 
leeches  applied  to  the  region  immedi- 
ately in  front  of  the  tragus,  and  the 
osmotic  effect  of  carbolic  acid  (10  per 
cent.)  and  glycerine1  tampons  applied  di- 
rectly against  the  drum  membrane;  The 
nasal  and  pharyngeal  mucous  membrane 
should  be  cleansed  with  a  saline  antisep- 
tic spray  or  douche.  Any  existing  hy- 
pertrophied  lymphoid  tissue  should  be 
removed.  Cautious  blowing  of  the  nose 
should  be  advised  to  limit  the  introduc- 
tion of  infection  to  the  tympanic  cavity. 
Dry  heat  should  be  applied  to  aid  in  con- 
trol of  pain. 

The  drum  membrane  should  be  in- 
cised  under  strict   septic  precautions  on 


326 


PARATYPHOID  FEVER. 


POTT'S  DISEASE. 


the  appearance  of  pronounced  redness  of 
any  portion  of  that  organ  when  accom- 
panied by  pain,  impairment  of  hearing, 
and  other  evidences  of  acute  inflamma- 
tion. Following  perforation  of  the 
drum  membrane,  the  nse  of  aseptic  dry 
gauze  is  advised  for  the  purpose  of  ex- 
cluding infection  from  without  and  also 
to  withdraw  the  discharge  from  the  tym- 
panic cavity  by  capillary  attraction. 

The  syringe  should  be  used  only  un- 
der aseptic  precautions,  when  the  dis- 
charge is  purulent  and  profuse,  to  he 
followed  by  as  thorough  drying  as  pos- 
sible with  sterile  absorbent  cotton.  Judi- 
cious inflation  by  Pollitzer's  method 
should  be  only  employed  after  the  acute 
symptoms  have  subsided  or  after  the 
drum  membrane  has  been  opened,  to 
facilitate  removal  of  discharge  from  the 
tympanic  cavity  and  to  prevent  adhesive 
changes  in  the  sound-conducting  appa- 
ratus. Any  associated  systemic  disease 
should  receive  appropriate  treatment. 
A.  E.  Bulson  (Journal  of  the  American 
Medical  Association,  June  17,  1905). 

PARATYPHOID  FEVER. 

The  writer  states  that  there  are  two 
varieties  of  paratyphoid  fever  produced 
by  organisms  which  differ  from  each 
other  only  in  minor  cultural  peculiari- 
ties. These  two  forms  are  difficult  to 
distinguish  either  from  one  another  or 
from  typhoid  fever.  Of  diagnostic  im- 
portance in  paratyphoid  fever  are  the 
more  abrupt  onset  and  the  earlier  ar- 
rival of  the  acme  of  the  disease  as  com- 
pared with  typhoid.  Otherwise  the 
symptoms  and  course  of  these  two  affec- 
tions may  bo  similar,  though  the  course 
of  paratyphoid  is  usually  shorter.  Spots, 
splenic  enlargement,  nose  bleed,  hemor- 
rhages, and  a  large  number  of  compli- 
cations may  be  present  in  these  allied 
infections.     The  rpiestion  of  the   possi- 


bility of  a  double  infection  of  typhoid 
fever  and  paratyphoid  has  been  raised 
by  the  presence  in  some  cases  of  a  double 
agglutination  reaction  of  about  the  same 
degree  of  positivencss.  Before  this  may 
be  assumed  as  a  certainty,  however,- it  is 
necessary  either  to  recover  simultane- 
ously both  organisms  from  the  blood  of 
the  patient  suspected  of  being  the  sub- 
ject of  a  double  infection,  or  to  satu- 
rate out  the  specific  and  group  agglu- 
tinins of  one  infection  and  demonstrate 
the  presence  of  the  others.  As  yet  these 
double  infections  have  not  been  proven, 
though  the  saturation  tests  have  not 
been  applied  to  any  great  extent  in  these 
diseases.  The  pathology  differs  widely 
from  that  of  typhoid  fever,  the  autopsy 
findings  being  largely  those  of  .a  septi- 
caemia. In  some  cases  ulceration  of  the 
intestine  has  been  found,  but  the  rdcers 
have  been  of  dysenteric  type  and  Peyer's 
patches  have  altogether  escaped.  The 
mortality  has  been  placed  at  about  6  per 
cent.,  being  somewhat  less  than  that  of 
typhoid.  J.  1ST.  Henry  (American  Medi- 
cine, April  15,  1905). 

POTTS  DISEASE. 

The  author  thinks  that  the  prognosis 
of  this  affection  is  not  so  grave  as  many 
believe.  There  is  a  tendency  to  spon- 
taneous recovery,  and  if  Nature  is  aided 
in  time  the  final  outcome  is  liable  to  be 
excellent.  Various  roads  lead  to  the 
desired  goal,  but,  in  general,  puncture 
and  rinsing  out  the  cavity  will  be  found 
sufficient.  This  simple  procedure  can  be 
done  by  any  one  and  almost  everywhere, 
while  it  is  much  safer  than  other  tech- 
niques. The  writer  prefers  to  rinse  the 
cavity  .after  puncture  with  a  1  per  1000 
salicylic-acid  solution,  using  at  least  5 
liters  of  the  fluid,  or  until  it  emerges 
clear.  It  may  be  necessary  to  repeat  the 
rinsing  two  or  three  times.     He  intro- 


PULMONARY  HEMORRHAGE.        ROENTGEN  RAYS  IN  DERMATOLOGY.       397 


duces  the  fluid  through  a  Plessi  return- 
flow  cannula,  and  the  rinsing  is  easily 
done  in  a  quarter  of  an  hour.  The  au- 
thor gives  the  history  of  several  cases 
thus  treated  and  re-examined  several 
years  afterward.  ♦  The  affection  healed 
slowly,  hut  surely,  after  the  injections, 
and  the  patients  are  all  free  from  any 
disturbances.  Those  whose  cases  are 
described  in  detail  were  from  20  to  12 
years  of  age.  There  is  scarcely  a  trace 
of  their  former  affection,  and  all  have 
gained  materially  in  weight,  one  nearly 
GO  pounds.  In  some  of  the  cases  the  dis- 
ease had  caused  paraplegia,  but  this 
rapidly  subsided  under  cold  hydrother- 
apy. A.  Campini  (Eiforma  Medica,  vol. 
xxi,  No.  14;  Journal  of  the  American 
Medical  Association,  June  3,  1905). 

PULMONARY       HEMORRHAGE,       TREAT- 
MENT   OF. 

In  the  great  majority  of  instances,  the 
author  considers  that  hemorrhage  from 
the  lung  is  due  to  the  erosion  of  a  blood- 
vessel in  a  tuberculous  cavity.  It  often 
becomes  a  serious  question  of  what  is  to 
be  done  in  these  cases.  In  the  general 
treatment  the  patient  should  be  kept  as 
quiet  as  possible,  in  some  cases  not  even 
allowing  him  to  be  moved.  The  clothing 
should  be  loosened  and  the  patient 
placed  in  a  semi-recumbent  position,  and 
on  the  diseased  side.  This  position  fa- 
vors gravity,  the  heart  being  less  able 
to  propel  the  blood  into  the  ruptured 
blood-vessel  ;  hence,  the  clot  is  more 
readily  and  quickly  formed.  This  posi- 
tion also  favors  the  removal  of  blood 
and  mucus.  If  fiber  hemorrhage  is  at 
all  severe,  the  patienl  should  be  given 
V4  grain  of  morphine  with  yri0  grain 
of  atropine.  In  this  way  he  is  quieted, 
the  cough  relieved,  and  the  shock  from 
which  he  is  suffering  is  very  largely  over- 
come.    If  the  heart  continues  to  beal 


rapidly  and  forcefully  there  are  three 
remedies  that  should  always  be  thought 
of:  aconite,  gelsemium,  and  ve  rat  rum 
viride.  These  are  all  cardiac  depres- 
sants, reducing  the  force  and  frequency 
of  the  heart  action.  At  present  adre- 
nalin chloride  is  being  highly  recom- 
mended, but  it  is  extremely  doubtful  if 
it  affects  deep-seated  hemorrhages.  In 
the  more  pronounced  cases  subcutaneous 
injections  of  40  to  50  cubic  centimeters 
of  a  10  per  cent,  solution  of  sterilized 
gelatine  can  be  used  with  advantage. 
Pellets  of  ice,  by  mouth,  and  an  ice-bag 
over  the  affected  side  ■  are  useful.  In 
those  cases  in  which  the  individual  is 
well-nigh  exsanguinated  in  a  short  time, 
and  the  heart  becomes  Aveak,  feeble  and 
rapid,  the  eyes  sunken,  the  nose  pinched, 
the  skin  cold  and  clammy,  in  short, 
every  symptom  of  collapse  is  present, 
prompt  action  is  necessary.  Digitalis 
should  never  be  used.  Camphor  hypo- 
dermically  given  in  sterilized  olive-oih 
1  part  to  4  of  oil,  aromatic  spirits  of 
ammonia,  hypodermoclysis  and  entero- 
clysis  are  advised.  Bandaging  of  the 
extremities  for  periods  of  fifteen  min- 
utes is  followed  by  good  results.  The 
diet  advised  is  liquid,  and  should  be 
highly  nutritious.  W.  A.  Dickey  (Med- 
ical Standard,  May,  1905). 

ROENTGEN    RAY    THERAPY    IN    DERMA- 
TOLOGY. 

Radiotherapy  must  nol  be  considered 
a  panacea.  Although  it  lias  a  large  field 
of  usefulness,  it  also  has  its  limitations 
and  dangers.  Most  consistently  good 
results  are  obtained  in  epithelioma,  ro- 
dent ulcer,  and  acne.  Great  benefit  may 
be  looked  for  in  eczema,  chiefly  the 
vesicular  variety  affecting  the  hands, 
Bycosis,  tine;i  tonsurans,  verruca,  lichen 
planus,  nevuses  and  portwine  marks, 
localized    pruritus,    favus,    r\r.      Deep- 


328 


SCARLATINA,  COMPLICATIONS  OF. 


SPLEEN. 


seated  epitheliomas,  with  exposure  of 
bone,  cartilage,  etc.,  appear  to  do  well 
for  a  while,  but  usually  get  worse  event- 
ually. The  judicious  combination  of 
radiotherapy  and  operation  is  highly  rec- 
ommended in  these  cases. 

The  Roentgen  rays  are  beneficial  when 
pain  is  particularly  to  be  avoided,  as  in 
old,  feeble  people. 

Radiotherapy  produces  the  best  cos- 
metic results.  Recurrences  after  radio- 
therapy are  less  frequent  than  after 
other  methods,  and  are  more  amenable 
to  reapplication  of  the  rays.  The  high 
vacuum  tube  is  preferable  in  epithe- 
lioma, rodent  ulcer,  aud  lupus,  the  me- 
dium or  soft  tube  being  employed  in 
other  cases.  Radiotherapeutic  treat- 
ment should  be  instituted  as  soon  as  pos- 
sible, the  result  being  -usually  in  direct 
proportion  to  this  factor.  Epithelioma 
of  the  skin  usually  reacts  better  than 
that  involving  the  mucous  membranes. 

Tampering  with  caustics  and  other 
irrational  forms  of  treatment  are  to  be 
condemned  as  measures  preceding  radio- 
therapy, since  they  undoubtedly  unfa- 
vorably alter  the  prognosis  in  such  cases. 

No  rule  can  be  laid  down  for  the  pre- 
vention of  burns,  etc.;  hence  the  dosage 
must  be  carefully  regulated  in  each  in- 
dividual case.  No  protective  ointments, 
powders,  etc.,  must  remain  on  the  part 
treated,  since  they  may  prohibit  or  lessen 
the  effect  of  the  rays  by  interfering  with 
their  passage.  J.  H.  Comroe  (Ameri- 
can Medicine,  June  17,  1905). 

SCARLATINA,    COMPLICATIONS    OF. 

The  most  common  complications  of 
scarlatina  on  the  part  of  the  nervous  sys- 
tem are  haemiplegia  and  peripheral  neu- 
ritis. More  rarely  this  disease  may  be 
followed  by  paraplegia,  optic  neuritis, 
amaurosis,  tetany,  pseudoataxia,  neural- 
gia,    epilepsy,     disseminated     sclerosis, 


Friedreich's  ataxia,  hysteria,  chorea,  hy- 
drocephalus, meningitis,  and  disordered 
mental  states. 

With  the  exception  of  haemiplegia  and 
imbecility,  the  prognosis  is  good,  if  those 
rare  organic  cases  such  as  Friedreich's 
ataxia,  disseminated  sclerosis  and  epi- 
lepsy, which  are  recorded  as  following 
scarlatina,  are  excluded.  Some  of  these 
conditions  like  Friedreich's  ataxia  arc 
probably  merely  hastened  in  their  mani- 
festations by  the  scarlatinal  process.  The 
pathologic  findings  consist  of  thrombosis, 
embolism,  small  cerebral  haemorrhage, 
rarely  abscess  of  the  brain,  congestion 
of  the  brain,  and  meningitis,  and  finally 
meningitis  and  encephalitis.  J.  H.  W. 
Rhein  (American  Medicine,  June  17, 
1905). 

SHOCK  IN  SURGERY. 

Every  tissue  and  organ  has  a  more 
or  less  individual  shock-producing  value 
and  must  be  individually  considered. 
The  amount  of  shock  produced  by  a 
given  trauma  varies  according  to  the 
amount  and  special  quality  of  nerve 
supply  involved  and  the  number  and 
intensity  of  the  afferent  impulses  orig- 
inated by  the  injury  or  operation. 

Cocaine  or  eucaine  may  wholly  "block" 
these  shock-producing  impulses.  When 
one  or  more  of  the  accessory  causes  of 
shock  are  present  the  highest  possible 
tax  is  laid  on  the  surgical  judgment  of 
the  operator.  A  precise  technique  offer- 
ing a  minimum  of  exposure  trauma, 
grafted  on  a  comprehensive  grasp  of  all 
the  factors  entering  into  the  operative 
consideration,  are  the  ideals  for  which 
we  must'  strive.  G.  W.  Crile"  (Journal 
of  the  American  Medical  Association. 
June  17,  1905). 

SPLEEN. 

Tn  the  young  embryo  prior  to  the  for- 
mation of  the  spleen,  the  primitive  meso- 


STOMACH  CONTENTS,  EXAMINATION  OF. 


SUGAK  IN   URINE. 


329 


derm  possesses  the  property  of  making 
blood-cells.  In  late  embryonic  life  this 
property  is  restricted  to  special  organs 
and  tissues.  In  adult  life  it  is  limited 
to  the  spleen  in  cold-blooded  animals 
(fishes  and  amphibians),  while  in  the 
warm-blooded  animals  the  red  marrow 
continues  throughout  life  to  officiate  as 
a  subsidiary  spleen.  In  this  way  Nature 
makes  provision  for  the  added  number 
of  red  corpuscles  required  by  the  higher 
animals  for  their  increased  respiratory 
activity  and  the  maintenance  of  their 
bodily  heat.  E.  T.  Williams  (American 
Medicine,  June  3,  1905). 

STOMACH  CONTENTS;  MICROSCOPICAL 
EXAMINATION  DURING  EASTING, 
AND  ITS  DIAGNOSTIC  VALUE. 
The  presence  or  absence  of  hydro- 
chloric acid  can  be  determined  by  a  mi- 
croscopical examination  of  the  fasting 
stomach  contents.  The  origin  of  mucus 
can  be  determined  only  by  a  microscop- 
ical examination.  By  the  microscopical 
examination,  mild  cases  of  pyloric  sten- 
osis can  be  differentiated  from  simple 
gastrosuccorrhcea.  Constant  presence 
of  pus,  blood  and  possibly  infusoria  in 
the  fasting  stomach  contents  is  absolute 
evidence  of  extra-pyloric  carcinoma. 

Benign  obstruction  can  be  diagnosed 
early  by  the  finding  of  sarcinae,  yeast 
cells  in  chains,  or  food  remnants.  The 
early  diagnosis  of  malignant  obstruction 
of  the  pylorus  can  be  made  by  the  find- 
ing of  the  Oppler-Boas  bacilli.  Wil- 
liam Ackerman  and  Li.  M.  Gompertz 
(Medical  Record,  April  8,  1905). 

STRUMA   AND   CATARACT. 

The  association  of  cataracl  with  dia- 
betes and  other  constitutional  diseased 
conditions  lias  long  been  recognized. 
The  writer  calls  attention  to  the  relation 
of    cataract    to    disease    of    the    thyroid 


gland.  This  latter  organ  is  now  recog- 
nized as  contributing  an  internal  secre- 
tion  to  the  body.  Any  disturbance  of 
this  function  produces  an  autointoxica- 
tion, which  frequently  causes,  among 
other  results,  changes  in  the  nutrition 
of  the  crystalline  lens.  After  a  detailed 
review  of  the  literature,  the  author  gives 
his  own  experiences,  which  embrace  28 
cases  of  cataract  with  struma.  All  the 
cases  were  in  females,  in  22  of  whom 
bilateral  cataracts  developed.  The 
goiter  was  usually  of  considerable  size, 
often  produced  marked  stridor  by  com- 
pression of  the  trachea.  The  cataract 
in  these  cases  does  not  usually  include, 
the  whole  lens;  it  involves  chiefly  the 
nuclear  zone  and  the  perinuclear  layers. 
The  outer  cortex,  which  is  usually  opaque 
in  senile  cataract,  is  quite  clear  in  these 
cases,  or  at  most,  exhibits  a  few  puncti- 
form  or  linear  opacities.  A  thorough 
examination  of  the  body,  including  the 
urine,  revealed  no  other  possible  cause 
for  the  cataract  in  these  patients.  A 
Vossius  (Zeitschrift  fiir  klinische  Med- 
icin,  Bd.  lv,  p.  63;  American  Medicine, 
June  10,  1905). 

SUGAR  IN  URINE,  DETECTION  OF. 

Two  forms  of  crystals  may  appear  in 
urine  after  treatment  with  phenylhy- 
drazin :  one  composed  of  slender  needles 
arranged  in  the  form  of  sheaves  and 
half-sheaves  is  typical  of  sugar;  the 
other,  much  smaller,  composed  of  radi- 
ating spiculse,  aggregated  into  spinous 
masses,   has   been    variously    interpreted. 

Glycuronic  acid  in  urine  produces  a 
crystal  very  similar  to  the  true  sugar 
crystal.  Tts  component  filaments  are 
very  slender,  and  are  never  short  and 
thick,  as  may  be  the  case  in  the  thorn- 
apple  crystal.     Glycuronic  acid  crystals 

c.i ii ii< il    be   removed   by   previous    fermen- 
tation    with     yeast.       The     thorn-apple 


330 


TABES,  CURABILITY  OF. 


crystal  appears  in  a  very  large  propor- 
tion of  all  urines  examined,  and  in- 
creases in  number  as  low  percentages  of 
sugar  are  added  to  urine  normally  show- 
ing them.  A  point  is  .ultimately  reached 
in  this  addition  where  typical  crystals 
appear.  Both  the  typical  crystal  and 
the  thorn-apple  crystal  can  be  removed 
by  previous  fermentation  with  yeast. 

It  may  therefore  be  said,  in  conclu- 
sion, that  the  small  "thorn-apple"  crys- 
tal indicates  the  presence  of  sugar,  that 
practically  all  urines  contain  traces  of 
sugar,  and  that  the  phenylhydrazin  test 
will  detect  its  presence.  E.  L.  McEwen 
(American  Journal  of  the  Medical  Sci- 
ences, June,  1905). 

TABES,   CURABILITY   OF. 

The  writer  points  out  the  contradic- 
tory opinions  which  exist  with  regard  to 
the  curability  of  tabes.  Some  authori- 
ties, such  as  Babinski  and  Lerredde, 
maintain  that  it  is  curable  by  intense 
mercurial  treatment;  while  others,  in- 
cluding Eournier  and  most  of  the  neu- 
rologists, hold  a  contrary  opinion.  The 
writer  attempts  to  reconcile  these  views 
as  follows :  1.  The  variety  in  tabetics 
is  such  that  often  they  cannot  be  com- 
pared, and  hence  give  different  results 
with  the  same  treatment.  Also  observa- 
tions made  on  analogous  cases  treated 
by  different  mercurial  methods  give  dif- 
ferent results,  and  even  also  with  the 
same  mercurial  treatment.  2.  The  tole- 
ration of  mercury  varies  with  the  con- 
dition of  the  patient,  earlier  stages  of 
the  disease  and  younger  patients  sup- 
porting it  best.  3.  Mercury  gives  dif- 
ferent results  according  to  the  dose  and 
method  of  administration.  Inunction 
is  uncertain ;  injection  of  insoluble  salts 
is  also  uncertain  and  may  lead  to  acci- 
dents; soluble  salts  are  the  best  for  in- 
jection, as  they  are  more  under  control. 


4.  The   result  varies   from   cure   to   ag- 
gravation of  symptoms,  according  to  the 
care  exercised  in  treatment  and  accord- 
ing as  the  case  is  more  or  less  favorable. 
Mercurial    treatment    well    carried    out 
may  arrest  the  disease  or  lessen  its  se- 
verity sufficiently  for  the  patient  to  go 
about  his  business.    But  work  should  be 
reduced   and   the   periods   of   treatment 
and   repose  should  be  annual  and  pro- 
longed.    Mercurial  treatment  badly  car- 
ried out  may  aggravate  the  disease,  or 
even  cause  new  symptoms  which  persist 
afterward.    By  careful  proportion  of  the 
dose  to  the  patient's  strength  the  maxi- 
mum useful  effect  may  be  obtained  with- 
out fatigue  or  malaise.     5.  Some  cases 
get  worse  under  the  most  careful  treat- 
ment,   and    probably   syphilis    docs   not 
play  an  equal  part  in  all  cases.     Cer- 
tain lesions  are  cicatricial,  and  are  not 
affected  by  mercury,  while  others  in  the 
inflammatory  stage  will  react  to  the  drug. 
The   improvement  under   mercury   does 
not   usually   prevent   the  persistence   of 
certain  signs,  such  as  modified  reflexes; 
nor  further  relapses  under  the  influence 
of   overwork,   other   infections,    etc.      6. 
Mercury  is  not  the  only  treatment  for 
tabes ;    the  general  hygiene  is  also  im- 
portant, and  work  should  be'  restricted. 
The    author    concludes    that    mercury 
does  not  cure  in  all  cases  of  tabes,  but 
under  certain  conditions  gives  favorable 
results.       The     contradictory     accounts 
given  by  different  observers  are  due  to 
the  complexity  of   the  cases  and  to  the 
different  methods   of  treatment.      It  is 
an  error  to  give  massive  doses  of  mer- 
cury to  all  cases  alike,  and  equally  an 
error  not  to  give  it  at  all.     All  tabetics 
should  receive  mercurial  treatment  com- 
bined with  rest,  hydrotherapeutics,  and 
re-education  of  the  muscles.    The  course 
of  tabes  is  not  progressive  in  all  cases, 
and  the  author  is  of  the  opinion  that  the 


THYMECTOMY. 


THYROID  GLAND  AND  ELIMINATION  OF  IODINE.        331 


classical  type  described  by  Duchenne  is 
less  common  now  than  formerly.  This 
is  probably  due  to  a  more  general  adop- 
tion of  mercurial  treatment.  Faure 
(Gaz.  des  Hopitaux,  December,  1904; 
British  Medical  Journal,  June  It), 
1905). 

THYMECTOMY,  DIMINISHED  RESIST- 
ANCE TO  INFECTION  AETER. 
The  writer  has  taken  up  the  work 
initiated  by  Abelous  and  Ballard,  who 
removed  the  thymus  gland  in  frogs,  and 
who  obtained  a  series  of  phenomena  in 
these  animals  which  pointed  to  the  ac- 
tivity of  toxic  substances  circulating  in 
their  blood.  The  results  obtained  by  the 
two  French  observers  just  named  were 
contradicted  by  Yer  Eecke,  who  showed, 
three  years  later,  that  the  thymus  gland 
might  be  removed  with  impunity  in  de- 
bilitated frogs,  but  that  after  the  opera- 
tion these  animals  exhibited  a  lowered 
resistance  to  infection.  The  writer  re- 
peated these  experiments,  and  found 
that  the  majority  of  the  frogs  in  which 
the  thymus  had  been  removed  recovered 
completely.  A  small  number  died  after 
air  illness  characterized  by  discoloration 
and  ulceration  of  the  skin,  gastroen- 
teritis, and  changes  in  the  various  or- 
gans, which  exhaled  a  putrefactive  odor 
even  during  life.  This  illness  the  au- 
thor found  to  be  due  to  the  presence  of 
a  certain  bacillus  which  stained  with 
Ziehl,  and  was  not  resistant  to  acids. 
These  bacilli,  injected  into  oilier  frogs 
with  extirpated  thymus,  produced  a  fatal 
infection.  The  bacillus  resembled  that 
df  the  gangrenous  septicemia  of  frogs 
described  by  Legrain.  As  the  author 
had  for  years  operated  on  frogs  and  has 
never  seen  a  case  of  gangrenous  septi- 
caemia among  them,  he  concludes  that 
the  extirpation  of  tin  thymus  dimin- 
ishes the  resistance  of  these  animals  to 


infection.  G.  A.  Pari  (Gazzetta  degli 
Ospedali  e  delle  Clinic-he,  March  12, 
1905;  New  York  Medical  Journal  and 
Philadelphia  Medical  Journal,  June  3, 
1905). 

THYROID  GLAND,  ELIMINATION  OF  IO- 
DINE AND  ITS  RELATION  TO  THE. 
The  author  has  been  making  extensive 
investigations  on  this  subject.  His  tests 
of  persons  with  sound  thyroid  glands 
showed  that  the  elimination  in  the  urine 
of  from  .5  to  1  gram  of  sodium  iodide, 
ingested  fasting,  showed  very  little  varia- 
tion under  like  conditions.  When  the 
thyroid  gland  was  diseased,  however, 
there  were  wide  variations  in  the  pro- 
portions eliminated  by  various  subjects 
and  also  by  the  same  person  at  different 
times.  Study  of  these  variations  demon- 
strated that  they  were  due  to  difference 
in  the  histologic  structure  of  the  struma. 
The  thyroid  gland  takes  up  the  iodine 
and  eliminates  it  rapidly  again  under 
normal  conditions.  The  elimination  is 
very  much  less  rapid  in  thyroidectom- 
ized  individuals.  When  the  elimination 
proceeds  rapidly  in  a  case  of  struma,  the 
gland  will  soon  be  found  to  have  shrunk 
in  size.  Sometimes  when  the  shrinking 
is  very  pronounced  more  iodine  will  be 
found  in  the  urine  than  had  been  in- 
gested. The  specific  parenchyma  evi- 
dently becomes  broken  down  in  these 
cases.  In  certain  others  less  iodine  is 
eliminated  than  normally,  and  the 
struma  docs  not  shrink  in  size.  This  is 
the  rule  in  the  colloid  goiter.  The  phys- 
iologic activity  of  the  thyroid  in  this 
case  is  reduced. 

Further  tests  revealed  that  goiters 
which  reacted  to  the  iodide  with  retro- 
gression and  increased  elimination  of 
iodine,  undoubtedly  took  up  an  abnor- 
mal amount  of  iodine  and  worked  it 
over  in  some  abnormal  manner,  allow- 


332 


TUBERCULOSIS,  EARLY  DIAGNOSIS. 


TUBERCULOSIS,  HEART  IN. 


ing  it  to  get  into  the  circulation  and  to 
induce  symptoms  of  iodism  or  thyroid- 
ism. 

The  practical  conclusions  are  to  the 
effect  that  iodide  treatment  should  he 
commenced  as  early  as  possible  in  in- 
cipient goiter,  with  small  doses  every 
second  day.  If  the  struma  is  capable  of 
recession,  an  unmistakable  effect  will  soon 
become  manifest,  and  small  periodical 
doses  will  suffice  to  keep  it  reduced  to  its 
smallest  possible  size.  It  is  unnecessary 
to  give  large  doses  in  these  cases,  as  they 
expose  to  a  needless  danger  of  iodism; 
that  is,  of  partially  abnormal  function- 
ing of  the  gland.  If  a  struma  does  not 
show  signs  of  retrogression  under  these 
small  doses,  and  if  it  is  a  diffuse  or 
nodular  colloid  struma,  a  longer  and 
more  intensive  iodine  treatment  should 
be  instituted.  There  is  no  risk  to  the 
patient  from  such  treatment,  as  the  col- 
loid takes  up  the  iodine,  and  even  large 
amounts  are  scarcely  able  to  bring  the 
proportion  in  the  gland  to  the  normal 
figure.  On  the  other  hand,  even  this 
iodine  treatment  is  rarely  successful.  A 
Koeher  (Mitteilungen  a.  d.  Grenzge- 
bieten  d.  Med.  u.  Chir.,  Jena,  Bd.  xiv., 
N"u.  4;  Journal  of  the  Amercan  Med- 
ical Association,  May  27,  1905). 

TUBERCULOSIS,     EARLY     DIAGNOSIS     OF. 

The  importance  of  diagnosis  in  the 
"closed"  stage,  before  bacilli  are  found 
in  the  sputum,  ;s  emphasized  by  the 
authors.  The  symptoms  are  rarely 
typical.  Haemoptysis  is  of  great  sig- 
nificance. Length  and  weight  of  bod  v. 
circumference  and  degree  of  chest  ex- 
pansion, give  indication  of  the  state  of 
nutrition.  A  slight  rise  of  temperature 
in  the  afternoon  ought  to  invariably 
aronse  suspicion.  A  two-hourly  record 
should  be  taken  for  several  days.  In 
some  patients  the  rise  appears  only  after 


exercise,  in  women  before  and  during 
menstruation.  On  inspection  there  is 
often  retardation  of  respiratory  move- 
ments over  the  affected  area.  Percussion 
may  elicit  contraction  of*  one  apex  as 
compared  with  the  other.  Rales,  which 
can  easily  be  discovered  in  the  morning 
or  on  damp  days,  will  regularly  be  ab- 
sent during  the  afternoon  or  in  dryer 
weather.  The  earliest  auscultatory  sign 
is  the  rough  and  slightly  diminished  re- 
spiratory murmur.  This  precedes  the 
appearance  of  rales.  Pleuritic  friction 
is  often  heard  in  or  near  the  axillary  line 
between  the  sixth  and  eighth  ribs.  Tu- 
berculin is  an  important  diagnostic 
method,  but  great  care  is  necessary  in 
its  application.  A.  C.  Klebs,  J.  II. 
Miisser,  F.  Billings,  J.  C.  Wilson,  and 
H.  E.  M.  Landis  (Boston  Medical  and 
Surgical  Journal,  June  1,  1905). 

TUBERCULOSIS,  HEART  AND  CIRCULA- 
TION IN  PROGNOSIS  AND  MANAGE- 
MENT  OF. 

The  relation  of  the  heart  and  circula- 
tion to  the  course  of  chronic  pulmonary 
tuberculosis  is  a  factor  both  in  the  prog- 
nosis and  management  of  such  cases 
which  is  not  generally  accorded  the  at- 
tention and  study  which  its  importance 
demands.  The  writer  suggests  the  anal- 
ogy between  the  relation  of  the  heart 
and  circulation  to  the  local  disease  in 
acute  pneumonia  and  in  chronic  pulmo- 
nary tuberculosis.  According  to  his  con- 
ception, this  relation  differs  chiefly  in 
that  the  pulmonary  obstruction  develops 
rapidly  in  the  one  and  more  slowly  in 
the  other.  By  reason  of  this  difference, 
more  can  be  done  to  conserve  or  to  in- 
crease the  power  of  the  heart  in  phthisis 
than  in  acute  pneumonia.  It  follows 
that  close  observation  of  the  circulation 
in  the  course  of  phthisis  is  imperative, 
and  that  a  weak  second  pulmonic  sound 


TUBERCULOSIS,  X-RAY  IN  DEEP-SEATED. 


WI  DAL  REACTION. 


33; 


is  to  be  regarded  as  a  danger  signal,  just 
as  in  acute  pneumonia.  Over-exercise  is 
considered  by  the  author  as  a  potent 
factor  in  the  production  of  tachycardia 
in  consumptives,  and  he  cites  statistics 
from  the  Winyah  Sanitarium  showing 
that  of  60  patients  with  disturbed  heart 
action,  in  58  per  cent,  over-exercise  had 
been  a  contributing  factor  in  its  causa- 
tion. For  the  entire  number  of  261  pa- 
tients, the  figures  show  72.9  per  cent., 
whereas  for  those  with  tachycardia  the 
figures  show  only  34.1  per  cent.  The 
restriction  of  exercise  for  consumptives 
with  weak  hearts  is  strongly  urged,  and 
the  physical  management  of  such  pa- 
tients, together  with  the  regulation  of 
the  diet,  bathing,  etc.,  is  described  in 
detail.  Yon  Ruck  (Medical  Record, 
June  3,  1905). 

TUBERCULOSIS,  X-RAY  IN  DEEP-SEATED. 

Tuberculous  laryngitis  may  be  aided 
and  even  cured  by  x-ray  treatment,  pro- 
vided there  can  be  brought  about  an  im- 
provement in  the  primary  pulmonary 
condition,  however  that  may  be  induced. 
Too  vigorous  treatment  will  cause  a  re- 
action, which  may  be  carried  to  an  un- 
favorable degree;  therefore,  great  care 
is  necessary  in  determining  the  proper 
dosage  in  each  case.  The  pulmonary  le- 
sions may  be  benefited,  probably,  in  se- 
lected cases,  but  even  greater  precau- 
tions should  be  observed. 

Finsen  light  applications  may  bo,  but 
are  probably  not,  of  any  value  in  treat- 
ing the  laryngeal  lesions.  Only  the  mosi 
powerful  lamps  need  be  tried.  Such  ex- 
posures are  of  value  in  lessening  or 
retarding  a  skin  reaction  from  the 
x-rays.  TT.  K.  Pancoast  (Proceedings 
of  the  Philadelphia  County  Medical  So- 
ciety,  May   31,   1905). 


VACCINATION   DURING    SMALLPOX. 

The  author  has  investigated  the  ques- 
tion as  to  whether  a  successful  vaccina- 
tion or  revaccination  of  .a  patient  suf- 
fering from  a  suspicious  rash,  speaks 
strongly  against  that  rash  being  one  of" 
smallpox.  In  20  cases  of  undoubted 
smallpox  which  were  vaccinated  or  re- 
vaccinated  after  the  appearance  of  the 
eruption,  11  vaccinations  or  revaccina- 
tions  were  successful.  In  the  greater 
proportion  of  the  successful  cases  well 
marked,  typical  vaccine  vesicles  ap- 
peared at  the  site  of  vaccination.  These 
vesicles  became  evident  from  the  fourth 
to  the  sixth  day  after  the  operation  and 
ran  the  usual  course.  In  some  cases, 
instead  of  the  typical  vesicle,  there  was 
merely  an  indurated  raised  papule.  Ten 
of  the  11  successful  cases  were  vaccinated 
during  the  first  four  days  of  the  disease. 
It  could  not  be  detected  that  vaccination 
or  revaccination  when  performed  after 
the  smallpox  eruption  had  appeared,  had 
definitely  any  modifying  influence  on  the 
rash  or  on  the  course  of  the  disease.  J. 
C.  Hibbert  (Lancet,  May  20,  1905). 

WIDAL   REACTION. 

Living  and  dead  cultures  are  about 
equally  sensitive  to  the  action  of  the  ag- 
glutinins of  typhoid  fever,  though  in 
dead  culture  the  reaction  may  require  a 
longer  time  to  take  effect,  and  it  is  there- 
fore necessary  to  keep  the  specimen  un- 
der observation  for  two  hours.  In  some 
cases  the  reaction  is  quicker  with  the 
dead  than  with  the  living  cultures.  The 
dried  blood  method  is  equally  effective 
with  dead  as  with  living  cultures.  The 
reaction,  when  it  takes  place,  is  more 
characteristic  with  dead  cultures  than 
with  living  cultures.  There  are  no 
p-eudo-reactions  with  dead  cultures. 


334  WIDAL  REACTION.  BOOK  REVIEWS. 

Dead    cultures    do    not    seem    to    lose  which  was  prepared  six  months  ago,  and 

their   sensibility    to    the    agglutinins   of  it  reacts  just  as  typically  as  when  first 

typhoid    fever    for    a    long   time.      The  used.     E.  Andrade  {Medical  News,  May 

writer  has  now   in  use  a   dead   culture  27,   1905). 


5ool<  Reviews. 

Atlas  and  Text-book  of  Topographic  and  Applied  Anatomy.  By  Dr.  0.  Sehultz.-. 
With  Additions.,  by  George  D.  Stewart,  M.D.  Contains  25  Figures  on  22  Colored  Litho- 
graphic Plates.,  89  Text-cuts  and  60  in  Colors.  Philadelphia  and  London:  W.  B.  Saunders 
&  Co.,  1905.     Cloth,  $5.50,  net. 

This  Atlas  is  admirably  fitted  for  the  needs  of  the  clinician.  The  shape  and  size  of  the 
book  is  convenient  and  the  arrangement  of  the  plates  and  text  so  simple  and  clear  as  to  offer 
a  most  pleasurable  opportunity  to  reinforce  the  mind  on  points  of  anatomy. 

The  authors  do  not  claim  to  include  everything,  but  it  is  eminently  practical  and  an 
admirable  supplement  to  more  systematic  works. 

The  contents  include  descriptions  of  the  hsad,  upper  extremities,  thorax,  abdomen,  lower 
extremities,  and  a  full  index. 

The  colored  plates  are  beautiful,  the  colors  being  fresh  and  clean.  The  drawing  is 
admirable. 

A  German  book  of  plates  is  sometimes  confusing  to  the  American  from  the  phrasing  of  the 
legends,  but  this  has  been  corrected  in  the  lithograph,  and  the  large  plates  are  covered  by  a 
transparent  paper  with  index  lines  leading  to  legends  in  plain  English. 

It  would  be  pleasant  to  compare  this  work  with  others  of  similar  scope,  but  this  is  scarcely 
necessary.  Altogether  the  book  is  highly  commendable  and  will  prove  a  valuable  desk  refer- 
ence for  frequent  consultation. — J.  M.  T. 

.Manual  or  Practical  Hygiene  for  Students,  Physicians  and  Health  Officers,  etc. 

By  Charles   Harrington,  M.D.,  Assistant  Professor   of   Hygiene   at  Harvard  University. 

Third  Edition,  Revised.     118  Engravings  and  12  Plates.     Cloth,  $4.25,  net.     Lea  Brothers: 

Philadelphia  and  New  York. 

This  admirable  manual  is  now  presented  in  its  third  edition,  thoroughly  revised.  Two 
large  editions  have  already  been  exhausted  in  less  than  four  years,  and  a  new  section  is  added 
on  Infection.  Susceptibility  and  Immunity.      The  price,  however,  remains  the  same. 

No  subject  is  more  interesting  to  the  active  practitioner  of  medicine  than  Hygiene. 
Unfortunately,  it  has  been  much  neglected.  The  absence  of  adequate  information  on  this  most 
practical  phase  of  medicine  is  of  grave  injury  to  the  reputation  of  many  otherwise  accomplished 
medical  men. 

To  select  two  or  three  chapters  for  comment,  the  reviewer  is  struck  with  the  value  of  the 
chapter  on  Milk  and  Milk  Products. 

The  chapter  on  Habitation  of  Schools  is  most  clearly  and  admirably  presented.  There  is 
an  admirable  review  of  the  subject  of  Vital  Statistics,  including  many  valuable  suggestions. 

The  subject  of  infections,  immunity  and  susceptibility  also  is  exceedingly  important. 

The  chapters  on  Military,  Naval,  and  Tropical  Hygiene,  the  relation  of  insects  to  human 
diseases,  and  the  hygiene  of  occupation,  are  admirably  presented. 

The  reviewer  cannot  refrain  from  saying  a  word  about  the  comments  on  the  splendid  work 
done  by  Reed,  Carrol,  A.^ramonte  and  the  self- sacrificing  Lazear,  facts  which  ought  to  be  clear 
in  the  mind  of  all  American  physicians  and  in  fact  all  loyal  Americans. 

Indeed,  few  books  that  have  passed  under  his  hands  have  given  him  more  pleasure  to 
read   than  this.— J.  M.  T. 

Satnokus's  Pocket  Medical  Formulary.     By  William  M.  Powell,  M.D.     Seventh  Edition. 
$1.75,  net.     W.  B.  Saunders  &  Co.,  Philadelphia  and  London,  .      ■ 


BOOKS  AND  MONOGRAPHS  RECEIVED.  ;;.;.-, 

It  is  scarcely  necessary  to  do  more  than  advert  to  this  excellent  little  book  which  has  been 
appreciated  so  largely  and  is  now  presented  in  an  improved  form. 

Most  medical  men  are  familiar  with  it  and  will  be  glad  to  welcome  it. — J.  M.  T. 

American  Edition  of  Nothnagel's  Practice,  Malaria,  Influenza  and  Dengue.      By 
Dr.  .1.  Mannaberg,  of  Vienna,  and  Dr.  O.  Leichtenstein,  of  Cologne.    Km  in-  Volume  Edited, 

with  Additions,  by  Ronald  Ross,  F.R.C.S.,  F.R.S.,  Professor  of  Tropical  Medicine  Univer- 
sity of  Liverpool;  J.  W.  W.  Stephens,  M.D.,  D.P.H.;  Walter  Myers,  Lecturer  in  Tropical 
Medicine,  University  of  Liverpool.  TOO  Pages,  Fully  Illustrated;  Eight  Full-page  Plates. 
Philadelphia  and  London:    W.  B.  Saunders  &  Co.,  1905.     $5.00. 

This  book  constitutes  the  tenth  volume  of  Nothnagel's  "Practice  of  Medicine."  The 
editors  have  made  a  number  of  additions  rendered  essential  by  recent  advances  in  the  stud, 
of  malaria,  e.g.,  in  its  relationship  to  the  mosquito.  Few  pages  fail  to  exhibit  evidences  of 
their  industry  and  judgment.  The  translation  is  authorized  and  made  under  the  supervision 
of  Alfred  Stengel.  The  three  subjects  presented  are  perhaps  of  uneven  importance  to  most  j  r.ic 
titioners,  and  occupy  space  proportionately,  but  if  the  data  on  Malaria  alone  were  presented, 
the  value  of  the  volume  would  have  been  fully  reached.  Few  books  could  so  entirely  claim  our 
attention  as  this  first  section  of  494  pages.  Tropical  medicine  is  now  so  definite  a  part  of  the 
equipment  of  the  American  physician  that  this  treatise  on  Malaria  and  Dengue  will  prove  most 
useful.  When  the  pages  devoted  to  Influenza  are  studied  they  will  be  similarly  welcomed,  so 
vivid  is  the  wording  and  varied  the  historic  and  clinical  pictures,  so  practical  the  bearing  upon 
the  daily  experience  of  all,  both  layman  and  practitioner.  Indeed,  much,  perhaps  most,  of  the 
volume  would  fix  the  attention  of  any  intelligent  reader.  The  character  of  the  work  being 
encyclopaedic,  it  is  impossible  to  do  justice  to  it  in  the  review  space  at  our  command.— J.  M.  T. 

The  Principles  and  Practice  of  Gynaecology.      For  Students  and  Practitioners.     By  E. 
C.  Dudley,  A.M.,  M.D.,  Professor  of  Gynaecology,  Northwestern  University  Medical  School, 
etc.      Fourth   Edition,   Revised.      With  419   Illustrations  in  Colors   and  Monochrome,  of 
which  18  are  Full-page  Plates.     Lea  Brothers  &  Co.:     Philadelphia  and  New  York.      1901. 
This  new.  revised  and  enlarged  edition  of  "Dudley's  Gynaecology"  is  a  valuable  addition  to 
the  already  rich  list  of  text-books  on  this  subject.      It  will  be  found  of  special  value  to  the 
student,  as  the  subjects  have  .been  most  advantageously  arranged,  the  author  having  chosen 
to  group  the  diseases  in  their  natural  pathological  and  etiological  sequence,  instead  of  con- 
sidering them  as  they  affect  each  organ  individually.      The  employment  of  heavy-faced  type 
for  headings  and  sub  headings,  the  use  of  parallel  tables  for  differential  diagnosis,  and  a  good 
index,  are  valuable  aids  to  both  student  and  practitioner.      The  text  is  clear  and  concise;    it 
treats  of  the  diseases  of  women  from  a  surgical  as  well  as  from  a  medical  point  of  view,  its 
teaching  is  sound   and  in  genera]   conservative;     it  contains  all   the  recent   advances   in  gyne- 
cology.     The  typography  is  excellent,  the  illustrations  deserve  special  mention,  many  opera- 
tions have  been  depicted  step  by  step  in  a  series  of  drawings,  of  value  to  those  having  limited 
operal  h  e  experience-  T.  II.  E. 


5ool<s  and  /Vlonographs  Received. 


The   Editor  begs  to  acknowledge,  with   thanks-,  (lie  receipt  of  the   following  books,  and 
monographs:  — 

"Practice  of  Gynaecology."     By  W.  Easterly  Ashton,  Philadelphia.    W.  B.  Saunders  &  Co., 

Philadelphia^ "Malaria,    Influenza,  and    Dengue."      By  J.  Mannaberg  and    O.   Leichenstein. 

W.  B.  Saunders  &  Co.,  Philadelphia.  '•Saunders's  Pocket  Medical  Formulary."  By  William 
M.  Powell.  W  B.  Saunders  &  Co.,  Philadelphia.  "Atlas  and  Text-Book  of  Topographical 
and  Applied  Anatomy."    By  0.  Schultze.    W.  B.  Saunders  &  Co., Philadelphia. — -  "Practical Hy- 


336 


BOOKS  AND  MONOGRAPHS  RECEIVED. 


giene."      By  Dr.   Harrington.      Lea  Bros.  &  Co.,  Philadelphia. "Year-book  of   the  United 

States  Department  of  Agriculture,"  1904.- — — "The  Use  of  Rubber  Gloves  as  an  Aid  to  Prophy- 
laxis in  Obstetrics."      By  F.  J.  W.  Maguire,  Detroit,  Mich.,  1904. — "The  Universal  Method  of 

Clinical  Writing  by  Means  of  Clinography."     By  Professor  V.  Pensuti,  Rome,  Italy,  1905. 

"Hay  Fever  and  Its  Preventative  Treatment."     By  A.  B.  Conklin,  Ambler,  Pa. "Die  Balneo- 

therapie  in  d>r  Nervenheilkunde."      Yon  A.  Enlenberg,  Berlin.  1905. "The  Progress  of  the 

Sanatorium  Movement  in  America."     By  W.  H.  Baldwin,  Washington,  D.  C,  1905. 

Received  from  the  United  States  Department  of  Agriculture  the  following:  — 

Inoculation  of  Soil  with  Nitrogen-Fixing  Baceria.      By  A.  E.  Woods,   1905. Practical 

Results  of  the  Cup  and  Gutter  System  of  Turpentining.     By  C.  H.  Herty,  1905. Canadi  in 

Field   Peas.       By    Thomas    Shaw,    1905. Miscellaneous    Cotton   Insects    in    Texas.      By   E. 

Dwight  Sanderson,  1905. Range  Management  in  the  State  of  Washington.     By  J.  S.  Cotton, 

1905.- Extermination  of  Johnson  Grass.     By  W.  J.  Spillman,  1905. Tomatoes.     By  L.  C. 

Corbett,   1905. Consumers'  Fancies.      By  George  K.  Holmes,   1904. Experiment  Station 

Work,  XXIX,  1905. 


EDITORIAL    STAFF. 
Sajous's  Analytical  Cyclopaedia  of  Practical  Medicine. 


J.  GEORGE  ADAMI,  M.D., 

MONTREAL,  P.  Q. 

LEWIS  11.  ADLER,  M.D., 

PHILADELPHIA. 

JAMES  M.  ANDERS,  M.D.,  LL.D., 

PHILADELPHIA. 

THOMAS  G.  ASHTON,  M.D.. 

PHILADELPHIA. 

A.  D.  BLACKADER,  M.D., 

MONTREAL,  P.  Q. 

E.  D.  BONDURANT,  M.D., 

MOBILE,  ALA. 

DAVID  BOVAIRD,  M.D., 

NEW  YORK  CUT. 

WILLIAM  BROWNING,  M.D., 

BROOKLYN,  N.  Y. 

WILLIAM  T.  BULL,  M.D., 

NEW  YORK  CITY. 

CHARLES  W.  BURR,  M.D., 

PHILADELPHIA. 

HENRY  T.  BYFORD,  M.D., 

CHICAGO,  ILL. 

HENRY  W.  CATTELL.  M.D., 

PHILADELPHIA. 

WILLIAM  B.  COLEY,  M.D., 

KKV  YORK  CITY. 

FLOYD  M.  CRANDALL.  M.D.. 

NEW  YORK  CITY. 

ANDREW  F.  CURRIER,  M.D.. 

NEW  YORK  CITY. 

ERNEST  W.  CUSHING,  M.D., 

BOSTON,  MASS. 

GWILYM  G.  DAVIS,  M.D., 

PHILADELPHIA. 

N.  S.  DAVIS,  M.D., 

CHICAGO,  ILL 

AUGUSTUS  A.  ESHNER,  M.D.. 

PHILADELPHIA. 

SIMON  FLEXNER.  M.D., 

PHILADELPHIA. 

LEONARD  FREEMAN,  M.D.. 

DENVER.  COL. 

8.  G.  GANT,  M.D., 

NEW  YORE  CITY. 

J.  McFADDEN  GASTON.  Sr..  M.I). 

ATLANTA,  GA. 

J.  McFADDEN  GASTON,  Jr.,  M.D. 

ATLANTA,  GA. 

£.  B.  GLEASON,  M.D., 

PHILADELPHIA. 

EGBERT  H.  GRAN  DIN,  M.D.. 

■SW  TOMJL  (STY. 


ASSOCIATE.     EDITORS. 

J.  P.  CROZER  GRIFFITH,  M.D  , 

PHILADELPHIA. 

C.  M.  HAY,  M.D., 

PHILADELPHIA. 

FREDERICK  P.  HENRY,  M.D., 

PHILADELPHIA. 

L.  EMMETT  HOLT,  M.D., 

NEW  YORK  CITY. 

EDWARD  JACKSON,  M.D., 

DENVER,  COL. 

W.  W.  KEEN,  M.D., 

PHILADELPHIA. 

»  EDWARD  L.  KEYES,  JR.,  M.D., 

NEW  YORK  CITY. 

ELWOOD  R.  KIRBY,  M.D., 

PHILADELPHIA. 

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NEW  YORK  CITY. 

ERNEST  LAPLACE,  M.D.,  LL.D., 

PHILADELPHIA. 

R.  LEPINE,  M.D., 

LYONS,  FRANCE. 

F.  LEVISON,  M.D., 

COPENHAGEN,  DENMARK. 

A.  LUTAUD,  M.D.. 

PARIS,  FRANCE. 

G.  FRANK  LYDSTON,  M.D., 

CHICAGO,  ILL. 

F.  W.  MARLOW,  M.D., 

SYRACUSE,  N.  Y. 
SIMON  MARX,  M:D., 

NEW  YORK  CITY. 

ALEXANDER  McPHEDRAN,  M.D., 

TORONTO,  ONT. 

E.  E.  MONTGOMERY,  M.D.. 

PHILADELPHIA. 

HOLGER  MYGIND,  M.D., 

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WASHINGTON,  D.  C. 

H.  OBERSTEINER.  M.D... 

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WILLIAM  OSLER.  M.D. . 

BALTIMORE,  MD. 


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LEWIS  A.  STIMSON,  M.D., 
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J.  EDWARD  STUBBERT,  M.D., 
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HERMAN  F.  VICKERY,  M.D., 

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ALFRED  C.  WOOD,  M.D., 

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WALTER  WYMAN,  M.D., 
WASHINGTON.  D.  C 


THE    MONTHLY   CYCLOPEDIA 


?> 


1 


PRACTICAL   MEDICINE 

(Published  the  Last  of  Each  Month) 


Vol.  XVIII. 
Old  Series. 


PHILADELPHIA,  AUGUST,  1905. 


Vol.  VIII,  No. 
New  Series. 


PAGE 

EDITORIALS 

ON     THE      MANAGEMENT     OF 
EPILEPTICS.     Matthew  Woods..  337 

PERICOLITIS    DEXTRA.     J.    F.    Bin- 

nie 341 

CHROMAFFIN  SUBSTANCE  IN  RE- 
LATION TO  VASOMOTOR 
ATAXIA,  AND  THE  EQUILIB- 
RIUM OP  INTERNAL  SECRE- 
TIONS.    Solomoa   Solis  Cohen 342 

8ELF-EDUCATI0N  OF  THE  GEN- 
ERAL PRACTITIONER.  J.  Mad- 
ison T  ylor 343 

CYCLOPEDIA    OF   CURRENT 
LITERATURE 

ABDOMINAL  PAIN  FROM  ADHE- 
SIONS.     C.  G.  Cumston 317 

AMENORRHEA     AND    SYSTEMIC 

DISEASE.    Journal  of  the  Ameri- 
can Medical  Association 318 

AMCEBA8  INFECTING  THE  HUMAN 

INTE8TINE.     C.  F.  Craig 350 

ANGINA  PECTORIS  AND  PSEUDO- 
ANGINA.     W.  H.    Broadbent 350 

BLOOD-PRESSURE  AND  THE  POSI- 
TION OF  THE  BODY.      C.  Gen- 

nari 351 

BRIGHT'S  DISEA8E.     A.  C.  Croltan...  352 
CARBOLIC     ACID     GANGRENE.      J. 

Herold 352 

CARCIMONA     OF     THE     STOMACH, 

DIAGNOSIS    OF.     Ewald 352 

CONSTIPATION,  SPABTIC,  TREAT- 
MENT   OF.      A.  All.li J53 

CONSUMPTION,      TREATMENT     OF. 

W.  Hutchison 353 

DIARRHOEA,  CHRONIC  :  TREAT- 
MENT.     K.  W.  Wilcox 351 

DIARRHOEA  IN  CHILDREN,  TREAT- 
MENT OF.      J.  E    Winters 355 

DYSPEPSIA,  DIETETIC,  TREAT- 
MENT OF.     Hutchison 355 

EXOPHTHALMIC  GOITER,  NEW 
OCULAR  SYMPTOMS  OF.  New 
Y  rk  Medical  Journal  and  Phila- 
delphia Medical  Journal 35f> 

EYE-STRAIN.      G.  L.  Walton 356 


TABLE  OF  CONTENTS. 

PAGE 
FATISUE,       ALBUMINURIA      AND 
GLYCOSURIA      FROM.       Gugli- 
elmo  Gobbi 357 

FEMORAL  HERNIA,   NEW  RADICAL 

OPERATION  FOR.     E.  A.  P61ia...358 

FRACTURE  OF  THE  CARPAL  SCA- 
PHOID. E.  A.  Codmau  and  H. 
M.    Chase 358 

GASTRIC  CANCER,  PATHOLOGY  OF. 

Von  Tobora 359 

GOUT.  THE  CARBON  FACTOR  IN: 
HYPERPYREMIA.  Francis 
Hare 300 

HEMORRHOIDS,  EXTERNAL,  PA- 
THOLOGY   OF.     L.  J.  Krouse...  361 

HAT     FEVER,     MASSAGE     OF     THE 

NOSE  IN.     A.  Denker 361 

HEART    MUSCLE,     FUNCTIONAL 

TEST  FOR.    M.  Hen 361 

INFANTILE  MARASMUS,    THE  FAT 
QUESTION  IN    ITS    RELATION 
TO    THE    PRODUCTION    AND 
CURE  OF.     Heinrkh  Stern 362 

INFERIOR  TURBINATED  BONE,  DIE- 
ORDERS  OF.     W.  C.  Phillips 361 

INSECT    STINGS.    P.  Fabre 365 

INTESTINAL    PERISTALSIS.      Isaac 

Ott  and  J.  F.  Ulinan 365 

ISCHOCHYMIA,     TREATMENT     OF. 

Max  Eiuhoru 366 

LARYNGEAL  PARALYSES  AND 
THEIR  DIAGNOSTIC  VALUE. 
II.  Barwell 367 


LOBAR  PNEUMONIA,  PROPHY- 
LAXIS OF.     J.  M.  Anders 36S 

MASTOIDITIS.      W.  C.  Phillips 369 

MESENTERIC  GLANDS  IN  THEIR 
RELATION  TO  TUBERCULO- 
SA.    K.    C.    Rosenberger 369 

NASAL  SEPTI,  DEFLECTED,  BUB- 
MUCOUS  RESECTION  OF.  F. 
W.  Alter 369 

NERVOUS  AND  MENTAL  DISEASES, 
RELATION  OF  THE  GASTRO- 
INTESTINAL TRACT  TO.  K. 
C.  Kemp 370 

OPHTHALMIA     NEONATORUM.       C. 

T..  Souther 371 


PAGE 

ORBITAL  8ARCOMA.    G.  Oram  Ring..  371 

PERITONEUM,  PHYSIOLOGY  AND 
PATHOLOGY  OF.  P.  Clairmont 
and  H.  Haberer 372 

PLACENTA     PREVIA,     CESAREAN 

SECTION  FOR.    R.  W.  Holmes...  372 

PLEURISY.     N.   Moore 373 

PRURITU8     ANI,     CAUSE     AND 

TREATMENT  OF.     F.  C.  WalllB.  371 

PSORIASIS,      TREATMENT      OF. 

Dreuw _ 371 

PUERPERAL     INFECTION.       Lea 375 

QUININE,     ADMINISTRATION      OF 

Luca 375 

RECTAL    8URGERY,     ANESTHESIA 

IN.     J.  P.  Tuttle 375 

RHEUMATISM,     FORMIC    ACID    IN. 

L.  B.  Couch 376 

8CABIE8.      J.  S.  Howe 376 

SPEECH,  RETARDED  DEVELOPMENT 
OF,  IN  YOUNG  CHILDREN. 
G.  Hudson-Makuen 

SUMMER  DIARRHOEAS  IN  IN- 
FANCY. ETIOLOGY  AND 
CLASSIFICATION  OF.  C.  II. 
Dunn 377 

TOXEMIA  OF  INTESTINAL 
ORIGIN  A8  A  CONDITION 
PREDISPOSING  TO  MINOR 
INFECTIONS.     H.  A.  Houghton..  378 

TUBERCULAR  PERITONITIS.  IAP- 
AROTOMY  IN.  P.  Y.  Eiseu- 
berg 379 

TUBERCULOSIS,    YEAST   IN.     W.  R. 

Huggard  and  E.  C.  Morland 379 

TYPHOID  FEVER,  IODINE  TREAT- 
MENT OF.     A.  Ceriolo 379 

TYPHUS     FEVER.       F.  Robinson   and 

E.  T.  lotts 380 

URINE,    PRESERVATION   OF.       J.  B. 

Ogden S81 

UTERU8,     MALPOSITIONS     OF.      C. 

G.  Child,  Jr._ 381 

X-RAY    INJURIES,    PROTECTION 

FROM.    C.  L.  Leonard 382 

BOOK    REVIEWS 3S3 

BOOKS  AND  MON0ORAPH8  RE- 
CEIVED.   381 

STAFF   LIST 381 


Editorials. 


DEPARTMENT   IN   CHARGE   OF 

J.  MADISON  TAYLOR,  A.M.,  M.D. 


ON  THE  MANAGEMENT  OF  EPILEPTICS. 

Since  epilepsy  is  due  to  many  causes  it  would  be  difficult  to  outline  a  uniform 
treatment  answering  all  or  even  a  definite  number  of  cases. 

It  is  so  proteus-like  in  its  amenability  to  treatment,  too,  that  it  is  possible  to 
cure  certain  forms  of  the  disease  without  medicine,  each  patient  requiring  such 
different  management.  (337) 


338  ON  THE  MANAGEMENT  OF  EPILEPTICS. 

The  important  thing  to  remember  is  that  Bromide  of  Potassium  (spelling  it 
with  capitals  because  of  its  popularity)  ought  not  to  be  used  as  a  matter  of  routine 
or  regarded  as  the  best  remedy  for  all  cases,  or  the  drug  to  be  always  and  persistently 
administered,  Professor.Memeyer  to  the  contrary  notwithstanding;  and  the  phy- 
sician who  relies  on  it  to  the  exclusion  of  other  remedies  and  the  neglect  of  careful 
and  specific  dietary  and  psychic  directions  is  not  doing  all  that  can  be  done  for  his 
patient.  Besides;  bromides  given  the  wrong  way  may,  increase  in  frequency  and 
violence  rather  than  diminish  the  attacks. 

There  is  no  chronic  disease  wherein  attention  to  hygienic  particulars  render 
such  good  results,  especially  in  the  prevention  of  nocturnal  attacks,  where  gastric 
and  intestinal  irritation  due  to  excessive  eating — not  excessive  in  quantity,  but 
beyond  the  digestive  capacity  of  the  individual — is  the  causative  factor  behind  most 
seizures. 

In  such  cases,  sometimes  the  happier  results  are  produced  by  so  regulating  the 
diet  that,  after  retiring,  nothing  remains  in  the  intestinal  tract  to  disturb  repose 
or  cause  the  irritation  that,  transmitted  presumably  to  the  medulla  oblongata,  ends 
in  convulsion,  for  intestinal  or  any  other  peripheral  irritation  may  be  the  button 
which,  when  pressed,  results  in  the  ringing  of  the  bell,  viz. :  the  explosion  or  spasm 
at  the  other  end  of  the  line. 

Epilepsy  is  not  a  matter  of  merely  morbid  muscular  activity  occurring  with 
irregular  periodicity,  but  a  series  of  phenomena,  beginning,  we  might  say,  in  con- 
vulsions and  ending  in  exhaustion.  Hence  the  treatment  should  include  more 
than  an  attempt  to  control  the  convulsive  elements  by  sedatives. 

In  taking  charge  of  an  epileptic  therefore — a  serious  and  responsible  task,  and 
one  not  to  be  lightly  undertaken — it  ought  to  be  done  with  the  resolute  purpose 
of  effecting  a  cure.  It  is  well  first  to  give  a  definite  period  to  the  intimate  study  of 
the  individual  before  resorting  to  the  use  of  bromides  or  other  sedatives,  as  these 
sometimes  disguise  or  conceal  the  remote  cause  of  the  disease,  preventing  a  proper 
diagnosis  and  prognosis,  just  as  morphia  may  do  the  same  thing  in  diseases  of  the 
abdominal  cavity. 

Indeed,  this  procedure  or  rather  preliminary  suspension-  of  drug  treatment 
is  necessary,  too,  in  order  to  get  rid  of  the  misleading  effect  of  former  treatment, 
especially  if  the  patient  has  been  taking  patent  nostrums,  for  excessive  medication 
is  the  rule  rather  than  the  exception  in  most  cases  of  epilepsy. 

Even  if  convulsions  should  occasionally  occur  during  this  period  of  preliminary 
study,  still  for  a  while  the  treatment  should  consist  chiefly  in  correcting  errors  of 
diet,  in  moral  suasion,  and  encouragement. 

Adoption  of  this  rule  is  very  important  as  the  physician  needs  to  effect  the 
removal  of  every  factor  likely  to  confuse  his  judgment  in  his  study  of  the  patient 
in  what  we  might  call  his  unmedicated  state. 


ON  THE  MANAGEMENT  OF  EPILEPTICS.  339 

Certain  varieties  of  hysteria,  epileptiform  attacks  in  incipient  paretic  de- 
mentia, mild  monomanias,  and  other  psychoses,  associated  with  hysterical  symp- 
toms simulating  epilepsy,  have  been  mistaken  for  it,  and  it  is  well  to  exclude  these 
in  the  beginning  by  rigid  differentiation. 

It  is  not  an  uncommon  occurrence  to  be  consulted  by  the  parents  of  girls  who 
are  merely  chloritic,  with  pale  complexions,  emaciated  forms,  faces  disfigured 
with  bromine  acne,  and  exhibiting  other  evidences  of  being  excessively  treated  for 
epilepsy,  when  disease  may  perhaps  be  hysteria  due  to  malnutrition,  or  some  dis- 
order of  the  uterus  or  its  appendages  with  epileptiform  symptoms. 

There  are  divers  conditions  so  similar  to  epilepsy  in  certain  impressive  par- 
ticulars that  one  needs  every  aid  to  distinguish  the  one  from  the  other.  To  the 
end  that  the  history  of  the  origin  and  peculiarities  of  each  attack  may  be  intimately 
studied,  the  patient,  when  possible,  for  a  while  should  be  under  the  daily  surveil- 
lance of  the  physician,  and  during  this  initial  period,  when  getting  medically  ac- 
quainted, there  will  occur  opportunities  of  noting  many  things  that  might  other- 
wise remain  unobserved. 

If  constipation  exists  it  should  be  corrected.  If  there  is  excessive  eating — 
epileptics,  especially  in  advanced  stages,  are  voracious  sometimes  to  the  point  of 
gluttony — diminish  the  quantity,  if  necessary  prescribing  nourishment  by  weight, 
and  limit  the  daily  allowance  to  food  easy  of  digestion,  avoiding  superabundance. 
A  bill  of  fare,  if  demanded  sometimes  by  certain  exigencies,  should  be  written  out 
and  no  deviation  from  it  should  be  permitted  without  consent  of  the  doctor. 

Epileptics  ought  to  be  liberally  fed,  but  they  should  not  be  expected  to  regulate 
their  own  food  or  administer  their  own  medicine,  and  in  most  cases  they  should 
become  vegetarians,  at  least  to  the  extent  of  avoiding  meat  in  bulk. 

If  there  is  elongation  of  the  prepuce,  with  impossibility  of  retraction  over  the 
gland,  with  inflammation  or  without,  with  irritating  accumulation  of  smegma  or 
without,  cut  it  off.  Within  the  past  5  years  I  have  had  three  cases  of  cure,  evident Iv 
resulting  from  this  simple  operation;  one  in  a  man  62  years  old.  In  two  of  these 
no  drugs  were  used.  Whether  those  euros  were  due  to  surgical  shock  or  psychic  in- 
fluence, or  the  removal  of  the  irritation,  I  cannot  tell.  In  either  event,  however, 
where  the  condition  mentioned  above  is  present,  circumcision  is  commendable. 

If  there  are  annoying  cicatrices,  the  result  of  injury  previous  to  the  first  appear- 
ance of  attacks,  they  should  be  extirpated,  and  any  consequent  adhesion  of  the  softer 
tissues  to  the  bone  should  be  detached.  Abrasions  or  fissures  of  the  os,  ovarian 
irritation,  or  other  disorder  of  the  uterus  or  its  appendages,  should  be  corrected. 
If  the  patient  belongs  to  the  unemployed  class,  or  has  been  advised  to  stop  work 
because  of  his  affliction,  sec  to  it  that  a  suitable,  safe  occupation  is  found  for  him 
where  he  may  he  in  a  position  to  acquire  independence  and  self-esteem  by  being 


340  ON  THE  MANAGEMENT  OP  EPILEPTICS. 

employed,  with  the  added  dignity,  when  possible,  of  a  bank  account  with  money  he 
has  earned  himself.  This  at  least  has  a  good  moral  effect  on  patients  who  have  been 
unnecessarily  invalided  and  consequently  ennuied  by  enforced  indolence. 

Epileptics  are  not  usually  lunatics,  not  even  invalids  in  the  ordinary  sense. 
There  is  no  invariable  impairment  of  the  mental  faculties.  Unless  complicated 
with  other  diseases  they  are  physically  sound.  There  is  no  constant  pathology,  no 
invariable  lesion.  Every  condition  mentioned  by  writers  as  a  cause  of  the  disorder 
has  been  known  to  exist  without  epileptic  manifestations.  Some  of  the  greatest 
intellects,  most  ingenious  and  comprehensive  minds  even,  have  been  thus  afflicted. 
Under  such  circumstances  enforced  idleness  serves  no  useful  purpose.  Moderate 
work  is  the  normal  state  of  civilized  man,  and  no  people  need  the  stimulation  con- 
sequent upon  employment  more  than  these  otherwise  healthy  people,  thus  handi- 
capped with  a  neurosis. 

All  patients,  especially  children,  in  the  beginning  of  treatment,  are  the  better 
to  have  an  anthelmintic  administered,  followed  by  a  brisk  cathartic,  but  in  treating 
epileptics  for  other  diseases  tincture  of  muriate  of  iron  and  large  doses  of  quinine 
should  be  avoided,  as  these,  like  the  bromides  in  concentrated  solution,  are  liable  to 
do  more  damage  than  good. 

Where  there  are  tumors  occurring  previous  to  attacks,  particularly  neuromatia, 
also  exostoses,  penetrating  spicula  of  bone  or  depression  of  cranium  due  to  fracture, 
surgical  interference  is  demanded,  and  of  course,  syphilis,  anaemia,  and  hydremia, 
possible  inferential  causes  of  the  disorder,  ought  to  be  corrected  with  the  proper 
remedies;  but,  as  intimated  above,  when  chalybeate  tonics  are  indicated,  hydro- 
cynanate  or  pyrophosphate  of  iron  should  be  preferred  to  other  preparations  of  iron. 
Tincture  of  muriate  should  never  be  given  to  epileptics. 

The  reader  will  understand  the  above  remarks  as  not  by  any  means  including 
all  that  might  have  been  said  about  the  preliminary  stage  of  management  if  there 
had  been  more  space  at  disposal,  but  merely  as  a  few  sugestions  likely  to  aid  in 
making  subsequent  treatment  more  effective. 

After  having  thus  cleared  the  field,  as  it  were,  of  conditions  calculated  to  pro- 
duce confusion  of  vision,  the  physician  is  better  prepared  to  treat  the  patient  by 
drugs. 

In  my  next  paper  I  shall  show  the  possibility  of  producing  a  greater  percentage 
of  cures  than  that  recorded  in  the  books,  and  with  less  discomfort  to  the  patient. 

Matthew  Woods,* 

Philadelphia. 


•Member  of  the  National  Association  for  the  Study  of  Epilepsy  and  the  Care  and  Treat- 
ment of  Epileptics. 


PERICOLITIS  DEXTRA.  341 

PEEICOLITIS  DEXTRA. 

One  meets_,  with  more  or  less  frequency,  cases  presenting  an  almost  typical 
history  of  chronic  appendicitis  with  one  or  more  acute  or  subacute  exacerbations. 
On  examination,  the  physical  signs  correspond  to  the  symptoms.  Frequently  ten- 
derness will  be  noted  extending  along  the  ascending  colon.  When  the  abdomen  is 
opened  there  is  found  a  delicate  curtain  or  web  of  adhesions  covering  the  caecum. 
The  ascending  colon  has  many  and  dense  adhesions  to  the  omentum,  etc.  The 
evidences  of  previous  inflammation  are  least  marked  near  the  appendix,  but  increase 
rapidly  toward  the  hepatic  flexure.  Often  after  tearing  through  the  delicate  csecal 
adhesions  one  discovers  the  end  of  the  caecum  with  the  appendix,  lying  perfectly 
free  and  healthy.  As  a  rule,  however,  the  appendix  is  unhealthy  and  frequently 
hidden  among  adhesions.  Removal  of  the  appendix  plus  destruction  of  adhesions 
often  leads  to  symptomatic  recovery;   but  often  it  does  not. 

The  conditions  found  in  such  cases  have  puzzled  me  much,  as  I  could  not  bring 
myself  to  believe  that  the  appendix  was  more  than  secondarily  involved.  There 
was  evidently  pericolitis  most  marked  near  the  hepatic  flexure.  In  one  case  where 
the  symptoms  simulated  hepatic  colic  there  was  the  scar  of  an  old  ulcer  on  the 
colon. 

In  December,  190-1  (Revue  de  Chirurgerie),  Alglave  published  some  observa- 
tions made  on  cadavera  in  the  dissecting  room.  There  were  8  male  and  8  female 
subjects.  In  4  of  the  latter  the  right  kidney  was  dislocated  downward,  carrying 
with  it  the  hepatic  flexure  of  the  colon.  As  the  caecum  remained  fixed,  wbile  the 
upper  part  of  the  colon  was  pressed  downward,  the  result  was  kinking  of  the  ascend- 
ing colon,  stasis  of  the  ceecal  contents,  dilatation  of  the  caecum  and  of  part  of  the 
colon,  colitis,  pericolitis,  adhesion  formation,  etc.  Alglave  attributed  the  whole 
series  of  conditions  to  the  nephroptosis.  Arbuthnot  Lane  (British  Medical  Jour- 
nal, 1905)  considers  the  nephroptosis  secondary  to  the  distention  and  descent  of 
the  colon,  which  are  due  to  chronic  constipation  resulting  from  errors  in  diet,  etc., 
which  may  date  back  to  childhood.  After  very  thorough  dietetic  and  medicinal 
treatment  has  been  tried  and  found  wanting.  Lane  recommends  divisioD  of  the 
ileum  about  six  or  eight  inches  from  the  caecum,  closure  of  the  divided  ends  of  the 
ileum  and  anastomosis  of  the  proximal  segment  to  the  sigmoid  or  rectum.  The 
results  following  this  operation  he  finds  excellent  and,  strange  to  say,  his  patients 
have  not  been  subsequently  troubled  with  diarrhoea. 

This  does  not  tally  with  the  findings  of  Macewen  in  cases  where  a  Large  csecal 

fistula  has  been  formed  or  where  the  caecum  and  much  of  the  ascending  colon  have 

been  excised.     In  these,  Macewen  has  found  must  troublesome  diarrhoea  leading  to 

great  reduction  in  weight.       Possibly  the  two  sets  of   observations  may  be  less  con- 

3 


342  CHROMAFFIN   SUBSTANCE  IN  VASOMOTOR  ATAXIA. 

tradictory  than  appears  at  first  glance.  In  Lane's  cases  the  colon  .prior  to  opera- 
tion was  in  a  diseased  condition  and  not  carrying  out  its  functions,  while  the  opera- 
tion put  the  excluded  segment  of  gut  at  rest,  i.e.,  in  a  state  favorable  for  the  recovery 
of  its  functional  powers.  After  the  operation  of  exclusion  the  intestinal  contents 
can  no  longer  pass  into  the  caecum  and  colon,  but  the  secretions  of  these  portions 
of  gut  can  and  do  drain  into  the  sigmoid,  where  they  mix  with  the  intestinal  con- 
tents. Of  course,  the  mingling  of  colonic  juices  and  intestinal  contents  cannot 
here  be  so  thorough  as  in  the  normal  site,  but  imperfect  as  it  is,  it  may  explain  why 
Lane's  patients  escaped  diarrhoea.  I  have  not  as  yet  carried  out  Lane's  recom- 
mendation, but  his  method  seems  reasonable  in  a  limited  series  of  cases. 

Although  the  appendix  is  not  the  starting  point  of  the  disease,  yet  if  it  is 
secondarily  affected  it  ought  to  be  removed,  because  the  dangers  to  be  apprehended 
from  a  secondary  are  probably  as  great  as  those  from  a  primary  appendicitis. 

J.  F.  Binnie,* 
Kansas  City,  Mo. 


CHROMAFFIN  SUBSTANCE  IN  RELATION  TO  VASOMOTOR  ATAXIA, 
AND    THE    EQUILIBRIUM    OF    INTERNAL    SECRETIONS. 

In  1892  I  called  attention  to  a  condition  I  denominated  vasomotor  ataxia, 
and  suggested  that  this  was  the  basis  upon  which  various  syndrome  groups — 
Graves's  disease  at  the  one  extreme  and  Raynaud's  disease  at  the  other  extreme — 
were  developed  in  accordance  with  the  incidence  of  various  additional  extrinsic,  and 
intrinsic  etiologic  factors.  In  subsequent  communications  I  have  reported  a  num- 
ber of  cases,  serving  to  complete  the  links  of  the  chain.  Among  the  various  con- 
ditions coining  under  the  designation  suggested  are  those  reported  by  Osier  under 
the  name  of  the  "erythema  group."  The  recent  experimental  observations  on  the 
production  of  arteriosclerosis  by  the  injections  of  adrenal  substance,  and  Wiessel's 
demonstration  of  the  chromaffin  system,  its  destruction  in  Addison's  disease,  and 
its  defective  development  in  arterial  hypoplasia  and  status  thymicus,  are  suggestive 
of  a  definite  pathologic  explanation  of  the  clinical  observations  alluded  to.  The 
vasomotor  ataxic  condition  may  be  dependent  on  imperfect  development  or  inhar- 
monious distribution  of  chromaffin;  angina  pectoris,  Raynaud's  disease,  erythyro- 
melalgia,  and  intermittent  claudication  may  be  associated  with  excessive  chromaffin 
development,  local  or  general;  while  Graves's  disease,  hay  fever,  status  thymicus, 
Addison's  disease,  acromegaly,  and  myxcedema  are  brought  into  relation  as  asso- 
ciated with  lack  of  chromaffin,  cither  from  deficient  development  or  excessive 
destruction.     This  leaves  many  etiologic  and  pathologic  problem's  still  to  be  solved. 


*  Professor  of  Surgery,  Kansas  Shite  University. 


SELF-EDUCATION  OF  THE  GENERAL  PRACTITIONER.  343 

It  brings  into  view  once  more  the  reciprocal  relations  of  the  thyroid,  pituitary, 
adrenal,  and  thymus  glands  on  which  Sajous  has  laid  such  stress,  substituting, 
however,  the  term  chromaffin  system  for  Sajous's  term  of  adrenal  system,  inas- 
much as  the  pressure-raising  substance  of  the  adrenal  is  shown  to  be  the  chromaffin 
of  which  its  medulla  consists,  and  which  is  identical  with  the  chromaffin  distributed 
throughout  the  sympathetic  system  of  nerves  and  in  certain  situations  in  the  heart 
and  vessels.  In  Addison's  disease  Wiesel  has  shown  that  chromaffin  disappears 
both  from  the  adrenal  and  the  sympathetics,  thus  reconciling  the  apparently  con- 
flicting necropsy  records  of  this  disease.  Leukoderma,,  which  is  often  associated 
with  vasomotor  ataxia,  may  be  found  to  have  some  relation  with  this  group  of  dis- 
orders, a  subject  that  can  be  better  discussed  when  the  cutaneous  pigmentation  of 
xiddison's  disease  is  brought  into  relation  with  the  disappearance  of  chromaffin. 
It  may  be  that  the  absorption  of  pigment  in  leukoderma  is  a  compensatory  process. 
At  all  events  the  metabolic  balance  of  the  internal  secretions  is  evidently  a  most 
important  matter  of  vital  equilibrium;  and  the  paths  indicated  by  Sajous  must 
be  fully  explored  experimentally.  When  this  is  done,  and  exact  knowledge  takes 
the  place  of  the  speculation  to  which  we  are  now,  in  many  directions,  restricted, 
our  hygienic,  therapeutic,  and  prophylactic  resources  will  be  much  increased.  At 
present  we  know  empirically  that  thyroid  gland  substance  is  valuable  in  arterio- 
sclerosis, and  should  be  used  in  myxcedema,  Raynaud's  disease,  angina  pectoris,  and 
intermittent  claudication — diseases  in  which  chromaffin  may  be  excessive.  As  I 
have  elsewhere  pointed  out,  it  belongs  therapeutically  with  the  nitrites.  Perhaps 
a  definite  substance,  antagonistic  to  chromaffin,  may  some  day  be  extracted  from 
it.  We  also  know  empirically  that  benefit  follows  the  use  of  thymus  and  adrenal 
substance  (chromaffin)  in  Graves's  disease,  hay  fever,  Addison's  disease,  and  other 
conditions  in  which  chromaffin  is  actually  or  relatively  deficient.  The  subject  in- 
vites investigation. 

Solomon  Solis-Coiien.* 


SELF-EDUCATION  OF  THE   GENERAL  PRACTITIONER 

Physicians  are  often  asked,  or  ask  themselves,  what  may  be  the  scope,  possi- 
bilities, and  limitations  of  their  spheres  of  usefulness.  A  host  of  critical,  even 
hostile,  forces  seem  arrayed  against  their  best  efforts.  Doubts  are  cast  on  their 
reasonings,  their  resources.  Sneers  are  plentiful.  They  are  confronted  with  "cures" 
wrought  by  old  mysticisms  cropping  up  in  new  and  convincing  guises.  Failures  to 
oyercome  insuperable  morbid  influences  are  often  magnified,  till  the  great  science 
of  medicine  with  its  heritage  of  the  ages  is  held  by  many  in  disesteem. 

"Professor  of  Clinical  Medicine  in  Jefferson  Medical  College,  Philadelphia. 


344  SELF-EDUCATION  OF  THE  GENERAL  PRACTITIONER. 

Interwoven  through  all  this  are  seen  glaring  instances  of  commercialism  sully- 
ing the  good  name  of  individuals,  vilifying  purity  of  motive,  impairing  that  price- 
less quality  of  humanitarianism  which  is  the  distinguishing  characteristic  of  our 
profession.  All  this  we  endure  with  varying  degrees  of  patience,  but  it  is  wrong 
to  submit  without  protest. 

To  recount  the  utilities  which  we  perpetually  furnish,  to  eulogize  our  triumphs, 
is  not  for  us  to  do.  Those  who  have  profited  by  our  rescues,  our  self-abnegation, 
by  our  deeds  wrought  in  the  sacred  privacy  of  terrified  households,  when  life 
trembled  on  the  verge  or  health  was  ebbing  away,  those  are  they  who  owe  it  to  us 
to  bear  witness.  Gratitude  to  the  rescuer  is  rare,  almost  a  figment  of  optimistic 
imagination.  At  least  we  can  lay  bare  our  hearts  to  each  other  and  take  counsel 
together,  rehearse  our  shortcomings,  purge  ourselves  of  follies,  and  by  frank  com- 
parisons seek  to  rid  ourselves  of  worn-out  measures,  to  rejuvenate  those  which 
deserve  to  live  and  make  choice,  cautiously,  among  the  endless  ruck  of  newly  devised 
methods  and  agencies. 

How  can  this  be  done?  The  subject  warrants  a  treatise.  Let  each  one  do  his 
own  thinking  unremittingly  and,  in  his  own  reading,  seize  the  vital  points  always 
with  critical  exclusiveness.  Here  only  a  few  suggestions  can  be  offered.  The  first 
thought  which  arises  is  that  we  have  accumulated  an  overwhelming  mass  of  litera- 
ture, not  one-third  of  which  is  worth  perusal.  It  is  the  product  of  much  loose 
thinking,  inexact  researches,  feverish  leapings  at  conclusions,  inordinate  hopeful- 
ness of  miraculous  discoveries.  Confusion,  to  the  point  of  confounding,  often 
results  from  accepting  specious  conjectures,  opinions,  based  on  theorizings  unforti- 
fied by  essential  facts.  Those  who  assume  the  duty  of  ascertaining  and  formulating 
these  fundamentals,  notably  the  physiologists,  have  failed  often  to  supply  us  work? 
ing  principles  where  we  chiefly  need  them.  The  most  practical  advances  have  been 
furnished  by  the  surgeons,  the  least  by  the  neurologists. 

In  general  medicine,  take  as  an  example  tuberculosis;  after  much  attention 
to  its  pathology  and  therapeutics  we  are  informed  by  "authorities"  as  a  finality, 
that  our  main,  some  say  our  only,  reliance,  shall  be  upon  open  air  and  dietetics. 
Such  a  conclusion  is  a  pitiable  confession  of  failure.  Upon  scrutiny  it  will  be 
felt  that  this  is  not  adequate  in  view  of  what  has  been  learned  from  empiricism 
alone,  much  less  from  the  scientific  researches  of  intellectual  giants.  It  is  fairer 
to  assume  that  we  have  either  omitted  to  learn  some  important  supplemental  facts 
or  have  not  achieved  a  practical  medical  philosophy.  Perhaps  both  are  true,  when 
we  reflect  that  it  has  been  pretty  thoroughly  established  that  by  far  the  larger  part 
of  our  heritage  in  medicine  is  derived  from  wise  empiricism. 

From  long  experience  we  have  evolved  invaluable  rules  governing  the  use  of 
medicines.    Less  exact  knowledge  exists  concerning  those  most  important  auxiliary 


SELF-EDUCATION  OF  THE  GENERAL  PRACTITIONER.  345 

remedial  agencies,  entitled  "physiologic,"  such  as  the  application  of  heat  and  cold, 
dry  or  through  water,  movements,  manipulations,  readjustments,  stretchings,  pres- 
sure on  nerve  points,  motor  and  respiratory  education,  diet,  climate,  and  such 
like  rational  agencies,  all  which  are  well  worth  our  practical  study  and  judicious 
employment.  The  deeply  scientific  yet  promising  realm  of  electricity,  special  rays, 
belong  to  the  specialist;   no  tyro  is  safe  to  meddle  with  them. 

More  puzzling  are  those  psychic  agencies,  hypnotic  suggestion,  mysticisms,  the 
contemplation  of  sacred  symbols,  which  have  exercised  powerful  effects  on  func- 
tional disabilities  and  psychoses  since  the  dawn  of  history.  These  justify  our  best 
attention  and  deserve  our  employment.  We  are  fully  alive  to  the  efficiency  of  these 
instruments,  but  too  rarely  exhibit  a  working  knowledge  of  how  to  use  them.  They 
are  not  only  legitimate  factors  in  our  armamentarium,  but  are  powerful  for  good 
when  judiciously  employed,  and  far  otherwise  when  effects  thereby  achieved  by 
fanatics  or  charlatans  are  brandished  in  our  faces.  All  this  constitutes  "a  large 
order,"  but  it  is  not  impossible  to  compass  a  working  knowledge  of  their  funda- 
mental potentialities. 

It  is  the  part  of  wisdom  to  formulate  clearly  in  the  mind  certain  principles 
of  treatment,  to  secure  all  the  light  possible  in  this  direction,  and  to  utilize  these 
constantly.  Since  it  may  not  be  feasible  (it  is  always  posssible)  to  ascertain  all 
those  which  the  wealth  of  data  on  record  is  capable  of  supplying,  it  is  desirable  for 
each  one  to  keep  a  note-book,  preferably  indexed,  wherein  is  preserved  memoranda 
of  those  elemental  principles  which,  when  learned,  shall  be  systematically  outlined 
for  prompt  reference.  Revision  will  be  frequently  needed,  but  the  fundamentals 
can  only  change  when  the  sum  total  of  knowledge  of  physiology  and  general  pathol- 
ogy shall  be  reached.1     Success  in  applying  these  comes  by  experience. 

For  analogy  note  the  work  of  handicraftsmen  in  any  line.  Simple  materials 
and  tools  are  no  bar  to  large  results  if  only  adequate  skill  be  displayed  in  their 
application. 

Empiricism  here  as  elsewhere  is  our  chief  guide,  always  to  be  supplemented  by 
the  findings  of  exact  science.  Modifications  weigh  more  forcefully  often  than  revo- 
lutions. Data  learned  from  authoritative  sources  often  fail  to  fit  to  our  facts, 
probably  because  we  do  not  always  grasp  the  proper  point  of  view  or  omit  to  con- 
sider some  important  factors  not  in  evidence.  Knowledge  is  only  power  when  we 
can  apply  it  consistently  to  the  concrete  instances.  Small  practical  points  gained 
by  experience  are  worth  often  more  than  some  scientific  conclusions,  and  justify 
recording. 


lThe  reading  of  carefully  prepared  abstracts,  such  as  are  furnished  l>y  The  Monthly 
Cyclopedia,  offers  to  the  general  praetitionerofUn  advantages  over  the  full  article;  at  least 
it  offers  economy  of  time.  If  the  subject  warrants,  the  original  can  be  secured  later.  Pencil 
underscoring  of  even  these  will  doubly  direct  attention  to  the  real  points. 


346  SELF-EDUCATION  OF  THE  GENERAL  PRACTITIONER. 

Again,  all  disease  is  of  so  complex  a  parentage  that  the  more  obvious  phe- 
nomena may  not  be  those  which  cause  the  major  distress.  Here  clear  concepts  of 
the  principles  of  general  pathology,  organic  interrelationships,  the  status  of  oxy- 
genation, metabolic  balance  will  be  needed  to  help  us  disentangle  the  problem. 
Unless  we  have  clearly  in  mind  these  fundamentals,  well  garnished  by  frequent 
revision,  we  can  only  form  conjectures,  not  conclusions.  A  man  has  need  of  a 
thorough  knowledge  of  his  tool  kit,  what  it  contains,  the  condition  of  each  and 
skill  in  applying  any  or  all.  He  requires  few  'tools  if  he  be  a  master  of  those  he 
lias.  No  science  and  few  arts  fail  to  form  points  of  contact  with  the  wide  realm  of 
medicine,  but  for  the  solution  of  every  day  problems  a  hand-book  on  practice  is  of 
more  use  than  an  encyclopaedia  or  ten-volume  "system."  The  hand  is  an  instrument 
alwaj^s  present  and  of  limitless  capabilities,  often  unsuspected  by  the  owner. 

It  is  true  the  instincts  become  educated  insensibly  by  long  years  of  meeting 
difficulties,  and  we  all  are  familiar  with  instances  where  we  know  what  is  right  to 
do,  but  would  be  sorely  puzzled  to  explain  our  reasoning.  Those  reasons,  never- 
theless, ought  to  be  more  definite  than  they  often  are.  We  can  attain  this  clarity 
of  concept  if  only  we  form  the  habit  of  condensing  our  attention  on  principles  of 
action,  their  bearing  on  causes  and  effects.  Why  does  the  average  practitioner  fail  to 
add  anything  to  the  sum  total  of  knowledge?  Not  because  he  is  untrained  in  literary 
construction,  as  he  usually  claims,  but  because  his  mind  is  a  mere  curiosity  shop 
of  unclear  impressions,  half-retained  beliefs,  half-released,  faulty  impressions,  alto- 
gether shop-worn  ideas,  bereft  of  definite  convictions.  He  may  fail  utterly  in 
utilizing  his  vague  notions  gained  by  reading  extensively  in  the  foremost  journals, 
whereupon  his  patient,  exhausted  in  patience  and  confidence,  seeks  and  gets  relief 
or  cure  from  some  narrow-minded  cancer  or  herb  doctor,  bone-setter  or  osteopath, 
Avho  at  least  can  and  does  apply  with  conviction  and  skill  simple  principles  of  drugs 
or  mechanics  to  definitely  indicated  problems. 

As  an  instance  of  broad  philosophic  formulation  and  interpretation  of  the 
fundamentals  of  medicine  the  most  conspicuous  instance  known  to  me  is  that  of 
Sajous.  Others  working  on  analagous  lines  may  display  brilliant  generalizations  in 
departments  of  thought,  and  of  their  conclusions  we  are  permitted  to  avail  our- 
selves fully.  No  one  has  given  us  the  breadth,  the  comprehensiveness  of  view 
offered  in  the  first  volume  of  Sajous's  book,  "The  Principles  of  Medicine,"  which 
includes  a  careful  critical  review  of  the  prevailing  doctrines  concerning  the  nature 
of  vital  processes,  the  physiologic  chemistry  of  cellular  metabolism,  and  the  avenues 
of  distribution  of  oxygen,  tissue  respiration,  etc.  Finding  certain  vital  points 
unclear,  often  in  chaos,  he  was  brought  to  realize  that  "  the  adrenals  could  be  con- 
sidered the  key,  to  not  only  tissue  respiration,  but  also  to  the  functions  of  all  organs 
called  the  'ductless  glands;'  also,  that  those  organs,  more  commonly  known  and 


ABDOMINAL  PAIN  FROM  ADHESIONS.  347 

constantly  discussed,  such  as  the  heart,  lungs,  liver,  etc.,  are  subsidiary  structures, 
instruments  in  a  measure  of  the  'ductless  glands'  and  destined  to  fulfill  the  man- 
dates of  the  latter"  (Sajous).  If  this  view  should  prove  to  be  correct  it  would 
change  our  customary  methods  of  interpreting  the  phenomena  of  life  and  disease; 
in  short,  we  should  at  once  possess  a  different  and  probably  a  simpler  and  more 
efficient  key  to  our  most  obscure  problems.  Whereupon  he  set  himself  the  herculean 
task  of  reviewing  the  whole  field  of  literature,  both  medical  and  all  those  branches 
of  science  bearing  directly  on  its  problems — embryology,  biology,  physics,  chem- 
istry, and  the  like.  He  is  peculiarly  fitted  to  do  the  work  because  primarily  edu- 
cated with  especial  thoroughness,  equipped  by  training  in  physiologic  experimenta- 
tion, wherein  he  taught  for  years;  he  also  has  been  compelled  to  survey  the  whole 
realm  of  medical  literature  since  1888  in  preparing  his  ''Annual  of  the  Medical 
Sciences."  Thus  he  achieved  a  concept  to  the  elaboration  of  which  he  has  given 
his  undivided  attention,  and  has  evolved  a  philosophic  presentation  based  upon  the 
conclusions  of  foremost  research  workers  and  clinical  observers.  Upon  their  find- 
ings he  has  steadily  and  carefully  built  up  his  argument.  This  has  been  before 
the  public  for  three  years,  subject  to  the  criticism  of  all.  Whatever  may  be  said 
of  his  conclusions  will  involve  the  data  and  opinion  of  these  others.  Whereas, 
there  are  in  the  work  many  original  and  endless  novel  observations,  there  is  nothing 
iconoclastic.  Moreover,  leaving  out  of  account  the  originality  of  the  concept  there 
can  be  no  two  opinions  as  to  the  practical  value  of  the  simplification  of  the  funda- 
mentals thus  presented.  No  one  can  read  this  first  volume  without  obtaining  a 
clearer  insight  into  vexing  dubiosities,  a  stimulation  of  thought,  and  many  practical 
working  axioms.  The  second  volume  soon  to  go  to  press  will  contain  a  critical 
revision  of  the  arguments  and  practical  applications  of  the  conclusions  to  clinical 
medicine,  to  the  everyday  needs  of  the  clinician. 

J.  Madison  Tayloh,* 


Cyclopaedia  of  Current  literature. 


abdominal  pain  FROM  adhesions.  The  pain  is  often  localized  at  one  spot 
Abdominal  pains  from  adhesions  have  and  here  there  is  sometimes  a  circum- 
little  conformity;  they  are  sometimes  scribed  pain  on  pressure.  A  character- 
continuous,  sometimes  colicky,  or  appear  istic  point  is  the  fact  that  pain  may  he- 
only  from  some  traumatic  action,  or  come  lessened  or  diminished  by  certain 
change  in  position  of  the  patient.  Re-  muscular  movements  or  positions  of  the 
ilex  manifestations,  such  as  nausea,  hie-  body.  Another  peculiarity  of  these  pains 
cough,  vomiting,  anorexia,  are  common,  is  that  they  arc  proportionate  in  inten- 


Formerly  Neurologist  to  tin;  Howard  Hospital,  Philadelphia,  Pa. 


348 


AMENORRHEA  AND  SYSTEMIC  DISEASE. 


sity  to  the  extent  of  the  adhesions.  As 
determined  by  the  experiments  of  Len- 
nander  on  the  sensitiveness  of  various 
parts  of  the  peritoneum,  only  those  ad- 
hesions cause  pain  which  are  inserted 
on  the  parietal  peritoneum  and  are 
stretched  or  pulled  upon.  In  stomach 
and  intestinal  adhesions  pain  is  fre- 
quently caused  by  peristalsis,  for  which 
reason  the  pain  increases  in  intensity 
after  the  ingestion  of  food. 

According  to  site,  the  various  disturb- 
ances due  to  adhesions  may  be  classified 
into  the  gastric,  intestinal,  and  pelvic 
forms.  The  gastric  forms  are  more  fre- 
quently due  to  ulcer,  cholelithiasis,  trau- 
matism, and  carcinoma  ventriculi.  The 
pains  may  radiate  to  the  breast  or  back ; 
in  some  cases  they  depend  on  the  inges- 
tion of  food,  while  at  other  times  they 
are  produced  by  mechanical  shock  or 
change  of  position.  Rosenheim's  diag- 
nostic indications  for  the  presence  of 
adhesions  are  extensive  and  of  extreme 
sensitiveness  when  pressure  is  exercised 
over  the  epigastrium,  and  especially  pain 
shooting  out  from  the  right  over  the 
border  of  the  stomach.  Those  on  the 
left  side  give  rise  to  severe  pain  which 
can  be  produced  deep  down  when  the 
lower  border  of  the  thorax  is  somewhat 
briskly  pulled  upwards.  Even  in  adhe- 
sions of  the  posterior  gastric  wall  pain 
is  occasionally  elicited  by  pressure  over 
the  first  and  second  lumbar  vertebras. 

The  pain  resulting  from  intestinal  ad- 
hesion is  usually  exhibited  in  the  form  of 
colic.  Tumors,  ulceration,  appendicitis, 
and  laparotomy  are  the  usual  causes  of 
these  adhesions. 

The  pelvic  forms  are  best  known  ami 
give  a  variety  of  symptoms  due  to  the 
prpsence  of  neighboring  organs.  Pain 
at  stool  or.  at  micturition  or  during  men- 
ses are  characteristic  of  perimetritic  ad- 


hesions. Straining,  walking,  changes  in 
position,  and  even  coitus  are  often  causes 
of  pain.  A  characteristic  group  of  symp- 
toms from  adhesions  are  found  in  the 
"typical  peritoneal  adhesion"  of  Ger- 
suny.  This  consists  in  a  bandlet  of 
adhesion  on  the  sigmoid  flexure  which 
causes  this  organ  to  be  fixed  laterally. 
Besides,  there  usually  exists  adhesions  of 
the  appendix,  as  well  as  delicate  ones 
running  between  the  uterus,  the  ovaries, 
tubes,  rectum,  and  peritoneum  of  the  pel- 
vis. These  patients  complain  of  pain  on 
both  sides  of  the  lower  abdominal  region, 
McBurney's  point  is  sensitive  to  pres- 
sure, and  there  is  another  point  lying 
symmetrically  on  the  left.  These  pains 
are  never  relieved  by  medical  treatment. 
The  treatment  is  purely  surgical.  In  the 
pelvic  form  only  may  massage  be  effi- 
cient. C.  G.  Cumston  (Albany  Medical 
Annals,  May,  1905). 

AMENORRHEA  AND  SYSTEMIC  DISEASE. 

It  is  usually  considered  that  amenor- 
rhea, especially  if  it  asserts  itself  after 
menstruation  has  once  been  thoroughly 
established,  is  due  to  some  affection  of 
the  genital  tract.  As  a  matter  of  fact, 
however,  the  cessation  is  more  likely  to 
be  the  consequence  of  some  systemic  dis- 
ease. The  cessation  of  the  menses  in 
young  women  may  be  the  first  signs  of 
tuberculosis,  when  there  is  otherwise 
little  general  disturbance  of  the  health. 
As  a  matter  of  fact,  menstruation  and 
the  menstrual  period  in  women  present 
conditions,  modifications  of  which  in 
various  ways  point  more  often  to  an 
active  tuberculous  process  in  the  sys- 
tem than  almost  any  other  set  of  symp- 
toms. Recently  it  has  been  noted  that 
chlorosis  is  reported  much  less  fre- 
quently than  used  to~be  the  case,  and 
there  would  seem  to  be  a  lessening  of 


AMENORRHCEA  AND  SYSTEMIC  DISEASE. 


349 


the  prevalence  of  this  blood  affection  in 
America.  It  has  been  suggested,  how- 
ever, that  the  apparent  diminution  of 
chlorosis  is  really  due  to  the  earlier  rec- 
ognition of  tuberculosis  than  formerly. 
The  two  affections  present  a  similar 
blood-picture  at  the  beginning,  and  the 
treatment — fresh  air  and  abundant  diet, 
with  care  of  the  bowels — is  the  same  for 
both.  It  is  more  favorable  to  find  tu- 
berculosis present  than  severe  chlorosis, 
since  genuine  cases  of  chlorosis  are 
likely  to  be  associated  with  defects  in 
the  blood-making  organs,  or  with  ab- 
normally small  size  of  the  heart  and 
arteries,  conditions  which  are  hopeless 
of  treatment. 

Certain  nutritional  disturbances  con- 
sequent on  a  marked  change  in  the  hab- 
its of  life  of  the  individual  are  often 
followed  by  a  cessation  of  the  menses. 
This  is  especially  true  when  young 
women  move  from  the  country  into  the 
city,  and  as  a  consequence  have  much 
less  outdoor  air  than  before,  and  usually, 
also,  much  less  nutritious  food.  Most 
immigrants  presents  a  period  during  the 
first  year  of  their  sojourn  in  America 
during  which  their  menses  are  irregu- 
lar, if  not  entirely  absent.  This,  too, 
would  seem  to  be  a  result  of  the  disturb- 
ance of  the  blood-making  function,  con- 
sequent on  a  lessened  amount  of  fresh 
air.  Sir  Andrew  Clarke  used  to  insist, 
however,  that  chlorotic  conditions,  asso- 
ciated with  amenorrhea,  are  more  often 
the  result  of  chronic  constipation  or  of 
insufficient  evacuation  of  the  bowels — 
two  quite  distinct  conditions — than  of 
any  other  single  cause.  Certain  it  is 
that  most  of  the  country  girls  who  come 
to  the  city,  as  well  as  most  of  the  for- 
eigners who  come  to  this  country,  are 
apt  to  suffer  for  a  time  from  irregularity 
of   the   bowels,    and    treatment   of   this 


symptom  does  more  to  bring  about  a 
return  to  their  normal  condition  than 
any  more  direct  remedial  measures  that 
may  be  considered  indicated  for  the 
menstrual  disturbance. 

In  quite  recent  years  it  has  come  to 
be  realized  that  many  of  the  serious 
nervous  affections  have  amenorrhcea  as 
one  of  their  preliminary  or  very  early 
symptoms.  This  is  especially  true  of 
affections  of  the  ductless  glands.  When 
there  is  lack  of  the  thyroid  substance  in 
the  system,  as  occurs  during  myxcedema, 
amenorrhcea  is  almost  the  rule.  In  a 
few  cases  of  exophthalmic  goiter  asso- 
ciated with  a  distinct  tendency  to  obesity 
during  the  years  between  fifteen  and 
twenty,  menstruation  is  often  scanty  or 
is  absent  entirely.  As  a  rule,  during 
exophthalmic  goiter,  however,  there  is 
an  increase  of  the  menstrual  flow.  It  is 
said  that  the  cases  marked  by  amenor- 
rhcea are  usually  amenable  to  treatment 
by  thyroid  extract.  The  first  symptom 
of  Addison's  disease  in  young  women  is 
likely  to  be  a  suppression  of  menstrua- 
tion. The  lowered  blood-pressure  con- 
sequent on  the  absence  of  the  internal 
secretion  of  the  suprarenal  bodies  some- 
how affects  the  function  of  the  uterine 
mucosa  so  as  to  prevent  the  usual  haem- 
orrhagic  exudation. 

The  disturbance  of  the  function  of  the 
pituitary  body  associated  with  the  en- 
largement of  the  face  and  the  extremi- 
ties, that  eventually  gives  the  clinical 
picture  of  acromegaly,  is  likely  to  have 
as  one  of  its  first  symptoms  the  absence 
of  menstruation.  This  occurs  at  a  time 
when  there  are  but  very  few  signs  of 
the  disease  that  is  developing.  A  cer- 
tain amount  of  eoarsening  of  the  feat- 
ures may  have  been  noticed,  but  even 
friends  are  not  likely  to  consider  this 
as   evidence   of  a  pathologic   condition. 


350 


AMCEBAS  INFECTING  INTESTINE. 


ANGINA,  TRUE  AND  FALSE. 


Sometimes  the  menses  are  absent  for 
several  months  before  any  pathogno- 
monic signs  of  the  serious  nervous  dis- 
ease that  is  at  work  can  be  recognized. 
Amenorrhcca  associated  with  very  se- 
vere headaches  for  which  treatment  is 
of  little  avail,  especially  if  there  is  also 
some  disturbance  of  vision,  or  if  there 
is  vomiting  without  cause,  must  be  con- 
sidered suspicious,  and  if  the  features 
of  the  patient  are  heavier  than  normal, 
then  the  development  of  a  tumor  of  the 
hypophysis  must  be  considered  as  one 
of  the  possibilities  in  the  case.  Edi- 
torial (Journal  of  the  American  Med- 
ical Association,  June  10,  1905). 

AMCEBAS    INFECTING    THE    HUMAN    IN- 
TESTINE. 

The  intestine  of  man  may  be  infected 
with  two  varieties  of  amcebas,  one  patho- 
genic (Entamoeba  dysenteric),  and  the 
other  non-pathogenic  (Entama'ba  coli). 
Entamoeba  coli,  the  non-pathogenic  va- 
riety, is  found  in  65  per  cent,  of  the 
healthy  individuals  studied,  and  in  50 
per  cent,  of  individuals  suffering  from 
diseases  other  than  dysentery,  if  a  saline 
cathartic  has  been  administered.  These 
organisms  can  be  easily  distinguished  in 
both  fresh  and  stained  specimens.  They 
differ  widely  in  their  method  of  repro- 
duction, and  this  is  the  most  important 
method  of  distinguishing  them. 

Entamoeba  dy sentence.,  whether  fed  in 
milk  or  injected  through  the  rectum, 
produces  in  kittens  the  typic  lesions  of 
amoebic  dysentery  as  observed  in  man. 
In  kittens,  Entamoeba  coli,  whether  fed 
in  milk  or  injected  through  the  rectum, 
is  absolutely  harmless.  Neither  feeding 
experiments  nor  rectal  injections  of 
faecal  material  or  the  bacteria  occurring 
in  such  material  produce  any  of  the  le- 
sions of  amoebic  dysentery,  unless  En- 


tamoeba dysenterice  is  present.  C.  F. 
Craig  (American  Medicine,  June  10, 
1905). 

ANGINA  PECTORIS  AND  PSEUDO-ANGINA. 

Angina  pectoris  is  defined  by  the  au- 
thor as  pain  in  the  cardiac  region,  chiefly 
behind  the  sternum,  with  radiation,  most 
frequently  down  the  inner  aspect  of  the 
left  arm  to  the  elbow  or  to  the  hand. 
The  pain  is  usually  accompanied  by  a 
sensation  of  impending  death,  and  the 
distinctive  characteristic  of  true  angina 
is  that  it  is  induced  by  exertion,  more 
easity  soon  after  food.  Next  to  exertion 
in  provoking  an  attack  comes  excitement. 
The  effect  on  the  circulation  is  increase 
of  the  blood-pressure  in  the  arterial  sys- 
tem— this  is  the  determining  antece- 
dent. The  attacks  are  usually  brief, 
subsiding  with  the  cessation  of  exertion 
or  with  the  inhalation  of  amyl  nitrite, 
etc.  Sooner  or  later  sudden  death  occurs 
during,  or  at  the  onset  of  a  paroxysm. 
But  the  pain  may  last  for  hours.  Dur- 
ing the  paroxysm  the  one  condition  that 
seems  to  be  always  present  is  contraction 
of  the  peripheral  arterioles.  The  pulse 
remains  steady  or  becomes  irregular,  but 
rarely  rapid.  The  most  constant  post- 
mortem condition  is  more  or  less  occlu- 
sion of  the  coronary  arteries  from  a  cal- 
careous or  atheromatous  or  sclerosed 
condition  of  these  vessels  with  perhaps 
thrombosis.  As  a  consequence  of  the 
obstruction  to  the  blood  supply,  general 
or  local  degeneration  of  the  walls  of  the 
heart  is  usually  produced. 

As  regards  the  causation,  the  author 
holds  that  the  condition  of  the  heart 
walls  is  the  dominant  factor.  Speaking 
generally,  in  all  cases  in  which  the  at- 
tacks come  on  chiefly  during  repose,  how- 
ever closely  they  conform  to  true  angina, 
the  presumption  is  that  they  are  spu- 


BLOOD -PRESSURE  AND  POSITION  OF  BODY: 


351 


rious,  false,  or  pseudo-angina.  The  cases 
which  most  closely  simulate  true  angina 
are  those  in  which  there  is  dilatation 
of  the  stomach.  True  angina  is  estab- 
lished when  the  coronary  arteries  are 
implicated.  Mitral  disease  does  not  give 
rise  to  angina,  nor  does  aortic  disease 
of  rheumatic  origin.  In  acute  aortitis, 
which  is  rare,  there  may  be  frequent 
anginoid  attacks  while  the  patient  is  ly- 
ing in  bed,  if  the  mouths  of  the  coronary 
arteries  are  blocked.  In  many  cases  of 
angina  general  arteriosclerosis  is  pres- 
ent, but  the  angina  may  manifest  itself 
in  a  very  early  stage.  The  cases  in  which 
the  prognosis  is  most  unfavorable,  and 
in  which  least  can  be  done  for  the  pa- 
tient, are  those  in  which  the  physical 
signs  are  negative.  The  treatment  re- 
solves itself  into  that  of  high  arterial 
tension.  Such  high  tension  is  due  to 
toxins  in  the  blood,  and  these  must  be 
prevented  from  forming,  and  eliminated. 
The  diet  should  be  simplified,  the  exer- 
cise regulated  and  supplemented  by  mas- 
sage, and  elimi nation  promoted  by  the 
use  of  water  and  the  alkaline  salts. 
Mercurial  aperients  and  iodides  defin- 
itely reduce  arterial  tension,  and  form 
the  basis  of  the  medicinal  treatment. 
The  direct  vascular  relaxants,  amyl  ni- 
trite, etc.,  are  invaluable  for  the  relief 
of  the  paroxysms,  but  their  influence  is, 
of  course,  brief.  Dilatation  of  the  stom- 
ach may  in  cases  of  angina  or  heart  dis- 
ease precipitate  death.  W.  IT.  Broadbent 
(Lancet.  May  27,  190:>). 

BLOOD-PRESSURE  AND  THE  POSITION  OF 
THE  BODY. 

Two    factors    which    cause    lowering 

of  the  blood-pressure  when  a  person 
changes  from  the  lying  lo  I  bo  Bitting 
or  the  ereel  position  are  the  influence 
of  gravity  and  the  anaemia  of  the  brain 


produced  by  this  change,  of  position. 
Gravity  favors  the  circulation  of  the 
blood  in  most  regions  of  the  body  when 
the  patient  is  standing  up,  and  thus  fa- 
vors the  lowering  of  the  blood-pressure. 
In  healthy  persons  the  vasoconstriction 
occurring  in  sitting  up  is  not  always 
marked  enough  to  counteract  the  influ- 
ence of  the  anaemia,  and  thus  the  blood- 
pressure  is  slightly  lowered  in  the  sit- 
ting position  as  compared  to  the  prone 
or  supine  position.  In  debilitated  per- 
sons, in  neurasthenics,  in  certain  forms 
of  cardiac  neurosis,  in  feeble  persons 
with  cardiac  disease,  in  whom  the  vasal 
tonicity  is  diminished,  the  vasoconstric- 
tion is  less  marked,  and  the  lowering  of 
blood-pressure  on  sitting  up  is  more 
prominent.  At  the  same  time  these 
persons  show  a  dicrotic  pulse  in  the  sit- 
ting or  standing  position,  which  is  due. 
according  to  Frcy,  to  an  increase  in  the 
frequency  of  the  heart  beats.  On  the 
other  hand,  in  patients  with  high  tension 
pulse,  such  as  nephritics,  in  arterioscle- 
rosis, in  aortic  insufficiency,  etc.,  the 
pressure  is  not  altered  by  sitting  up,  or 
standing,  because  the  vasoconstriction  is 
so  great  that  it  counteracts  any  tendency 
of  gravity  to  lower  the  pressure.  In 
such  patients,  therefore,  the  blood-pres- 
sure is  stable  in  either  position.  An  in- 
teresting fact  is,  however,  that  the  blood- 
pressure  is  also  stable  in  compensated 
heart  disease,  in  which  vasoconstriction 
is  sufficient  to  counteract  any  other  in- 
fluence lowering  the  pressure,  when  the 
patient  sils  or  stands  after  lying  down. 
Morphine  acts  well  in  cardiac  asthma, 
because  it  diminishes  the  vasoconstric- 
tion and  lowers  the  blood-pressure,  con- 
trary to  the  statements  found  in  some 
text-books.  It  must  be  given,  however, 
in  small  doses.  0.  Gennari  (Biformu 
Med'iea,    April    15,    1905;     New    York 


352 


BRIGHT'S  DISEASE. 


CARCINOMA  OF  STOMACH,  DIAGNOSIS. 


Medical  Journal  and  Philadelphia  Med- 
ical Journal,  May  27,  1905). 

BRIGHT'S  DISEASE. 

A  radical  distinction  between  Bright's 
disease  and  nephritis  is  made  by  the  au- 
thor. Nephritis  is  an  inflammation  of 
the  kidneys;  Bright's  disease  is  a  sys- 
temic affection  that  usually  leads  to  ne- 
phritis, but  does  not  invariably  do  so. 
The  sequence  of  events  which  leads  to 
Bright's  disease  may  be  stated  thus :  In- 
testinal putrefaction,  absorption  of  toxic 
substances  in  such  quantities  as  to  over- 
power the  liver  and  thus  pass  through 
it  unchanged  into  the  general  circula- 
tion, rise  in  blood-pressure,  due  to  such 
toxins.  This  sooner  or  later  leads  to  car- 
dio-vascular  degeneration  and  at  times 
nephritis.  This  sequence  of  events  is 
Bright's  disease. 

Treatment  should  consist  in  combat- 
ing its  development  at  whatever  stage  it 
is  encountered.  Begarding  specific  lines 
of  treatment,  the  surgical  treatment  of 
Bright's  disease  is  mentioned  only  to  be 
condemned.  Acute  nephritis  is  prop- 
erly treated  by  starvation,  but  not 
chronic  nephritis.  As  the  nephritis  of 
Bright's  disease  is  the  most  chronic 
form  of  nephritis,  starvation  is  irra- 
tional. A  proper  mixed  diet  which  will 
furnish  thirty  calories  per  kilo  of  body 
weigbt  is  essential.  Milk  diet  is  unde- 
sirable. It  contains  albumins  in  excess. 
it  is  deficient  in  iron:  it  floods  the  heart 
and  arteries  with  water,  it  dilutes  too 
much  the  digestive  fluids,  it  is  monoto- 
nous. Abundant  water  drinking  is  in- 
jurious. The  chief  value  of  "sweating" 
depends  on  its  power  to  deplete  the  sys- 
tem of  water.  To  sweat  a  patient  and 
at  the  same  time  to  give  him  abundant 
water  is  irrational.  The  withdrawal  of 
salt  from  the  food  has  much  in  its  favor, 


both  theoretically  and  practically.  A. 
C.  Croftan  (Journal  of  the  American 
Medical  Association,  June  24,  1905). 

CARBOLIC  ACID  GANGRENE. 

The  author  cautions  against  the  care- 
less use  of  weak  solutions  of  carbolic 
acid  by  physicians,  pharmacists,  and  the 
general  public.  Constitutional  disturb- 
ances and  even  death  have  resulted  from 
its  external  use  and  in  some  cases  gan- 
grene has  occurred  in  the  part  to  which 
it  has  been  applied.  Strong  solutions 
form  a  scab  preventing  penetration  into 
the  deeper  tissues.  When  evaporation 
of  a  1  or  2  per  cent,  solution  is  pre- 
vented, the  skin  becomes  macerated,  a 
numbness  follows  from  the  toxic  effect 
on  the  nerves,  the  acid  is  absorbed  into 
the  deeper  tissues  coagulating  the  albu- 
min, the  vasomotor  nerves  are  first  irri- 
tated and  then  paralyzed,  and  there  may 
be  the  same  effect  on  the  sensitive  and 
trophic  nerves.  In  treating  the  injury 
an  alcoholic  dressing  may  be  tried  with 
the  hope  that  it  may  destroy  any  acid 
remaining  in  the  partially  dead  tissue. 
When  the  disorganization  is  hopeless, 
amputation  is  the  only  measure.  J. 
Herold  (Medical  News,  July'  1,  1905). 

CARCINOMA   OF  THE  STOMACH,  DIAGNO- 
SIS OF. 

Attention  is  called  to  the  fact  that 
carcinoma  of  the  stomach  more  fre- 
quently has  a  sudden  onset  than  the 
gradual  one  which  would  be  expected 
from  its  pathology.  Vomiting  is  an 
important  symptom,  but  is  frequently 
absent,  especially  in  tumors  of  either 
curvatures.  Should  vomiting  in  the 
course  of  time  cease,  it  is  due  either  to 
infiltration  of  Ihe  stomach  walls,  render- 
ing them  non-contractile,  or  to  a  break- 
ing down  of  a  neoplasm,  obstructing  the 


CONSTIPATION,  SPASTIC. 


CONSUMPTION,  TREATMENT. 


353 


pylorus.  Vomiting  of  small  quantities 
of  blood  or  coffee-ground  material  is  a 
very  important  element  in  the  diagnosis. 
Of  special  importance,  however,  is  the 
presence  of  blood  and  pus  in  the  fasting 
stomach.  Pain  is  usually  absent.  Con- 
stipation, in  the  author's  experience,  has 
been  more  frequent  than  diarrhoea.  The 
enlargement  of  the  supra-  or  infra-clav- 
icular glands  of  Virchow  is  sugestive, 
but  may  mean  a  cancer  in  parts  of  the 
body  other  than  the  stomach,  or  an  asso- 
ciated tuberculosis.  Another  point  to 
be  remembered  is  that  cancer  of  the 
lesser  curvature  is  apt  to  cause  pleural 
irritation.  The  absence  of  HC1  is  sug- 
gestive, but  not  by  any  means  conclu- 
sive. The  writer  thinks  highly  of  tlie 
Gucinski  and  Solomon  methods  of  diag- 
nosis. More  important  even  than  the 
absence  of  HC1  is  perhaps  the  presence 
of  lactic  acid.  Sarcinae  are  only  an  indi- 
cation of  stomach  stagnation.  Of  course 
the  examination  microscopically  of  small 
shreds  of  tissue  in  the  vomitus  or  stom- 
ach washing  is  the  only  exact  method  of 
diagnosis.  Ewald  (Chicago  Clinical 
Review,  May,  1905). 

CONSTIPATION,      SPASTIC,      TREATMENT 

or. 

The  author  states  that  while  it  is  true 
that  in  most  cases  of  constipation  the 
older  view  that  the  condition  is  due  to 
atony  of  the  intestine  holds  good,  it  has 
of  late  years  been  recognized  that  there 
is  another  type  of  the  disease  depending 
upon  an  exactly  opposite  state  of  affairs, 
in  which  the  gut  is  in  a  state  of  spastic 
contraction.  The  proportion  of  such 
cases  is  not  small,  and  the  author  esti- 
mates that  at  least  25  per  cent,  of  the 
cases  of  constipation  in  women  belong 
to  this  variety.  It  is  important  to  recog- 
nize it,  as  the  treatment  of  constipation 


due  to  spasm  is  naturally  very  different 
from  that  of  constipation  dependent  on 
atony,  but  the  diagnosis  is  often  diffi- 
cult or  impossible.  The  patients  are  usu- 
ally neurasthenic  or  hysteric  individuals, 
who  may  exhibit  spasm  in  other  regions 
of  the  body,  such  as  cardiospasm, 
pharyngeal  spasm,  etc.  The  intestinal 
spasm  is  not  continuous,  and  gives  rise 
to  sensations  that  may  range  merely 
from  a  feeling  of  discomfort  to  positive 
colics.  The  contracted  knots  of  the  in- 
testine may  be  palpable  as  tender  sau- 
sage-shaped masses,  and  rectal  examina- 
tion may  reveal  a  spastic  condition  of 
the  sphincters.  The  fasces  sometimes  as- 
sume the  characteristic  ribbon  or  lead- 
pencil  shape. 

The  treatment  comprises  the  avoid- 
ance of  all  irritation  of  the  intestine, 
especially  massage,  and  the  use  of  sooth- 
ing and  relaxing  measures,  such  as  warm 
baths,  hot  applications  to  the  abdomen, 
warm  oil  enemas,  belladonna,  non-irri- 
tating, gruel-like  diet,  and  rectal  bou- 
gies. A.  Albu  (Medical  Eecord,  July  1, 
1905). 

CONSUMPTION,   TREATMENT   OF. 

It  has  been  learned  by  bitter  experi- 
ence that  one  must  practically  ignore 
the  bacillus  in  the  treatment  of  the  con- 
sumptive, and  that  the  same  point  of 
view  is  being  arrived  at  in  regard  to  the 
lungs.  Among  the  reasons  for  letting 
the  lungs  alone  in  treatment  is  the  fact 
that  very  few  remedial  measures  at  com- 
mand have  any  specific  action  whatever 
on  the  lungs,  and  it  is  being  more  and 
more  clearly  recognized  that  consump- 
tion is  not,  properly  speaking,  a  disease 
of  ilie  lungs,  but  is  merely  a  local  (pul- 
monary) expression  of  a  disease  which 
involves  the  entire  system.  There  are 
no  tonics  or  alteratives  which  improve 


354 


DIARRHCEA,  CHRONIC,  TREATMENT. 


the  nutrition  of  the  lungs,  and  even  the 
expectorant  drugs  have  been  proved  to 
be  lacking  in  the  virtues  formerly  as- 
cribed ( to  them.  Sprays,  etc.,  are  in- 
effectual in  reaching  the  bronchi,  and 
in  most  cases  the  so-called  pulmonary 
gymnastics  and  exercises  serve  simply 
to  drive  the  infectious  material  deeper 
into  the  hitherto  uninvaded  areas  of  the 
lungs.  The  author  has  already  shown 
that  the  chest  of  the  consumptive  is 
round  instead  of  flat,  and  that  exercises 
intended  to  develop  the  chest  as  such  do 
harm  instead  of  good.  Bodily  exercise 
of  any  kind  is  now  believed  to  be  dis- 
tinctly injurious,  and  absolute  rest  is 
indicated  in  any  case  in  which  the  after- 
noon temperature  rises  above  100°  F. 
Kesearches  by  Eobin  and  Binet  made 
over  four  years  ago  on  the  actual  gase- 
ous interchange  in  consumptives  have 
shown  that  the  tuberculous  patient  con- 
sumes a  much  greater  amount  of  oxygen 
and  gives  off  more  carbon  dioxide  in 
proportion  to  his  body-weight  than  the 
normal  individual.  In  short,  it  would 
appear  highly  probable  that  the  tuber- 
culous patient  is  to  be  regarded  in  the 
light  of  one  who  is  pouring  nearly  half 
the  heat  of  the  fuel  which  is  burned 
in  his  body  furnace  up  the  chimney,  in 
the  form  of  smoke ;  that  the  food  which 
he  takes,  instead  of  being  assimilated 
and  decomposed  by  anaerobic  processes 
in  the  body  cells,  is  burned  in  the  blood 
and  in  the  lungs.  Any  means,  therefore, 
which  will  tend,  so  to  speak,  to  clog  the 
throat  of  his  chimney  and  prevent  this 
fatal  escape  of  heat  and  energy,  whether 
by  drugs  like  creosote,  iodoform,  cod- 
liver-oil,  and  arsenic,  or  by  pouring  in  an 
enormous  quantity  of  food  rich  in  heat 
value,  will  tend  to  restore  the  balance 
of  gaseous  interchange  and  enable  him 
to  return  to  the  normal.  W.  Hutchin- 
son  (Medical  Record,  April  29,  1905). 


DIARRHCEA,  CHRONIC:      TREATMENT. 

Diarrhoea  being  a  symptom,  the  cause, 
which  may  be  mechanical,  nervous  or 
hgemic,  always  should  be  ascertained. 
The  treatment  of  the  mechanical  forms 
of  diarrhoea  is  based  primarily  on  re- 
moving the  cause  of  the  irritation.  This 
is  accomplished  by  freeing  the  alimen- 
tary tract  from  all  substances  likely  to 
cause  increased  peristalsis.  This,  in  the 
dyspeptic  form  of  mechanical  irritation, 
is  accomplished  by  a  full  dose  of  castor- 
oil.  If  there  is  proteid  indigestion,  the 
process  can  be  checked  by  resorcin,  (5 
grains,  four  times  daily,  to  which  20 
minims  of  tincture  of  nux  vomica  should 
be  added  if  there  is  diminished  motor 
function  of  the  stomach.  After  a  few 
days  3  drops  of  strong  nitrohydrochloric 
acid  or  10  drops  of  hydrochloric  acid 
with  1/20  grain  of  strychnine  sulphate, 
should  be  given  in  the  midst  of  each 
meal.  In  amylaceous  indigestion,  thor- 
ough mastication  of  starchy  food,  lim- 
itation of  fluids  with  their  ingestion,  and 
the  administration  of  diastase,  in  15- 
grain  doses,  an  hour  after  meals,  will 
generally  correct  the  difficulty.  The  use 
of  sodium  bicarbonate  is  considered  im- 
proper by  the  author,  in  all  gastric  and 
in  most  intestinal  indigestions.  Mag- 
nesia ponderosa  in  10-grain  doses  after 
meals  meets  all  indications.  If  bile  pig- 
ment is  present  in  the  stools,  a  combina- 
tion of  salicylic  acid,  6  grains,  with  the 
same  amount  of  acid  sodium  oleate,  with 
4  grains  of  phenolphthalein  and  1/i 
grain  of  menthol,  may  be  given  once 
daily,  for  several  days.  Frecal  impac- 
tions are  best  relieved  by  softening  them 
by  quart  injections  of  warmed  olive-oil, 
or  1-drachm  doses  of  arsenic-free  sodium 
phosphate  twice  daily;  1/100  grain  phy- 
sostigmin  salicylate  three  times  daily,  to 
enable  the  intestinal  muscle  to  recover 


DIARRHCEA  IN   CHILDREN. 


DYSPEPSIA,  DIET  IN. 


355 


its  tone.  Opium  is  only  admissible  when 
the  alimentary  canal  lias  been  thoroughly 
emptied,  to  check  excessive  peristalsis. 
It  should  be  given  hypodermically,  as 
morphine,  in  substantial  doses,  and  not 
repeated.  A  prescription  for  opium,  or 
any  of  its  preparations  or  alkaloids, 
should  never  be  trusted  to  nervous  pa- 
tients. There  is  too  great  clanger  of 
habit  formation.  The  tannin  prepara- 
tions are  sometimes  useful  by  tempor- 
arily inhibiting  the  action  of  the  bac- 
teria and  their  toxins.  Bismuth  napto- 
late,  bismuth  tribromophenolate,  and 
bismuth  tetraiodophenolphthaleinate 
are  more  effective.  E.  W.  Wilcox 
(American    Medicine,   June    10,    1905). 

DIARRHCEA   IN   CHILDREN,    TREATMENT 
OF. 

Appropriate  treatment  at  its  incep- 
tion arrests  diarrhoea  in  children  at  once, 
and  vet  it  registers  more  deaths  than 
all  the  contagious  exanthemas  combined. 
To  prevent  a  local  affection  becoming  a 
constitutional  infection  the  fermenting 
food  must  be  quickly  and  radically 
ejected  by  castor-oil,  and  this  must  be 
followed  by  a  period  of  absolute  rest, 
in  which  nothing  passes  through  the 
digestive  tract  but  water  from  one  to 
several  days,  according  to  the  severity 
of  the  case.  In  young  infants,  hot  water 
from  a  bottle  is  preferable.  Some  in- 
fants and  most  older  children  prefer 
cold  water.  From  three  to  five  drops  of 
very  hot  water  from  a  dropper  on  the 
tongue  every  \'>  minutes  is  at  times 
magical  in  checking  vomiting.  'The 
auspicious  moment  for  food  having  ar- 
rived, milk  should  l>e  given  with  the 
proteid  content  minimized.  The  food 
must  be  of  low  proteid  until  cool 
weather.  The  mortality  in  young  in- 
fants with  diarrhoea  is  principally  due 


to  the  use  of  cereals,  in  older  children 
to  animal  broths.  The  vegetable  proteid 
cannot  be  utilized,  the  animal  extrac- 
tives stimulate  metabolism,  both  result 
in  starvation.  Cereals  are  indispensable 
to  the  treatment  of  diarrhoea  in  the 
second  year.  Those  of  most  value  are 
barley,  imperial  granum,  arrow-root, 
rice,  cream  of  wheat.  They  must  he 
cooked  with  water,  never  with  milk.  In 
subacute  and  chronic  cases,  the  tempor- 
ary use  of  condensed  milk  is  strongly 
recommended.  The  castor-oil  may  be 
supplemented  with  irrigation  on  the 
first  day,  but  repeated  irrigations  are 
exhausting  and  seldom  advisable.  J.  E. 
Winters  (Medical  News,  July  15,  1905). 

DYSPEPSIA,    DIETETIC    TREATMENT    OF. 

Two  groups  of  dyspepsia  cases  are 
considered  by  the  author:  (1)  Those  in 
which  there  is  organic  lesion  of  the 
stomach;  (2)  purely  functional  cases. 
Digestible  food  for  either  group  means 
that  which  is  easily  dissolved.  The  se- 
cretion of  gastric  juice  is  influenced  by 
the  chemical  constituents  of  the  meal  and 
by  the  psychical  condition  of  the  pa- 
tient. Of  the  organic  diseases,  ulcer, 
dilatation,  and  acute  and  chronic  gas- 
tritis are  considered.  In  ulcer,  rest  and 
unirritating  food  in  small  quantities  are 
indicated.  In  dilatation,  the  meals 
should  he  small,  fermenting  substances 
should  he  avoided,  and  the  object  should 
be  to  supply  food  which  can  be  readily 
passed  into  the  intestine.  In  gastritis, 
rest  and  unirritating  food  are  again  the 
indications.  In  the  functional  dyspep- 
sias there  may  he  excess  of  acid,  de- 
ficiency of  acid  with  impaired  motility, 
or  flatulency.  For  the  acid  dyspepsia 
the  author  advises  such  foods  as  arc  most 
capable  of  absorbing  and  fixing  hydro- 
chloric acid,  that  is,  a  diet  rich  in  pro- 


356 


EXOPHTHALMIC  GOITER,  OCULAR  SYMPTOMS. 


EYE-STRAIN. 


teids.  Fats  may  also  be  taken  freely. 
If  the  acid  production  is  excessive,  milk 
alone  may  be  indicated.  If  the  acid 
secretion  is  deficient,  soups,  salts,  alco- 
hol, and  condiments  should  be  taken 
freely,  while  proteids  should  be  avoided. 
In  the  case  in  which  flatulency  is  the 
chief  symptom,  fermenting  substances 
must  be  avoided,  and  the  food  should 
be  as  dry  as  possible.  Hot  water  may 
be  taken  freely.  Hutchison  (Practi- 
tioner, May,  1905). 

EXOPHTHALMIC    GOITER,    NEW    OCULAR 
SYMPTOMS   OF. 

In  the  Gazette  Medicale  de  Nantes  for 
May  20th,  M.  Teillais  recounts  having 
met  with  three  cases  of  exophthalmic 
goiter  in  which  a  deep  brown  pigmen- 
tation of  the  cutaneous  surface  of  the 
eyelids  was  noticeable.  In  the  first  in- 
stance he  was  disposed  to  regard  the 
phenomenon  as  accidental,  but  the  sec- 
ond and  third  examples  led  him  to  look 
upon  the  pigmentation  as  intimately 
connected  with  the  cause  of  the  dis- 
ease. According  to  his  observations,  the 
brown  color  is  diffused  evenly  over  the 
lids,  being  bounded  above  by  the  eye- 
brow and  below  by  the  inferior  orbito- 
palpebral  furrow.  The  conjunctiva  is 
not  pigmented.  The  effect  of  the  pig- 
mentation is  to  heighten  the  apparent 
extent  of  the  exophthalmia  and  to  in- 
tensify the  fixity  of  gaze  observed  in  the 
subjects  of  the  disease. 

This  pigmentation,  though  it  has  been 
observed  by  others,  is  not  sufficiently 
common  to  be  of  much  diagnostic  value, 
but  it  does  seem  to  coincide  with  an 
unusual  activity  of  the  morbid  process 
that  lies  at  the  root  of  the  trouble,  for 
it  may  accompany  the  onset  of  the  mani- 
festations and  then  disappear,  or  it  may 
come  on  in  a  late  recrudescence.     It  is 


not  always  uniform,  Schroetter  having 
observed  a  case  in  which  irregularity  of  » 
its  distribution  was  a  feature,  accom- 
panied with  changes  in  the  subcutane- 
ous tissue,  both  of  which  phenomena  he 
attributed  to  an  anomaly  of  the  secre- 
tory action  of  the  thyroid  gland.  Teil- 
lais is  inclined  to  accept  the  theory  that 
exophthalmic  goiter  is  due  to  overaction 
of  the  thyroid,  while  myxcedema  depends 
on  defective  action  or  absence  of  the 
gland,  and  he  cites  in  support  of  this 
view  the  temporary  exophthalmia  that 
sometimes  results  from  excessive  thyroid 
medication.  Editorial  (New  York  Med- 
ical Journal  and  Philadelphia  Medical 
Journal,  June  10,  1905). 

EYE-STRAIN. 

By  way  of  establishing  a  control,  the 
writer  questioned,  regarding  headache, 
100  healthy  individuals  with  sight,  and 
42  patients  were  examined  who  were 
either  partially  blind  (whether  the  blind- 
ness was  acquired  or  congenital),  or  who 
suffered  from  acquired  blindness  coming 
on  at  an  age  after  the  habit  of  fixation 
and  convergence  was  well  established. 
The  third  class  examined  contained  in- 
dividuals totally  blind  since  infancy. 
From  a  study  of  these  cases,  the  follow- 
ing conclusions  were  drawn :  Among  in- 
dividuals totally  blind  since  infancy,  66 
per  cent,  were  free  from  tendency  to 
headache,  as  contrasted  with  31  per  cent, 
of  those  having  sight,  and  29  per  cent, 
of  those  with  partial  or  with  acquired 
blindness.  If  these  figures  should  prove 
constant,  the  inference  would  seem  jusi- 
fiable  that  half  the  headaches  in  health 
are  due  to  eye-strain.  The  headache, 
when  present  among  those  totally  blind 
since  infancy,  partook  sufficiently  often 
of  the  migrainoid  character  to  preclude 
the  supposition  that  all  migraine  is  due 


FATIGUE,  ALBUMINURIA  AND  GLYCOSURIA  FROM. 


357 


to  eye-strain.  The  results  of  this  study 
would  indicate  that  while  migraine  and 
migrainoid  headaches  have  a  constitu- 
tional basis,  and  while  other  factors  than 
eye-strain  may  act  as  exciting  causes, 
still,  eye-strain  is  one  of  the  most,  if  not 
the  most,  important  of  these  exciting 
causes,  and  steps  for  its  relief  are  im- 
perative. 

In  no  case  has  correction  of  refraction 
been  given  a  thorough  trial  until  (a)  the 
glasses  are  properly  centered,  (b)  their 
continued  readjustment  is  practiced,  (c) 
the  patient  looks  as  much  as  possible 
through  their  centers  instead  of  from 
side  to  side,  (d)  efforts  are  avoided  at 
straining  the  eyes  to  see  distant  objects 
with  the  glasses,  (e)  spectacles  instead  of 
eye-glasses  are  used,  and  (f)  the  use  of 
spectacles  is  constant,  not  intermittent. 
The  constitutional  headache  of  the  de- 
viate is  probably  allied  to  the  headache 
of  "brain  fag,"  but  is  out  of  all  propor- 
tion to  the  sources  of  fag.  Little  can 
here  be  expected  of  spectacles. 

In  the  proportion  in  which  obsessive 
tendencies  and  other  signs  of  constitu- 
tional peculiarity  accompany  errors  of 
refraction,  efforts  at  the  correction  of 
refraction  will  prove  unavailing  for  the 
relief  of  nervous- symptoms.  G.  L.  Wal- 
ton (Boston  Medical  and  Surgical  Jour- 
nal, June  22,  1905). 

FATIGUE,     ALBUMINURIA     AND     GLYCO- 
SURIA FROM. 

The  author  has  made  observations  and 
urinary  examinations  of  eight  men,  run- 
ners of  a  race  of  2G  kilometers,  both 
before  and  after  the  race,  and  gives  the 
results  of  his  observations.  Four  of  the 
contestants  examined  were  soldiers  and 
four  gymnasts.  The  author  ascertained 
that  before  the  race  they  were  abso- 
lutely sound  and  healthy,  and  that  ex- 

4 


animation  of  the  urine  showed  the  kid- 
neys to  be  in  a  normal  condition.  The 
course  was  over  an  ordinary  road,  with 
hills  and  hollows;  the  day  was  cold 
and  humid;  one-half  the  course  was 
with  and  one-half  against  the  wind. 
The  race  was  run  in  from  one  hour  and 
fifty-four  minutes  to  two  hours  and 
forty-five  minutes.  The  first  part  of  the 
race  was  run  easily,  without  appearance 
of  fatigue,  the  second  half  with  evident 
painful  muscular  contractions,  ending 
in  exhaustion.  After  the  race  some 
showed  transient  excitations,  others  ab- 
solute exhaustion,  but  all  were  recovered 
in  three  hours.  The  urine  examined  was 
for  less  than  three  hours.  There  was  no 
relation  between  the  amounts  of  albumin 
and  sugar  eliminated  by  each  individual ; 
there  was  no  relation  between  the  albu- 
min and  the  amount  of  sediment  for 
each  individual;  the  amount  of  urine 
varied  greatly;  the  amount  bore  no 
relation  to  the  abnormal  constituents; 
in  two  cases  a  large  amount  of  albumin 
was  present  with  a  low  specific  gravity, 
and  the  amount  of  total  solids  was  very 
low  in  those  individuals  who  were  ex- 
hausted and  their  pulses  were  very  fre- 
quent. Seven  individuals  had  albumin 
in  the  urine;  four  had  blood;  hyaline, 
granular,  and  epithelial  casts  were  pres- 
ent in  some  cases,  and  sugar  in  all  cases. 
Tbese  observations  show  more  albumin 
than  is  normally  present  from  simple 
fatigue,  and  indicate  a  new  form  of  gly- 
cosuria. Eight  days  after  the  race  all 
had  returned  to  a  normal  condition. 
The  author  believes  the  albumin  to  have 
been  due  to  complex  actions  of  the  or- 
ganism,  the  results  of  prolonged  fatigue. 
One  clement  is  the  irritation  by  poisons 
arising  from  muscular  action.  There  is 
also  a  disturbance  of  circulation,  and 
there  might  be  a  reflex  influence  from 


358 


FEMORAL  HERNIA. 


FRACTURE  OF  CARPAL  SCAPHOID. 


nervous  disturbance  clue  to  excitement. 
The  glycosuria  was  due  to  stimulation 
of  the  glycosuria  center  in  the  bulbar 
region  of  the  medulla,  by  the  excite- 
ment of  the  race.  Guglielmo  Gobbi 
(Medical  Record,  May  27,  1905). 

FEMORAL    HERNIA,    NEW    RADICAL    OP- 
ERATION FOR. 

The  author  describes  a  new  myopias  - 
tic  operation  applicable  to  large  hernia?, 
small  ruptures  being  readily  cured  by 
any  of  the  recognized  methods.  The 
sartorius  sheath  is  opened  longitudi- 
nally after  the  hernia  has  been  reduced, 
the  sac  tied  and  ablated  high  up,  and  the 
saphenous  vein  removed.  The  sartorius 
muscle  is  cut  across  in  the  middle  of  the 
thigh  and  pushed  through  an  opening  in 
its  sheath,  across  the  great  vessels,  and 
pulled  into  the  hernial  canal,  where  it  is 
attached  with  catgut  sutures  to  the  pec- 
tineal fascia,  Poupart's,  Gimbernat's, 
and  Cowper's  ligaments.  Additional  su- 
tures through  Poupart's  ligament,  the 
sartorius  and  the  pectineal  fascia  bury 
the  muscle  stump  within  the  canal.  A 
triangular  fascia  flap  is  turned  upward, 
covering  the  hernial  region.  Two  cases 
were  thus  operated  upon.  The  second 
case  died  twenty-five  days  later  from  an 
accidental  erysipelas.  At  autopsy  an  ex- 
cellent anatomical  closure  of  the  canal 
was  found.  E.  A.  Polya  (Zentralblatt 
fiir  Ohirurgie,  Nu.  IS,  1905;  American 
Journal  of  Surgery,  July,  1905). 

FRACTURE  OF  THE  CARPAL  SCAPHOID. 

"Sprains"  of  the  wrist  which  do  not 
promptly  recover  are  in  many  cases  frac- 
tures or  dislocations  of  the  carpal  bones. 
The  large  majority  of  such  carpal  in- 
juries are  either  simple  fractures  of  the 
scaphoid  or  anterior  dislocations  of  the 
semilunar  bone.    These  two  injuries  are 


frequently  combined,  and  in  such  cases 
the  proximal  fragment  of  the  scaphoid  is 
usually  dislocated  forward  with  the  semi- 
lunar. 

Simple  fracture  of  the  scaphoid  gives 
a  definite  clinical  picture,  and  may  be 
recognized  even  without  the  x-ray  by 
the  association  of  the  following  symp- 
toms, viz.,  (a)  the  history  of  a  fall  on 
the  extended  hand ;  (b)  localized  swell- 
ing in  the  radial  half  of  the  wrist-joint; 

(c)  acute  tenderness  in  the  anatomical 
snuff-box  when  the  hand  is   adducted; 

(d)  limitation  of  extension  by  muscular 
spasm,  the  overcoming  of  which  by  force 
causes  unbearable  pain. 

A  broken  scaphoid  has  little  power  of 
repair  and  appears  capable  of  but  slight 
callous  formation.  Fractures  of  the 
scaphoid  which  remain  untreated  or  are 
treated  by  massage  and  active  and  pas- 
sive motion,  generally,  if  not  always,  re- 
main ununited,  and  the  original  symp- 
toms often  persist  for  years  with  only 
slightly  abated  intensity.  Cases  of  frac- 
ture of  the  scaphoid  may  unite  if  motion 
of  the  wrist  is  prevented  during  the  first 
four  weeks  after  the  injury,  but  if  by 
this  time  no  union  has  occurred,  future 
union  is  unlikely. 

Excision  of  the  proximal  half  of  a 
fractured  scaphoid  gives  a  somewhat  bet- 
ter result  than  conservative  treatment. 
A  posterior  incision  to  the  outer  side  of 
the  tendons  of  the  extensor  communis 
digitorum  gives  an  easy  and  safe  access 
to  the  proximal  half  of  the  scaphoid. 
Passive  motion  of  the  wrist-joint  and 
active  motion  of  the  fingers  should  be 
begun  within  a  week  after  this  operation. 

The"  possibility  of  the  existence  of  a 
bipartite  scaphoid  should  be  considered 
in  interpreting  x-rays  of  simple  fracture 
of  the  scaphoid,  but  "its  occurrence  must 
be  very  rare  in  comparison  with  fracture. 


GASTRIC  CANCER,  PATHOLOGY  OF. 


359 


Anterior  dislocation  of  the  semilunar 
bone  should  be  recognized  clinically, 
even  without  the  x-ray,  by  the  association 
of  the  following  symptoms,  viz. :  (a) 
The  history  of  an  injury  of  considerable 
violence  to  the  extended  or  twisted  wrist ; 
(b)  a  silver-fork  deformity,  the  posterior 
prominence  of  which  corresponds  with 
the  head  of  the  os  magnum,  and  between 
which  and  the  lower  end  of  the  radius 
is  found  a  groove  representing  the  posi- 
tion formerly  occupied  by  the  now  ante- 
riorly dislocated  semilunar;  (c)  a  tumor 
under  the  flexor,  tendons  of  the  wrist  just 
anterior  to  the  lower  end  of  the  radius; 
(d)  a  shortened  appearance  of  the  palm 
as  compared  to  the  other  hand ;  (e)  stiff- 
ness of  the  partially  flexed  fingers,  mo- 
tion of  which,  either  active  or  passive, 
is  painful;  (f)  the  persistence  of  the 
normal  relation  of  the  styloid  processes 
of  the  ulna  and  radius  and  the  existence 
of  shortening  of  the  distance  from  the 
radial  styloid  to  the  base  of  the  first 
metacarpal. 

Recent  dislocations  of  the  semilunar 
may  be  reduced  with  good  result  even 
after  the  fifth  week  by  hyperextension 
followed  by  hyperflexion  over  the  thumbs 
of  an  assistant  held  firmly  in  the  flexure 
of  the  wrist  on  the  semilunar. 

Irreducible  dislocations  demand  ex- 
cision of  the  semilunar  and  the  whole 
or  a  portion  of  the  scaphoid  if  there  is 
a  coincident  fracture  of  the  latter.  E. 
A.  Codman  and  H.  M.  Chase  (Annals 
of  Surgery,  June,  1905). 

GASTRIC    CANCER,    PATHOLOGY    OF. 

Among  the  early  signs  of  cancor  the 
writer  mentions  the  small  clots,  less  than 
the  head  of  a  pin  in  size,  generally 
merely  little  black  points,  which  are 
found  in  the  siphoned-out  stomach  con- 
tent.     These   clots    are   frequently    en- 


countered in  case  of  cancer  of  the  py- 
lorus, although  they  may  require  the 
microscope  for  their  differentiation. 
Hemorrhage  in  case  of  mere  achylia 
gastrica  is  passed  along  out  of  the  stom- 
ach too  rapidly  for  the  blood  to  form 
into  clots.  These  clots  have  proved  to 
be  the  very  earliest  symptom  of  cancer 
in  the  stomach,  in  the  author's  experi- 
ence, preceding  the  discovery  of  lactic 
acid.  The  presence  of  Oppler's  bacillus 
adds  to  the  probability  of  cancer,  as 
both  require  a  long  sojourn  in  the  stom- 
ach. He  has  not  found  that  the  patients 
lose  in  weight,  unless  there  is  marked 
motor  insufficiency  with  the  cancer.  A 
cancer  of  the  lesser  curvature  may  exist 
for  months  and  years  without  appre- 
ciable loss  in  weight.  With  proper 
feeding,  there  may  even  be  a  gain  in 
weight. 

The  author  believes  that  it  is  almost 
impossible  to  distinguish  between  a  be- 
nign ulcer  and  cancer  of  the  pylorus, 
and  the  possibility  of  malignant  trans- 
formation of  the  ulcer  should  not  be 
forgotten.  It  is  advisable  to  raise  the 
general  tone  by  dietetic  and  other  meas- 
ures before  attempting  any  intervention 
on  a  pyloric  cancer.  If  this  is  impos- 
sible, gastroenterostomy  should  be  done 
first,  and  the  radical  operation  should 
follow  after  an  interval  for  recuperation. 
The  benefit  is  sometimes  surprisingly 
fine,  even  when  a  radical  operation  is  not 
practicable. 

The  diagnosis  of  cancer  of  the  nor- 
mally located  lesser  curvature  is  more 
difficult,  and  this  form  of  malignant 
disease  is  the  despair  of  surgery.  Cer- 
tain surgeons  have  reported  compara- 
tively long  survivals  after  operations,  but 
analysis  of  their  cases  will  show  that  the 
survivals  are  no  more  than  the  average 
life  expectancy  of  cancers  of  the  lesser 


360 


GOUT,  CARBON  FACTOR  IN:    HYPERPYR^MIA. 


curvature  when  left  untouched.  Even  at 
best,  the  definite  cures  are  less  than  1 
per  cent.  Exploratory  puncture  has  a 
high  mortality,  and  is  very  depressing  to 
the  patient,  generally  convincing  him  of 
the  absolute  hopelessness  of  his  condi- 
tion. As  a  rule,  it  may  be  said  that  a 
good  Congo  reaction,  with  increased 
amount  of  stomach  content  retained,  in- 
dicates that  the  radical  removal  of  the 
neoplasm  is  still  possible,  and  gastro- 
enterostomy is  indicated.  If  the  Congo 
reaction  is  negative,  with  increased 
amount  of  stomach  content  retained, 
then  gastroenterostomy  to  relieve  the 
motor  insufficiency  is  indicated.  If  the 
Congo  reaction  is  negative,  and  if  there 
is  no  retention  of  stomach  content,  and 
the  lesser  curvature  is  in  the  normal 
location,  then  any  surgical  interference 
is  useless,  except  to  relieve  severe,  urg- 
ent symptoms,  when  there  is  nothing 
to  lose  and  everything  to  gain.  Von 
Tabora  (Deutsche  Medizinische  Woch- 
enschrift,  April  20,  1905 ;  Journal  of 
the  American  Medical  Association,  June 
3,  1905). 

GOUT,  THE  CARBON  FACTOR  IN:  HY- 
PERPYR-ffiMIA. 
A  new  view  on  the  nature  of  gout  is 
presented  by  the  author,  his  theory  be- 
ing that  the  retention  in  the  body  of  car- 
bonaceous material  is  largely  concerned 
in  the  causation  of  the  disease.  Nor- 
mally, there  must  be  a  systematic  equi- 
librium between  the  carbonization  of  the 
blood  from  the  body's  carbon  intake  and 
its  decarbonization,  but  the  author  be- 
lieves that  at  times  this  balance  may  be 
disturbed  and  carbonaceous  material  ac- 
cumulate in  the  blood  to  an  ultraphys- 
iologic  or  pathologic  degree.  To  this 
hypothetic  state  he  applies  the  term  hy- 
perpyraemia,   and   to   the   normal   state, 


the  term  pyrgemia.  The  exact  nature  of 
the  hyperpyramric  load  is  undetermined, 
but  we  have  a  right  to  suppose  that  it  is 
carbonaceous,  and  it  certainly  is  not  a 
glycosuria.  The  means  by  which  hyper- 
pyraemia  may  be  dispersed  are  numerous, 
and  include  bilious  attacks,  migraine, 
gastralgia  with  anorexia,  asthma,  major 
epilepsy,  and  acute  articular  gout.  Some 
of  these  operate  through  increased  ex- 
penditure, others  through  restricting  the 
intake,  and  their  action  is  called  by  the 
author,  carbonization.  In  order  to  prove 
that  acute  articular  gout  depends  upon 
hyperpyra3mia,  the  author  draws  upon 
evidence  obtained  by  a  consideration  of 
the  action  in  gout  of  such  factors  as  the 
dietetic  treatment,  exercise,  temperature, 
fat  formation,  plumbism,  haamorrhage, 
etc.,  and  he  then  shows  that  the  parox- 
ysms represent  an  acarbonizing  process. 
The  mechanism  of  acute  articular  gout, 
according  to  this  supposition,  involves  an 
interdependence  between  hyperpyraemia 
and  uricsemia  through  which  the  kidneys 
at  times  become  more  active  in  excreting 
uric  acid;  that  is,  the  renal  disability 
depending  on  hyperpyraemia  is  termin- 
ated by  acarbonization  of  the  blood. 

The  author  summarizes  as  follows  his 
view  of  the  steps  in  acute  gout:  1.  Hy- 
perpyraemia from  excess  of  carbonaceous 
income  or  deficiency  of  carbonaceous  ex- 
penditure. 2.  Progressive  accumulation 
of  uric  acid  in  the  blood:  uricaemia.  3. 
Deposition  of  a  portion  of  the  uric  acid 
in  a  joint.  4.  Acute  arthritis.  5.  Py- 
rexia involving  increased  combustion,  fi. 
Acarbonization  of  the  blood.  7.  Free 
renal  elimination  of  uric  acid  retained 
in  the  blood.  8.  Recovery  by  the  blood 
of  its  solvent  power  for  uric  acid.  9. 
Reabsorption  of  the_extravascular  artic- 
ular deposits  of  uric  acid.  Thus  the 
acute  gouty  paroxysm  may  be  regarded 


HAEMORRHOIDS,  EXTERNAL. 


HEART  MUSCLE,  TEST  FOR. 


361 


as  a  "pathologic  function" — as  a  con- 
servative reinforcement  of  inadequate 
physiologic  function ;  arid  uric  acid  may 
be  regarded  as  an  essential  instrument 
therein.  Francis  Hare  (Medical  Record, 
June  17,  1905). 

HEMORRHOIDS,  EXTERNAL,  PATHOLOGY 
OF. 

The  walls  of  the  hemorrhoidal  veins 
must  undergo  some  pathological  altera- 
tions before  an  external  hemorrhoid  can 
develop.  These  pathological  changes  be- 
ing present,  any  undue  pressure  may 
cause  an  aneurismal  dilatation  of  the 
vein.  The  internal  coat  of  the  vessel  be- 
ing altered,  there  is  more  tendency  for 
coagulation  of  blood  with  the  formation 
of  a  clot.  The  sexual  activity  of  an  in- 
dividual increases  the  intra-venous  pres- 
sure and  favors  the  development  of  the 
sanguineous  tumor.  It  is  therefore  a 
disease  of  adult  life.  The  clot  is  always 
found  in  the  diseased  vessel  and  never  in 
the  connective  tissue  outside  of  the  ves- 
sel. L.  J.  Krouse  (Lancet-Clinic,  June 
24,  1905). 

HAY  FEVER,  MASSAGE  OF  THE  NOSE  IN. 
The  author  reports  that  he  has  abso- 
lutely cured  eight  hay  fever  victims  by 
massage  of  the  mucous  lining  of  the  nose. 
By  this  means  he  was  able  not  only  to 
cure  an  existing  attack,  but  to  prevent 
its  recurrence  in  following  seasons.  The 
sensitive  mucosa  is  first  anaesthetized  by 
swabbing  it  with  a  mixture  of  1  part 
cocaine  and  .01  part  adrenalin  in  10 
parts  distilled  water,  using  a  cotton- 
wound  nose  sound  for  the  purpose.  The 
massage  is  done  with  this  sound  dipped 
in  a  10  per  cent,  antiseptic  oil.  The 
author  commences  with  slow,  light  strok- 
ing of  the  inferior  turbinate,  gradually 
increasing  the  rapidity  and  the  pressure 


and  passing  to  the  middle  turbinate,  and 
thence,  if  possible,  to  the  superior,  re- 
turning over  the  mucosa  of  the  septum. 
The  massage  is  completed  in  two  or  three 
minutes  at  first  and  in  from  three  to 
four  as  the  patient  becomes  used  to  it. 
The  procedure  is  repeated  through  each 
nostril  every  day,  supplemented,  if  nec- 
essary, by  instillation  of  diluted  lauda- 
num in  the  conjunctival  sac.  The  writer 
thinks  that  it  is  more  logical  to  remove 
the  cause  than  to  attempt  to  combat  the 
established  affection  by  antitoxin  or  oth- 
erwise. A.  Denker  (Miinchener  medi- 
zinische  Wochenschrift,  May  9,   1905). 

HEART  MUSCLE,  FUNCTIONAL  TEST  FOR. 
The  earlier  an  insufficiency  of  the 
cardiac  muscle  is  recognized,  the  better 
the  prognosis  of  the  case.  According 
to  the  writer,  insufficiency  can  be  deter- 
mined long  before  there  are  valvular 
changes,  and  the  method  described  by 
him  for  this  purpose  is  very  easily  car- 
ried out.  .  He  counts  the  patient's  pulse 
and  then  holding  him  by  elbow  and  wrist 
of  flexed  forearm,  the  patient  is  told  to 
extend  this  as  slowly  as  he  possibly  can, 
his  attention  being  fixed  on  the  move- 
ment; the  right  forearm  is  usually 
chosen  as  having  a  finer  innervation. 
The  patient  must  not  contract  his  mus- 
cle, nor  open  the  arm  too  quickly;  nor 
must  the  physician  •  aid  the  movement 
in  the  slightest.  Flexion  and  extension 
are  performed  several  times,  and  the 
pulse  again  counted.  In  the  ense  of  a 
normal  heart  the  pulse-rate  will  be  the 
same  or  slightly  increased  ;  in  the  case 
of  an  insufficiently  strong  muscle,  the 
pulse-rate  will  be  lowered,  the  pulse 
fuller  and  slower.  In  abnormally  rapid 
hearts  ho  has  known  the  pulse  to  slow 
;i<  much  as  40  beats.  The  author  con- 
siders this  a  certain  means  of  determin- 


362 


INFANTILE  MARASMUS,  FAT  QUESTION  IN  RELATION  TO. 


ing  at  a  very  early  date  an  insufficiency 
of  the  cardiac  muscle.  In  cases  of  athe- 
roma, diabetes,  nicotine  poisoning,  etc., 
he  has  made  a  diagnosis  of  muscular  in- 
sufficiency, no  other  symptom  pointing 
to  its  existence;  later  developments 
justified  the  diagnosis.  In  fatty  heart 
the  result  was  always  inconstant ;  in  the 
hypertrophied  heart  of  chronic  nephritis 
the  result  was  always  negative,  and  the 
author  believes  such  a  muscle  to  be 
healthy,  even  though  enlarged.  M.  Herz 
(Deutsche  Medicinische  Wochenschrift, 
Bd.  xxxi,  Nil.  6,  1905 ;  American  Medi- 
cine, June  3,  1905). 

INFANTILE  MARASMUS,  THE  FAT  QUES- 
TION IN  ITS  RELATION  TO  THE  PRO- 
DUCTION AND  CURE  OF. 

Food  physically,  chemically,  or  bio- 
logically unsuited  to  the  needs  of  the 
delicate  infantile  organism  is  the  most 
frequent  instigator  of  the  gastrointes- 
tinal disturbances,  which  again  are  the 
usual  forerunners  of  athrepsia  infantum. 
In  the  overwhelming  majority  of  in- 
stances, wasting  and  atrophy  supervene 
in  bottle-fed,  that  is,  in  artificially  nour- 
ished children.  A  fat  compound  con- 
sisting of  10  per  cent,  of  volatile  acids 
cannot  be  a  rational  substitute  for  a 
fatty  nutrient.  The  most  important  of 
these  volatile  fatty  acids  is  butyric  acid, 
whose  very  presence  in  the  fat  of  human 
milk  has  been  denied  by  some  investi- 
gators. The  more  the  fat  output  by  the 
faeces  approaches  the  minimum  figure, 
the  better  the  gastro-intestinal  organ* 
perform  their  work. 

Milk  fat,  chemically  speaking,  is  a 
compound  of  mixed  glycerine  esters.  A 
certain  degree  of  decomposition  of  the 
neutral  milk  fat  into  glycerine  and  fatty 
acid  occurs  already  in  the  stomach.  A 
reconversion  into  neutral  fats  must  take 


place  in  the  intestinal  wall.  The  vola- 
tile acids  appearing  in  the  fasces  are  the 
result  of  carbohydrate  fermentation  in 
the  intestines.  Acetone  of  supposedly 
intestinal  fermentation  has  not  infre- 
quently been  accused  of  being  the  pro- 
motor  of  periodical  vomiting.  The  vola- 
tile fatty  acids  as  furnished  by  the  fat 
of  cow's  milk  are  very  decided  irritants 
of  the  delicate  intestinal  mucosa  of  the 
infant.  The  fatty  constituents  of  the 
milk  furnish  the  source  of  the  patho- 
logic condition  or  prevent  its  ameliora- 
tion. 

The  author  advises  the  use  of  the  fats 
furnished  by  the  yolk  of  the  hen's  egg. 
Yolk-fat  is  the  ideal  fat  for  infants  suf- 
fering from  chronic  gastro-intestinal  dis- 
turbances. The  writer  mentions  some  of 
the  factors  which  prompted  him  to  sub- 
stitute yolks  for  milk-fat  in  the  treat- 
ment of  under-nourished  infants  afflicted 
with  gastro-intestinal  disease.  Yolk-fat, 
in  its  native  state,  in  suitable  amounts 
and  admixture,  is  well  borne  and  well 
liked  by  the  majority  of  infants  (idio- 
syncrasy is  rather  due  to  the  white  than 
to  the  yolk  of  the  egg).  The  great  ab- 
sorbability of  yolk-fat,  the  residue  left 
by  yolk-fat  in  the  fasces,  is  smaller  than 
that  of  any  other  animal  fat.  The  fat- 
components  of  the  yolk  of  the  hen's  egg, 
palmitin,  stearin,  and  olein.  yield  no,  or 
hardly  any,  volatile  fatty  acids,  and  con- 
sequently give  no  occasion  to  the  pro- 
duction of  the  acetone  bodies.  The  large 
amount  of  lecithin  contained  in  the  yolk 
tends  to  the  restoration  of  nerve  force, 
and  acting  as  a  general  reconstituent 
ameliorates  the  cachectic  condition  ;  the 
occurrence  in  the  yolk  of  a  diastatic  fer- 
ment assisting  in  the  conversion  of  amy- 
loid substances.  The  property  of  the 
yolk  is  to  stimulate  -the  digestive  secre- 
tions. 


INFANTILE  MARASMUS,  FAT  QUESTION  IN  RELATION  TO. 


363 


The  entire  egg  has  been  frequently 
employed  by  the  pediatrist,  the  yolk 
alone  but  rarely.  There  is  no  consensus 
of  opinion  as  regards  the  digestibility  of 
the  whole  egg  in  the  infantile  alimen- 
tary tract.  Some  extol  the  egg  as  an 
important  and  readily  digestible  nutrient 
in  early  life,  while  others  are  absolutely 
opposed  to  its  utilization.  The  total  egg 
is  badly  borne  by  the  average  nursling. 
Constitutional  aversion  to  eggs,  in  the 
author's  opinion,  is  solely  due  to  the 
white  of  the  egg.  He  has  never  met 
with  it  when  raw,  fresh  yolks  alone  were 
partaken  of.  The  white  of  the  egg, 
which  exhibits  the  bulk  of  the  hitter's 
proteid  substances,  is  apt  to  yield  undue 
amounts  of  hydrogen  sulphide  and  am- 
monia. This  is  particularly  liable  to 
oceir  in  instances  of  retarded  digestion 
of  whatever  causation.  The  yolks  leave 
the  stomach  in  a  very  short  time  and  do 
not  contain  the  elements  giving  rise  to 
hydrogen  sulphide  to  the  degree  that  the 
latter  could  produce  any  untoward  re- 
sults. The  author  suggests  the  use  of 
yolks  only  in  such  pathologic  conditions 
which  may  lead  to  athrepsia  infantum, 
and  which  are  due  to,  or  aggravated  by, 
the  fat  constituents  of  the  nourishment. 

There  are  two  essentials  which  must 
be  followed  when  good  shall  result  from 
the  ingestion  of  yolks:  First,  the  yolk- 
fat  must  completely  replace  the  milk- fat. 
Second,  the  amount  of  yolk-fat,  without 
being  in  excess,  must  be  adequate;  that 
is,  it  must  conform  to  the  calorie  and 
nutritive  demands  of  the  organism. 

By  withholding  (be  milk-fat  from  the 
nutriment,  the  eventual  etiologic  or  ag- 
gravating factor  of  the  underlying  dis- 
ease is  removed,  or  a  fat-compound 
which,  in  the  specific  instance,  has  dem- 
onstrated its  inadequacy  in  supplving 
the  systemic  demands.     Substituting  for 


it  yolk-fat,  a  fat-combination  is  fur- 
nished to  the  deteriorated  or  diseased  in- 
fantile organism  which  does  not  yield 
butyric  acid  or  its  derivatives,  and  which 
it  is  able  to  anabolize  in  the  great  ma- 
jority of  instances.  Untoward  results 
obtained  by  yolks  in  the  treatment  of 
the  under-nourished,  and  more  especially 
of  athrepsia  infantum,  in  a  great  meas- 
ure are  due  to  the  non-withdrawal  from 
the  nourishment  of  the  mischievous 
milk-fat. 

A  marasmic  infant,  in  spite  of  abun- 
dant milk-fat,  may  continue  to  decline. 
It  is  evident,  therefore,  that  the  child 
does  not  properly  anabolize  the  fatty 
substances  introduced  by  the  milk-fat. 
When  this  is  replaced  by  another  fat- 
compound,  as  yolk,  for  instance,  it  is 
not  the  amount  of  the  latter  but  its 
physico-chemical  constitution  and  its 
absorbability  which  primarily  count. 
All  that  seems  necessary  in  the  dietetic 
management  of  marasmic  children  is  to 
start  with  a  very  small  amount  of  yolk, 
probably  a  quarter  of  a  teasponful  for 
each  feeding,  and  to  very  slowly  increase 
it  to  the  physiologic  requirements  of 
each  individual  case.  The  correspond- 
ing caloric  and  nutritive  value  of  both 
fat  compounds  cannot  be  accurately  cal- 
culated. 

The  overwhelming  majority  of  cases 
of  infantile  marasmus  occur  in  artifi- 
cially-nourished children.  The  gastro- 
intestinal disturbances  underlying  in- 
fantile atrophy  are  very  often  due  to  the 
character  of  the  food  and  not  infre- 
quently  to  its  fatty  contents.  While  the 
quantity  of  fa1  aliment  has  found  fre- 
quent practical  consideration,  the  chem- 
ical character  of  the  fatly  substances  en- 
tering into  the  baby's  nutriment  have 
hardly  ever  been  inquired  into  by  the 
clinician, 


364 


INFERIOR  TURBINATED  BONE,  DISORDERS  OF. 


The  composition  of  the  fat  of  cows' 
milk  is  greatly  at  variance  with  that  of 
the  fat  of  human  milk,  differing  espe- 
cially in  its  far  greater  contents  of  vola- 
tile fatty  acids  among  which  butyric  acid 
is  the  most  important.  Butyric  acid  is 
the  mother  substance  of  the  acetone  bod- 
ies to  the  presence  of  which  a  number  of 
disorders  to  which  the  infant  is  prone 
have  been  ascribed  by  various  observers. 
Butyric,  caproic,  caprylic,  and  capric 
acids  are  contained  in  the  fat  of  cows' 
milk  in  from  six  to  eight  times  the 
amount  in  which  they  are  present  in  that 
of  human  milk. 

The  infantile  organism  cannot  cope 
successfully  with  the  fat  of  cows'  milk, 
even  in  a  mere  physical  sense.  This  is 
evidenced  by  the  decidedly  smaller  ab- 
sorption of  the  fat-compound  derived 
from  cows'  milk  than  from  human  milk. 
The  occurrence  in  the  faeces  of  absolutely 
and  relatively  larger  amounts  of  fat  of 
cows'  milk  is  prima  facie  evidence  of  its 
more  incomplete  utilization  by  the 
youthful  organism. 

As  the  physical  and  chemical  proper- 
ties of  the  milk-fat  are  dependent  upon 
the  absolute  and  relative  amount  of  lower 
and  higher  and  uncombined  fatty  acids, 
it  is  evident  that  the  vast  discrepancy 
existing  between  the  constitution  of 
cows'  milk-fat  and  mothers'  milk-fat 
cannot  be  overcome  by  any  possible  mod- 
ification of  the  former. 

Apart  from  the  butyric  acid  origin  of 
the  acetone  bodies,  the  volatile  fatty 
acids  as  furnished  by  the  fat  of  cows' 
milk  are  decided  irritants  of  the  delicate 
intestinal  mucosa  of  the  infant.  The 
ingestion  of  these  acids  is,  therefore,  the 
primary  cause  of  many  instances  of  gas- 
trointestinal irritation  and  disease  fol- 
lowed by  under-nutrition,  bodily  retro- 
gression, and  athrepsia. infantum. 


Alteration  in  the  fat-supply  as  exer- 
cised to-day  is  almost  without  exception 
a  quantitative  one,  consisting  of  reduc- 
tion, suspension,  and  even  increased  sup- 
ply of  fat-aliment. 

Withdrawal  of  milk-fat  in  hand-fed 
infants  frequently  results  in  cessation  of 
the  local  disturbance.  It  is,  however,  ob- 
vious that  the  infant  cannot  exist  for 
any  length  of  time  without  fatty  ingesta 
of  some  kind.  Furthermore,  the  in- 
cipient marasmic  condition  cannot  be  re- 
lieved unless  a  sufficient  amount  of  as- 
similable fats  yielding  but  insignificant 
amounts  of  volatile  fatty  acids  is  added 
to  the  nutriment. 

Yolk-fat  seems  to  be  the  ideal  fat  for 
infants  suffering  from  chronic  gastro- 
intestinal disturbance  together  with 
latent  or  even  pronounced  athrepsia  in- 
fantum. Yolks  should  be  used  only  in 
those  pathologic  conditions  which  may 
lead  to  athrepsia  infantum  and  in  those 
which  are  due  to,  or  aggravated,  by  the 
fat  constituents  of  the  nourishment. 

There  are  two  essentials  which  must  be 
followed  for  good  results  from  the  inges- 
tion of  yolks,  viz.,  the  yolk-fat  must  com- 
pletely replace  the  milk-fat,  and  the 
amount  of  yolk-fat,  without  being  in  ex- 
cess, must  be  adequate,  that  is,  it  must 
conform  to  the  caloric  and  nutritive  de- 
mands of  the  organism.  The  electrical 
conductivity  of  skimmed  milk  plus  phys- 
iological amounts  of  yolk-fat  is  probably 
somewhat  greater  than  that  of  native 
milk.  Heinrich  Stern  (Archives  of 
Pediatrics,  June,  1905). 

INFERIOR     TURBINATED     BONE,     DISOR- 
DERS OF. 

Hypertrophy  and  deformities  of  the 
inferior  turbinated  bone  may  interfere 
with  nasal  respiration  and  also  with 
drainage.     They   give   rise  to  pressure 


INSECT  STINGS. 


INTESTINAL  PERISTALSIS. 


365 


symptoms  and  subsequently  to  mental 
depression,  and  further,  prevent  proper 
intranasal  hygiene.  True  hypertrophy 
must  not  be  confounded  with  congestion 
or  inflammation. 

Hypertrophic  tissue  and  portions  of 
the  bone  should  be  removed  when  symp- 
toms and  appearances  indicate  pressure, 
altered  secretions,  interference  with 
drainage,  and  the  normal  functions  of 
the  nose.  Escharotics  should  never  be 
employed  and  the  galvanic  cautery  is  of 
doubtful  efficiency.  A  clean  cut  by 
means  of  specially  devised  scissors 
through  both  soft  tissue  and  bone  is  by 
far  the  best  method  for  operation.  The 
snare  offers  the  best  method  for  the  re- 
moval of  posterior  hypertrophies. 

The  resultant  wound  should  be  pro- 
tected by  a  thin  layer  of  gauze,  moistened 
with  a  13  per  cent,  solution  of  aceto-tar- 
trate  of  aluminum,  to  which  may  be 
added  a  few  drops  of  weak  adrenalin 
solution.  W.  C.  Phillips  (American 
Journal  Medical  Sciences,  July,  1905). 

INSECT  STINGS. 

The  author  relates  about  a  dozen  cases 
of  stings  followed  by  severe  general 
symptoms,  fatal  in  some  instances.  The 
symptoms  involve  the  respiratory,  diges- 
tive, nervous,  and  secretory  systems,  and 
are  distinguished  by  the  rapidity  with 
which  they  develop  and  their  intensity. 
The  action  of  the  poison  of  the  hymenop- 
tera  is  frequently  more  subtle  and  gen- 
erally more  rapid  than  that  of  snake  or 
viper  venom,  which  it  resembles  in  many 
respects.  Antivenin  might  be  used  if 
the  symptoms  did  not  develop  with  such 
rapidity.  The  most  effectual  treatment 
is  by  niding  nature  to  eliminate  the  poi- 
son through  the  sweat,  urine,  saliva,  and 
fseces.  Her  efforts  in  tin's  direction  arc 
plainly    evident    in    the    symptoms    ob- 


served, and  the  physician  should  coop- 
erate by  administering  diffusible  stimu- 
lants, diuretics,  sialagogues,  and  purga- 
tives. Experimental  and  clinical  experi- 
ence seems  to  indicate  that  the  kidneys 
are  the  chief  emunctories  concerned. 
Among  the  general  symptoms  cited  in 
the  cases  described  by  the  writer  are 
oedema  suggesting  erysipelas,  eruptions, 
syncope,  nausea,  vomiting,  diarrhoea,  and 
irregularities  in  the  pulse. 

Local  treatment  should  be  by  the  im- 
mediate application  of  lime  water,  salt 
or  strong  brine,  supplemented  by  a  hot 
aromatic  drink  containing  some  diffusi- 
ble stimulant  such  as  ether  or  pepper- 
mint, to  favor  the  elimination  of  the 
venom  through  the  skin  and  kidneys. 
Vinegar  water  or  ammonia  usually  neu- 
tralizes bee  stings.  The  little  blister 
formed  by  the  clear  venom  deposited  by 
the  insect  should  be  carefully  removed 
without  extracting  the  sting  beforehand 
and  without  the  slightest  pressure  on  the 
latter,  as  this  would  merely  squeeze  out 
more  of  the  venom.  Attempts  to  induce 
immunity  by  submitting  to  the  stings  of 
bees  have  been  successful  in  some  in- 
stances to  a  certain  extent.  P.  Pabre 
(Bulletin  de  1' Academic  de  Medecine, 
Paris,  year  lxix.  No.  21 ;  Journal  of  the 
American  Medical  Association,  July  1. 
1905). 

INTESTINAL  PERISTALSIS. 

The  authors  have  studied  the  effects  of 
various  agents  on  the  intestinal  move- 
ments, confirming  Ott's  earlier  findings 
that  adrenalin  arrests  the  pendulum 
movements  and  causes  relaxation  of  the 
longitudinal  musculature,  and  that 
splenic  extract  increases  the  peristaltic 
action  both  in  frequency  and  force.  In- 
fusion of  the  pancreas  was  found  to  relax 
the  muscles  and  slow  the  movements  of 


366 


ISCHOCHYMIA,  TREATMENT  OF. 


the  intestine,  at  the  same  time  increasing 
the  force  of  the  contraction.  Experi- 
ments were  also  made  with  other  animal 
extracts,  ovary,  testes,  parotid  and  mam- 
mary glands,  pituitary,  thyroid,  brain, 
and  spinal  cord,  but  they  had  no  marked 
effect  on  intestinal  peristalsis.  The  thy- 
mus seemed  occasionally  to  increase  its 
force.  Sodium  citrate  increased  the 
force  of  the  contraction,  which  was 
slowed,  weakened,  and  made  irregular 
by  the  addition  of  calcium  chloridQ,  thus 
agreeing  with  McCallum's  observations. 
It  is  suggested,  therefore,  that  calcium  is 
indicated,  in  agreement  with  McCallum's 
and  with  Loeb's  theories  of  the  action 
of  the  calcium  ions,  in  persistent  diar- 
rhoea of  nervous  and  hysterical  cases. 
A  series  of  experiments  were  made  test- 
ing the  effects  of  various  drugs,  atropine, 
eserine,  nicotine,  muscarine,  pilocarpine, 
strychnine,  curare,  morphine,  etc.,  on 
intestinal  peristalsis  and  also  on  their 
antagonistic  action  to  each  other,  which 
are  discussed  in  detail,  especially  their 
relations  to  the.  nervous  supply  of  the 
intestine,  and  the  conclusion  is  deduced 
that  the  automatic  movements  of  the 
bowel  are  not  myogenic,  but  are  depend- 
ent, as  shown  by  Magnus,  on  Auerbach's 
plexus.  The  action  of  certain  organic 
bodies,  bile,  albumoses,  peptones,  leucine, 
tyrosine,  was  also  tested;  they  all  in- 
creased the  force,  and  most  of  them  also 
the  frequency  of  the  intestinal  move- 
ments. It  is  evident,  the  authors  re- 
mark, that  the  products  of  proteid  di- 
gestion are  active  stimulants  of  peristal- 
sis. A  good  digestion  predisposes  to  reg- 
ular evacuation  of  the  bowels,  and  this 
accounts  for  the  habitual  constipation  of 
dyspeptics.  Isaac  Ott  and  J.  P.  ITlman 
(Journal  of  the  American  Medical  Asso- 
ciation, June  17,  1905). 


ISCHOCHYMIA,    TREATMENT    OF. 

There  are  two  ways  of  treating  ischo- 
chymia:  (1)  Dietetic  and  medicinal 
measures  (rectal  alimentation,  fluid  diet, 
lavage  of  the  stomach,  bismuth,  etc.)  ; 
(2)  operative  procedures  (gastroenter- 
ostomy, pyloroplasty).  These  two  meth- 
ods of  treatment  do  not  antagonize  but 
supplement  one  another.  The  indica- 
tions for  both  are  fairly  well  determined, 
where  one  ceases  the  other  begins. 

Since  in  by  far  the  larger  number  of 
cases  of  ischochymia  a  stenosis  of  the 
pylorus  is  present,  the  ideal  method  of 
treatment  would  consist  in  forming  a 
new  passage  for  the  exit  of  the  chyme 
from  the  stomach.  Yet  surgical  inter- 
vention ought  not  to  be  recommended 
■immediately  in  every  case,  as  a  certain 
element  of  risk  is  still  attached  to  this 
procedure.  The  mortality  of  gastro- 
enterostomy and  pyloroplasty  is  rather 
high.  It  varies  among  different  sur- 
geons and  in  different  countries  between 
5  per  cent,  and  20  per  cent.  If  we  as- 
sume 10  per  cent,  as  the  average  (among 
the  writer's  own  patients  the  mortality 
was  much  higher),  we  see  that  we  have 
a  mortality  percentage  that  ought  to  be 
taken  into  consideration  in  advising  an 
operation. 

The  indications  for  medical  and  sur- 
gical treatment  of  ischochymia  may  be 
placed   as   follows : — 

1.  Benign  ischochymia  requires,  first, 
medical  treatment;  if  this  be  unsuccess- 
ful, i.e.,  if  after  a  longer  period  of  treat- 
ment the  fasting  stomach,  on  a  fluid  diet, 
is  not  empty,  but  contains  food  rem- 
nants, an  operation  is  advisable. 

2.  Surgical  intervention  is  also  indi- 
cated in  benign  ischochymia  whioh  has 
developed  subsequent  to  a  condition  of 
continuous  hypersecretion  of  gastric 
juice  (preceded  by  haemorrhage  or  not). 


LARYNGEAL  PARALYSES  AND  THEIR  DIAGNOSTIC  VALUE. 


367 


3.  Malignant  ischochymia  or  one  of 
dubious  nature  in  which,  however,  a 
thickening  of  the  pylorus  is  found, 
should  also  be  treated  surgically  (gas- 
troenterostomy, and,  if  possible,  resec- 
tion of  the  pylorus). 

Benign  ischochymia  should  first  be 
treated  by  dietetic  and  medicinal  meas- 
ures, because  many  patients  with  appa- 
rently grave  cases  of  this  kind  frequently 
get  well  in  this  way;  and  second,  be- 
cause an  operation  is  a  procedure  con- 
nected with  a  considerable  amount  of 
danger,  and  should  be  suggested  only 
when  absolutely  necessary. 

Those  cases  of  ischochymia  with  pre- 
ceding gastro-succorrhcea  form  an  ex- 
ception, and  require  operation  sooner, 
because  they  are  generally  complicated 
with  active  ulcerated  processes  in  the 
pyloric  region,  and  because  they  are  fre- 
quently accompanied  by  severe  compli- 
cations (perforations  and  severe  haemor- 
rhages). The  danger  from  operation  in 
this  variety  of  ischochymia  is  less  than 
that  from  possible  complications,  there- 
fore an  operation  is  indicated. 

As  regards  the  third  class  of  cases,  re- 
ferring to  malignant  ischochymia,  oper- 
ative procedures  must  be  recommended, 
first,  because,  these  cases  grow  pro- 
gressively worse,  and  second,  because  a 
possibility  of  a  radical  cure  (either  by 
extirpation  of  the  tumor  or  in  conse- 
quence of  the  disappearance  of  the  same 
after  gastroenterostomy) ,  even  if  re- 
mote, is  given.  Max  Einhorn  (Ameri- 
can Medicine,  June  3,  1905). 

LARYNGEAL     PARALYSES     AND     THEIR 
DIAGNOSTIC  VALUE. 

In    a    knowledge    of    the    appearance 

and  of  the  causes  of  laryngeal  paral- 
yses may  be  found  an  important  aid 
to    diagnosis    in    many    obscure    cases. 


Many  laryngeal  palsies  give  rise  to 
no  symptoms  whatever,  and  cannot  be 
diagnosticated  or  even  suspected  without 
the  use  of  the  laryngoscope.  In  the  com- 
mon form  —  abductor  paralysis  —  there 
need  be  no  disturbance  of  vocalization. 
When  abductor  paralysis  has  occurred 
the  affected  cord  lies  in  the  middle  line; 
during  phonation  the  sound  cord  ad  ducts 
to  meet  it  and  the  larynx  appears  nor- 
mal. But  on  inspiration  the  affected 
cord  remains  stationary,  while  the  sound 
one  is  drawn  outward  and  backward. 
The  voice  is  not  altered,  but  there  is 
some  dyspnoea  on  active  exertion;  in 
children  this  may  be  so  severe  as  to  neces- 
sitate tracheotomy.  In  bilateral  paral- 
ysis the  cords  are  drawn  closer  together 
on  inspiration,  and  dyspnoea  is  a  marked 
symptom.  It  is  inspiratory  and  is  ac- 
companied by  stridor.  As  severe  parox- 
ysmal exacerbations  may  occur  at  any 
time  and  prove  fatal,  tracheotomy  should 
always  be  done  as  a  precautionary  meas- 
ure. Phonation  is  good,  but  has  a 
breathless  character. 

The  lesion  causing  the  paralysis  may 
be  situated  (1)  in  the  medulla;  (2)  at 
the  base  of  the  brain  ;  (3)  in  the  vagus; 
or  (4)  in  the  recurrent  laryngeal  nerve. 
In  the  first  two  classes  neighboring  nu- 
clei are  prone  to  be  affected  as  well,  so 
that  there  is  usually  concomitant  paral- 
ysis of  the  soft  palate,  uvula,  and 
pharynx.  Persistent  frequency  of  the 
pulse  is  an  important  sign  of  bulbar  dis- 
ease. Bulbar  paralyses  are  frequently 
bilateral,  tabes  dorsalis  being  the  com- 
monest cause  of  such  paralyses.  Syph- 
ilitic nuclear  disease,  gummata  at  tin- 
base  of  the  brain,  and  syphilitic  pachy- 
meningitis are  also  common  causes  of 
abductor  paralysis.  Disseminated  scle- 
rosis seldom  produces  paralysis.  Of 
peripheral  causes  neuritis  is  a  frequent 


368 


LOBAR  PNEUMONIA,  PROPHYLAXIS  OF. 


factor;    it  may  be  toxic   (lead,  alcohol, 
or    arsenic),    or    infective     (diphtheria, 
typhoid,  influenza,  etc.) .    Paralysis  from 
involvement  of  the  vagus  is  usually  due 
to  compression  of  the  nerve,  from   (a) 
aneurism;    (b)  enlarged  glands,  usually 
tuberculous;     and    (c)    cancer    of    the 
oesophagus.     Rarer   causes   are  medias- 
tinal  growths,    pulmonary   tuberculosis, 
goiter,  etc.     Aneurism  is  the  most  fre- 
quent of  all  causes  of  laryngeal  palsy, 
being  the  most  often  occurring.    In  ad- 
dition there  may  be  glottic  spasm,  and 
the  peculiar  "brassy"  cough,  which  later 
becomes    wheezing   in    character.      Left 
vocal  cord  paralysis  may  be  the  earliest 
sign   of  aneurism.     Tuberculosis  causes 
paralysis  either  by  pressure  of  bronchial 
or  tracheal  glands,  or  by  involvement  of 
the  nerve  in  tuberculous  infiltration  at 
the  apex  of  the  lung.    The  association  of 
laryngeal   palsy  with   a  thyroid   tumor, 
though  suspicious,  is  no  conclusive  proof 
of  malignancy.    Adductor  palsies  always 
affect  the  phonatory  function.    They  are 
usually  bilateral  and  are  not  due  to  or- 
ganic disease  of  the  nerve  path,  either 
to  a  neurosis  (functional  aphonia)  or  to 
local  disease,  such  as  laryngitis.     Func- 
tional aphonia  is  a  common  manifesta- 
tion   of   hysteria,    but    anything   which 
makes  the  effort  of  phonation  more  diffi- 
cult than  usual  (such  as  debility,  thick- 
ening of  the  cords,  or  laryngeal  catarrh) , 
predisposes  to  this  affection.     It  occurs 
in  men  as  well  as  women;   the  onset  is 
sudden,  and  so  is  the  recovery.     Paral- 
ysis is  very  seldom  complete,  and  uni- 
lateral  adductor  paralysis   is   extremely 
rare.    It  is  due  to  local  interference  with 
the  muscles  and  in  a  few  instances  to 
toxic  causes.    IT.  Barwell  (Lancet,  Juno 
3,  1905). 


LOBAR    PNEUMONIA,    PROPHYLAXIS    OF. 

The  prevalence  of  influenza  during 
the  last  fifteen  years  has  brought  about 
an  increased  receptivity  for  and  inci-- 
dence  of  the  pneumococcus  infection. 
Certain  degenerative  lesions,  especially 
of  the  cardio-vascular  system  and  the 
kidneys,  have  shown  an  increased  inci- 
dence during  the  last  two  decades;  and 
these  are  found  to  be  associated  or  ante- 
cedent conditions  in  the  majority  of 
cases  of  pneumonia;  hence  are  prob- 
ably potent,  predisposing  factors. 
'  The  indoor  conditions  during  the  cold 
season  favor  multiplication  and  propa- 
gation of  the  pneumococcus  and  at  the 
same  time  tend  to  diminish  resistance  to 
infection  by  the  specific  organism.  The 
aged  are  peculiarly  susceptible  to  pneu- 
mococcus infection,  hence  their  bodies 
should  be  kept  as  strong  and  healthy  as 
possible,  especially  during  the  pneumo- 
nia season. 

To  overcome  the  predominating  fac- 
tors in  individual  predisposition,  special 
attention  must  be  paid  to  the  subject  of 
ventilation,  to  appropriate  clothing,  and 
the  avoidance  of  agencies  that  cause  de- 
generation of  the  heart,  blood-vessel  sys- 
tem, and  kidneys,  as  -alcohol,  social  ex- 
cesses, an  over-strenuous  business  or  pro- 
fessional life,  and  the  like. 

The  sputum  is  the  principal  source 
of  infection  and  should  be  thoroughly 
disinfected  so  soon  as  it  is  expectorated, 
and  then  destroyed  by  burning.  A  large 
proportion  of  the  general  populace  har- 
bors the  pneumococcus  in  the  naso- 
pharynx, and  this  is  especially  true  in 
families  and  institutions  in  which  cases 
of  pneumonia  have  occurred ;  hence 
thorough  cleanliness  and  systematic  dis- 
infection of  these  chambers  should  bo 
carried  out  during  the  pneumonia  sea- 
son, more  particularly  in  the  case  of  per- 


MASTOIDITIS. 


NASAL  SEPTI,  DEFLECTED,  RESECTION  OF. 


369 


sons  more  or  less  exposed  to  the  virus 
of  the  disease.  Means  to  prevent  dust 
from  accumulating  and  its  daily  re- 
moval from  home  and  the  city  streets, 
are  imperatively  demanded.  Public 
health  authorities  should  be  given  full 
executive  power  to  carry  out  rules  and 
regulations  relative  to  pneumonia  look- 
ing to  the  prevention  of  its  spread,  as 
in  the  case  of  other  infectious  diseases; 
they  should  also  carry  on  a  campaign  of 
public  education.  Measures  of  prophy- 
laxis must  accord  with  intelligent  public 
opinion  before  they  can  be  rendered 
wholly  efficient  either  by  municipal  or 
private  authority.  J.  M.  Anders  (Med- 
ical News,  June  3,  1905). 

MASTOIDITIS. 

Patients  suffering  from  acute  otitis 
media  should  be  confined  to  bed  during 
the  acute  inflammatory  stage. 

Recurrent  suppurative  otitis  media  is 
usually  the  result  of  adenoid  vegetation 
in  the  vault  of  the  pharynx,  plus  infec- 
tion. Chronic  suppurative  otitis  media 
exists  only  as  a  result  of  incompetent  or 
neglected  treatment  of  the  acute  state. 
Grippe  infection  produces  a  large  per- 
centage of  the  serious  complications  of 
middle  ear  suppuration. 

A  chronic  suppurative  and  necrotic 
process  in  the  middle  ear,  because  of  its 
environment,  calls  for  serious  considera- 
tion. The  practitioners  of  medicine 
should  acquire  sufficient  skill  to  make  an 
intelligent  examination  of  the  drum 
membrane,  and  sufficient  familiarity  with 
symptoms  to  diagnosticate  the  serious 
complications.  Well-developed  suppura- 
tion which  has  gone  beyond  the  confines 
of  the  mastoid  antrum  and  involves  the 
mastoid  cells  in  general  calls  for  external 
operative  interference. 

In  the  treatment  of  chronic  suppura- 


tive otitis  media  local  measures  should 
be  exhausted  before  considering  radical 
operative  interference.  Failure  to  cure 
chronic  suppurative  cases,  especially 
when  evidences  of  necrosis  are  present, 
should  be  followed  by  some  form  of  op- 
eration. The  Stacke  and  Schwartze- 
Stacke  operations,  while  they  are  rather 
serious  in  nature  and  require  marked 
skill,  offer  the  best  hope  of  permanent 
cure.  In  the  consideration  of  both  the 
mastoid  operation  and  the  radical  op- 
eration for  chronic  suppurative  otitis 
media,  wise  conservatism  should  guide 
the  action  of  the  surgeon.  W.  C.  Phillips 
(American  Journal  of  Surgery,  July, 
1905). 

MESENTERIC  GLANDS  IN  THEIR  RELA- 
TION TO  TUBERCULOSIS. 
In  all  cases  of  active  tuberculosis,  and 
in  almost  all  cases  of  inactive  tubercu- 
losis, the  mesenteric  glands  are  tuber- 
culously  infective.  The  mesenteric 
glands  in  these  cases  may  or  may  not 
show  gross  evidence  of  tuberculosis  or 
tubercle  bacilli  in  spreads;  the  result  is 
the  same  as  far  as  the  qualitative  pro- 
duction of  tuberculosis  is  concerned.  In 
a  certain  percentage  of  cases  showing  no 
tuberculous  lesions  in  any  part  of  the 
body,  these  glands  are  tuberculously  in- 
fective. In  the  present  study  the  per- 
centage was  about  40.  Tbe  tuberculous 
infectivity  of  the  mesenteric  glands  is 
probably  shared  by  the  other  groups  of 
lymph  nodes  throughout  the  body.  1?. 
C.  Piosenbergor  (American  Journal  Med- 
ical Sciences,  July,  1905). 

NASAL    SEPTI,    DEFLECTED,    SUBMUCOUS 
RESECTION  OF. 

This  operation  consists  essentially  in 
a  dissection  away,  from  before  backward, 
of  the  mucous  membrane  on  both  sides 


370         NERVOUS  AND  MENTAL  DISEASES,    GASTROINTESTINAL  TRACT  IN. 


of  the  septum,  perichondrium,  etc.,  and 
resection  of  the  deflected  portion,  except- 
ing the  upper  part,  from  the  roof  of  the 
nose.  This  is  important,  as  the  reten- 
tion of  this  part  of  the  septum  is  con- 
sidered by  Hajek  as  essential  for  the 
symmetry  of  the  nose.  In  one  of  his 
cases  the  author  purposely  left  small 
islands  of  cartilage  to  stiffen  the  new 
septum,  and  he  thinks  with  advantage. 

Submucous  resection  of  deflected  nasal 
septi  can  be  performed  under  local  anaes- 
thesia with  but  a  relatively  small  amount 
of  pain.  This  operation  offers  the  most 
certain  results  in  all  deflected  septi, 
whether  in  the  cartilage  or  bony  septum, 
or  both.  The  sagging  back  into  the  for- 
mer pathologic  position,  as  is  often  seen 
in  other  operations,  notably  by  the 
method  of  Asch  and  by  the  use  of  the 
punch,  cannot  occur  with  this  operation. 
The  offending  area  is  removed,  and 
hence  is  not  susceptible  of  recurrence. 

The  correction  of  this  condition  by 
an  operation  without  the  necessity  of  em- 
ploying splints  places  it  well  in  the  fore- 
ground from  a  humanitarian  point  of 
view,  for,  splints  are  painful,  do  not  al- 
ways accomplish  their  purpose,  and  make 
the  operation  unpopular.  Any  operation 
which  does  away  with  their  use  can  safely 
be  accepted  as  a  valuable  step  in  advance. 

The  after-treatment  with  this  opera- 
tion has  been  cut  down  from  four  to  six 
weeks  by  the  old  method,  to  two  weeks 
at  the  most.  It  is  painless,  less  apt  to 
have  sepsis,  and  with  care,  perforation 
can  be  avoided.  It  gives  the  most  cer- 
tain and  enduring  results,  is  not  so  hard 
to  perform  as  it  looks,  and  requires  no 
special  instruments  beyond  what  are  usu- 
ally found  in  a  rhinologist's  armamen- 
tarium, except  a  Killian  long-blade  nasal 
speculum.  F.  W.  Alter  (Journal  of  the 
American  Medical  Association,  July  1, 
1905). 


NERVOUS  AND  MENTAL  DISEASES,  RE- 
LATION OF  THE  GASTROINTES- 
TINAL TRACT  TO. 

The  writer  discusses  conditions  favor- 
ing fermentation  and  the  production  of 
abnormal  products."  Ethylidenediamin, 
a  ptomaine  found  in  gastric  liquids  in 
dilatation  of  the  stomach,  will  produce 
exophthalmos  and  some  symptoms  found 
in  Graves's  disease.  Methyl  guanidin 
resulting  from  putrefactive  processes  in 
the  small  intestine  causes  nervous  irri- 
tability and  tetanic  convulsions.  Stasis 
favors  putrefaction.  Among  the  pto- 
maines found  in  the  colon  after  stasis 
are  cadaverine  and  putrescine,  which 
give  the  symptoms  of  muscarine  poison- 
ing. Indol  given  to  animals  causes  car- 
diac and  respiratory  depression,  clonic 
spasm,  and  reflex  irritability.  Small 
quantities  taken  daily  for  several  weeks 
cause  headache,  colic,  diarrhoea,  unna- 
tural mental  activity,  and  a  tendency  to 
neurasthenia.  Bile,  when  absorbed,  pro- 
duces a  definite  toxaemia.  Large  doses 
of  choline  cause  nearly  instantaneous 
death  in  cats  and  rabbits.  Ferine,  a  de- 
rivative, causes  dyspnoea,  salivation,  my- 
driasis, labored  respiration,  unconscious- 
ness, and  clonic  convulsions.  Muscarine 
causes  convulsive  seizures.  All  these 
substances  produce  epileptiform  attacks. 
In  many  cases  of  nervous  and  mental 
diseases,  derangement  of  the  gastroin- 
testinal function  may  aggravate  the 
original  condition,  creating  a  vicious  cir- 
cle. A  thorough  investigation  should 
be  made  in  each  case.  Carnivora  are 
subject  to  convulsive  seizures  from  die- 
tetic disturbances,  whereas  herbivora  are 
exempt.  Eed  meats  tend  to  aggravate 
nervous  conditions,  and  in  epilepsy  and 
other  nervous  diseases  are  largely  elim- 
inated from  the  dietary.  Some  convul- 
sive seizures  in  children  come  on  a  short 


OPHTHALMIA  NEONATORUM. 


ORBITAL  SARCOMA. 


371 


time  after  the  administration  of  im- 
proper food,  others  not  for  several  hours, 
representing  gastric  and  enteric  types. 
Bickets,  a  factor  in  epilepsy,  is  often  as- 
sociated with  dilatation  of  the  stomach. 
W.  H.  Thompson  has  secured  brilliant 
results  in  epilepsy  from  treatment  of  the 
gastro-intestinal  tract.  Even  when  de- 
generative brain  changes  have  occurred, 
the  convulsions  may  be  lessened  by  ap- 
propriate treatment.  Mental  depression 
often  accompanies  toxaemia,  and  may  re- 
sult in  depressive  insanity.  Among 
other  symptoms  of  auto-infection  are 
apathy,  insomnia,  somnolence,  and  in- 
ability to  concentrate  the  attention. 
Mucous  colic  is  one  of  the  manifestations 
of  Glenard's  disease,  and  the  neuras- 
thenic condition  is  probably  the  result 
of  auto-infection.  The  writer  believes 
that  in  surgical  procedures  for  dilata- 
tion there  is  a  brilliant  future  for  the 
relief  of  some  nervous  diseases.  E.  C. 
Kemp  (Medical  News,  July  8,  1905). 

OPHTHALMIA  NEONATORUM. 

Thorough  cleansing  of  the  vagina  be- 
fore rupture  of  the  waters,  where  possi- 
ble, is  advised  by  the  author,  as  a  later 
cleansing  may  tend  to  carry  some  infec- 
tion higher.  The  use  of  argyrol  or  pro- 
targol  should  be  continued  for  three  to 
six  days  in  any  suspected  case  as  a 
prophylactic  measure.  The  termination 
of  labor  with  forceps  is  justified  when 
the  membranes  are  ruptured  and  the 
second  stage  is  delayed  in  suspected 
cases.  When  once  ophthalmia  is  devel- 
oped, thorough  vigorous  treatment 
should  be  instituted,  and  no  effort  spared 
in  having  it  carried  out  to  the  letter. 
Care  should  be  taken  not  to  produce  a 
conjunctivitis  either  with  strong  antisep- 
tics or  rough  handling  of  the  lids.    Even 


the  semblance  of  traumatism  should  be 
avoided.  C.  T.  Souther  (Lancet-Clinic, 
July  1,  1905). 

ORBITAL   SARCOMA. 

The  difficulty  in  accurate  diagnosis 
under  certain  conditions  entirely  justi- 
fies an  exploratory  excision  with  removal 
of  a  section  of  growth  for  microscopic 
study,  said  exploration  likewise  serving 
to  determine  the  ramification  of  the  tu- 
mor. 

The  brilliant  results  achieved  by  a 
number  of  accurate  observers  in  the 
field  of  Eoentgen  ray  therapy  justify  the 
immediate  tentative  application  of  the 
method  before  any  radical  operation  is 
attempted.  If  unsuccessful  in  removal 
of  the  growth,  the  virulence  of  the  latter 
will  probably  be  decreased  and  the  dan- 
gers of  metastasis  lessened.     (Leonard.) 

If  the  sarcoma  is  encapsulated,  opera- 
tive intervention  without  orbital  evis- 
ceration promises  a  successful  outcome. 
In  view  of  the  almost  constant  recur- 
rences after  orbital  evisceration,  the  re- 
moval of  the  growth  itself  is  regarded 
as  sufficient  unless  the  periosteum  or 
bony  wall  is  involved. 

The  encouraging  results  reported  from 
the  cataphoric  sterilization  of  malignant 
growths  in  other  parts  of  the  body  seem 
to  warrant  the  utilization  of  this  method 
in  the  orbit,  due  care  being  exercised  as 
to  strength  of  current  used.  (Massey.) 
Future  experience  must  determine 
whether  better  results  will  be  achieved 
by  using  this  method  for  the  original 
growth,  or  reserving  it  for  recurrences 
in  loco.  If  operation  has  been  per- 
formed and  the  growth  has  recurred,  we 
have  at  command  these  two  valuable 
methods  of  attack.  G.  Oram  Eing  (New 
York  Medical  Journal  and  Philadelphia 
Medical  Journal,  June  10,  1905). 


372        PERITONEUM. 


PLACENTA  PREVIA,  CESAREAN  SECTION  FOR. 


PERITONEUM,      PHYSIOLOGY      AND      PA- 
THOLOGY OF. 

The  ability  of  the  peritoneum  to  pro- 
tect itself  has  been  exhaustively  studied 
by  the  authors,  on  rabbits.  About  10 
cubic  centimeters  of  a  2  per  cent,  solu- 
tion of  potassium  iodide  was  injected  di- 
rectly into  the  peritoneum  without  pre- 
vious incision.  The  results  have  con- 
vincingly demonstrated,  the  authors 
think,  that  moist  eventration  and  rins- 
ing is  not  only  the  best  means  of  pre- 
venting, but  also  aids  in  curing  perito- 
nitis. The  favorable  effects  were  evi- 
dent whether  the  peritoneum  was  nor- 
mal or  already  inflamed. 

In  regard  to  leucocytosis  and  phago- 
cytosis there  did  not  seem  to  be  much 
difference  between  irrigated  and  dry  op- 
erations. Eventration  cannot  be  done 
without  an  abundant  emigration  of  leu- 
cocytes. They  display  at  first  an  ener- 
getic phagocytosis,  but  this  soon  sub- 
sides and  finally  sinks  considerably  be- 
low normal. 

The  authors'  experiments  confirmed 
their  former  assertions  in  regard  to  the 
way  in  which  increased  peristalsis  after 
administration  of  a  little  physostigmine 
hastens  peritoneal  absorption,  and  that 
sterile  fluids  injected  into  the  perito- 
neum do  not  check  absorption.  In  in- 
cipient peritonitis  absorption  proceeds 
more  vigorously  at  first,  but  later  be- 
comes very  sluggish.  A  moist  laparot- 
omy has  much  less  disturbing  effect  on 
the  process  of  absorption  than  dry  lapa- 
rotomies. In  the  latter  there  is  venous 
hyperaemia  and  the  peristalsis  is  ar- 
rested ;  this  docs  not  occur  when  the 
peritoneum  is  irrigated.  Transudation 
in  the  abdominal  cavity  is  not  materially 
affected  by  a  laparotomy.  The  active 
hyperaBmia  which  accompanies  the  in- 
flammation  is  the   cause  of  the   rapid 


absorption  at  first.  The  intensity  of  the 
inflammation  depends  on  the  virulence 
of  the  germs  more  than  on  all  the  other 
conditions  combined. 

In  regard  to  the  benefits  of  rinsing 
after  laparotomy,  the  peritoneum  of  the 
rinsed  animals  was  invariably  found  in 
much  better  condition  than  in  the  con- 
trols. Eighty-seven  rabbits  and  guinea- 
pigs  were  infected  with  pus  of  a  stand- 
ard virulence,  laparotomized  after  an 
interval  of  from  ten  minutes  to  ten 
hours,  and  the  peritoneum  was  then 
rinsed  without  tamponing.  The  animals 
all  died,  some  of  them  even  earlier  than 
the  controls,  but  the  peritoneum  was  al- 
ways in  a  much  better  condition  than  in 
the  controls.  There  was  none  of  the 
turbid  effusion  nor  fibrinous  deposits  on 
the  intestines  nor  loose  adhesions  be- 
tween them.  Scarcely  a  trace  of  inflam- 
matory changes  could  be  detected.  In 
a  further  series  of  ten  experiments  diph- 
theria toxin  was  injected  into  the  peri- 
toneum and  it  was  then  rinsed  out. 
Twenty  times  the  fatal  dose  could  thus 
be  injected  and  rinsed  out  again  with- 
out the  slightest  symptoms,  wnile  all  the 
controls  died  with  the  typical  syndrome. 
P.  Clairmont  and  H.  Haberer  (Archiv 
fur  klinische  Chirurgie,  Bd.  lxxvi,  Nu. 
1  and  2;  Journal  of  the  American  Med- 
ical Association,  July  1,  1905). 

PLACENTA  PREVIA,  CESAREAN  SECTION 
FOR. 

Caesarean  section  for  placenta  prasvia 
lowers  the  fcetal  mortality  30  per  cent, 
and  raises  the  maternal  death  rate 
nearly  three-fold.  Approximately  the 
life  of  the  mother  is  taken  to  save  the 
uncertain  existence  of  one  baby. 

A  rigid  os  is  one  of  the  rarest  compli- 
cations of  placenta""prasvia.  Undoubt- 
edly most  cases  of  so-called  rigid  os  are 


PLEURISY. 


373 


simply  instances  of  cervices  unprepared 
for  dilatation,  or  a  misconception  based 
on  too  brusque  and  rapid  attempts  to 
dilate  or  to  extract.  A  true  cicatricial 
cervix,  and  rigid  cervices  of  old  primi- 
parae,  may  offer  an  indication  for 
Caesarean  section  in  placenta  praevia. 

Pelvic  contractions  are  indications  for 
Caesarean  section  in  the  presence  of  a 
praevial  haemorrhage;  the  pelvic  con- 
traction, not  the  prsevia,  is  the  deter- 
mining indication.  The  earlier  the  in- 
terruption of  gestation,  cceteris  paribus, 
the  more  may  pelvic  deformity  be  disre- 
garded. In  general,  the  presence  of  a 
placenta  praevia  will  not  be  recognized 
before  haemorrhages  appear. 

Caesarean  section  for  placenta  praevia 
never  will  have  so  low  a  maternal  mor- 
tality as  when  performed  for  a  pelvic 
indication.  Eepeated  examinations  by 
the  physician  and  his  consultants  must 
be  made  for  diagnostic  purposes;  often 
a  vaginal  tampon  must  be  introduced  as 
a  temporizing  measure,  at  least  until  the 
woman  may  be  transported  to  a  hospital, 
or  preparations  made  at  home  for  the 
laparotomy.  The  acute  anaemia  and  fi- 
nally the  anatomic  conditions  post- 
partum all  render  the  operation  a  pecu- 
liarly dangerous  one.  Placenta  praevia 
cases  appropriate  for  Caesarean  section 
generally  will  demand  the  procedure  ir- 
respective of  the  fcetal  condition,  as  the 
primal  motive  should  be  to  save  the 
mother  Caesarean  section  for  placenta 
praevia  should  only  be  considered  a 
dernier  ressort.  If  an  abdominal  opera- 
tion is  forced  on  the  obstetrician,  he 
should  remove  the  uterus  as  a  prophy- 
lactic against  haemorrhage  and  infec- 
tion. E.  W.  Holmes  (Journal  of  the 
American  Medical  Association,  May  20, 
1905). 
5 


PLEURISY. 

Regarding  the  pathology  of  pleurisy, 
the  author  maintains  the  following  prop- 
ositions :  Apart  from  injuries,  pleurisy 
is  to  be  regarded  as  part  of  a  condition 
that  has  generally  begun  in  the  respira- 
tory tract,  but  sometimes  in  the  pericar- 
dium (especially  in  rheumatic  fever), 
and  now  and  then  in  the  peritoneum,  and 
that  the  origin  ought  always  to  be  care- 
fully investigated.  Empyema  is  a  fre- 
quent result  of  lobar  pneumonia  and  also 
of  tubercle.  Large  non-purulent  effu- 
sions are  due  to  pneumomoccal  or  tuber- 
culous affection.  Tubercle  reaches  the 
pleura  from  the  lung  in  most  cases  and 
in  a  few  from  the  peritoneum.  Diag- 
nosis should  take  a  wide  survey  of  the 
origin  of  the  disease  and  not  be  limited 
to  the  interpretation  of  physical  signs. 

As  regards  treatment,  the  author  is  in 
favor  of  letting  out  all  large  serous  ef- 
fusions and  all  empyemata,  and  in  the 
latter  case  he  favors  more  and  more  the 
method  of  resecting  a  piece  of  rib  as  pro- 
curing better  drainage  and  therefore 
more  speedy  recovery.  Another  and 
more  general  principle  of  treatment  is 
that  the  patient  should  be  kept  under  ob- 
servation till  he  may  be  considered  free 
from  the  condition  of  which  the  pleurisy 
was  the  most  prominent  manifestation. 
Typhoid  fever  is  almost  the  only  acute 
disease  in  which  patients  are  kept  long 
enough  under  control.  In  rheumatic 
fever  rest  in  bed  in  all  cases  for  from 
three  to  four  weeks  after  the  temperature 
is  normal  would  lead  to  a  diminished 
percentage  of  permanent  valvular  dis- 
ease, and  it  is  only  by  a  prolonged  tem- 
perature chart  that  certainty  can  be  ar- 
rived at  as  to  the  cessation  of  the  endo- 
carditis. In  pleurisy,  regulations  as  re- 
gards fresh  air  and  diet  followed  out  in 
all  cases  would  often  prevent  the  devel- 


374 


PRURITIS  ANI,  CAUSE  OF. 


PSORIASIS,  TREATMENT. 


opment  of  permanent  tuberculosis  later 
in  life.  N.  Moore  (Lancet,  June  10, 
1905). 

PRURITUS  ANI,  CAUSE  AND  TREATMENT 
OF. 

The  writer  has  found  in  over  90  per 
cent,  of  cases  of  pruritus  ani  which  he 
has  examined,  a  shallow  ulcer  situated 
between  the  two  sphincters.  It  has  been 
more  often  in  the  posterior  segment  than 
in  the  anterior  and  generally  near  the 
dorsal  mid-line.  In  some  cases  there  is 
more  than  one  ulcer,  and  in  others  there 
are  various  clefts  which  almost  or  en- 
tirely surround  the  bowel.  The  writer 
believes  that  the  method  of  fusion  of  the 
proctodeum  with  the  blind  end  of  the 
gut  is  the  cause  of  this  frequent  ulcer. 
The  lining  of  the  proctodeum  is  thin 
and  is  scantily  supplied  with  blood-ves- 
sels. Thus  abrasions  here  are  easily 
brought  about.  They  rarely  heal  of  their 
own  accord.  The  ulcer  exudes  an  irri- 
tating secretion  which  causes  pruritus. 
The  writer  gives  the  ordinary  prepara- 
tion for  a  rectal  operation.  It  is  well 
for  the  patient  to  give  up  about  two 
weeks  for  the  treatment.  When  he  is 
anaesthetized,  the  sphincter  is  moder- 
ately stretched,  and  the  ulcer  or  ulcers 
are  brought  into  view  and  treated  with 
the  electric  thermocautery.  The  cau- 
tery is  also  applied  to  the  thickened  skin 
as  well.  Vaseline  is  applied  to  the  cau- 
terized area,  and  a  morphine  supposi- 
tory inserted  into  the  bowel.  A  pad  of 
wool  is  held  in  place  by  a  T -bandage,  and 
the  patient  is  put  back  to  bed.  On  the 
third  night  a  purge  is  given,  and  a  warm 
boracic  bath  is  taken  twice  a  day.  The 
skin  is  then  thoroughly  dried  and  pow- 
dered with  starch  and  zinc  powder,  and 
a  small  piece  of  cotton-wool  covered  with 
powder    is    introduced    just    inside    the 


sphincter.  The  irritation  ceases  at  once 
or  after  a  few  days.  Even  out-patients 
are  treated  either  with  lactic  acid  or  with 
the  thermo-cautery.  The  results  of  this 
treatment  are  most  gratifying.  F.  C. 
Wallis  (British  Medical  Journal,  May 
13,   1905). 

PSORIASIS,  TREATMENT  OF. 

The  writer  reports  that  he  has  used 
with  great  success  the  following  oint- 
ment, the  formula  of  which  was  first 
published  by  him  in  1903,  in  the  treat- 
ment of  psoriasis : — 

R   Acid  salicylic,  Siiss. 
Chrysarobin, 

01.  rusci.  (birch  tar),  of  each,  5v. 
Sapo  virid., 
Vaseline,  of  each,  5viss. 

This  combination  contains,  he  says, 
keratolytic  reducing  as  well  as  macerat- 
ing and  antipsoriatic  remedies  in  rather 
large  doses.  His  method  of  using  it  is 
as  follows :  For  from  four  to  six  days 
the  ointment  is  applied  by  the  aid  of  a 
stiff  brush  to  the  affected  area  (after 
this  has  dried  somewhat  it  is  well  to 
apply  a  starch  or  zinc  powder) .  On  the 
fifth  or  sixth  day,  the  patient  starts  tak- 
ing hot  baths  daily  for  from  one  to  three 
days,  and  after  the  bath,  vaseline  is  to 
be  well  rubbed  in  from  one  to  three  times 
a  day.  This  treatment,  which  covers 
eight  days,  may  be  repeated  several 
times,  according  to  the  severity  of  the 
disease,  but,  as  a  rule,  the  psoriasis 
patches  disappear  soon  after  the  first 
treatment.  The  ointment  causes  a 
marked  scaling  of  the  entire  plaque,  and 
the  black  cruris  which  become  closely  ad- 
herent after  five  or  six  days'  treatment 
gradually  loosen  after  a  few  days  of 
bathing  and  inunetton  with  vaseline  or 
with  zinc  sulphur  ointment. 


PUERPERAL  INFECTION. 


RECTAL  SURGERY,  ANAESTHESIA  IN.        375 


The  application  of  this  ointment 
causes  an  intense  feeling  wherever  pso- 
riasis exists,  and  the  writer  considers  it 
an  indicator  of  areas  of  psoriasis.  It  also 
limits  the  chrysarobin  irritation  exclu- 
sively to  the  diseased  area  and  causes  no 
diffuse  staining.  For  the  best  effects, 
the  solid  constituents  of  this  ointment 
must  be  thoroughly  rubbed  together. 
For  prolonged  use  with  this  ointment, 
a  material  called  mull  has  been  prepared 
by  the  writer  which  is  practically  un- 
irritating.  The  use  of  these  prepara- 
tions is  not  limited  to  psoriasis,  but  they 
can  be  employed  in  other  conditions 
where  a  special  macerating  effect  is  de- 
sired with  the  smallest  possible  amount 
of  irritation.  It  has  been  used  thus  in 
trichophytosis  and  in  local  circumscribed 
dry  eczema.  It  can  be  kept  on  six  or 
eight  days,  after  which  any  mild  oint- 
ment may  be  applied.  Dreuw  (Journal 
of  the  American  Medical  Association, 
June  10,  1905). 

PUERPERAL  INFECTION. 

The  author's  custom  is  to  make  a 
careful  examination  of  the  genital  or- 
gans as  soon  as  the  temperature  exceeds 
38°  C,  unless  there  is  a  very  good  reason 
for  the  elevation  of  temperature.  If  no 
unfavorable  conditions  as  to  vagina  or 
perineum  are  found,  but  the  uterus  is 
large  and  soft,  the  lochia  should  be  care- 
fully removed  with  a  uterine  catheter. 
In  48  cases  in  which  this  procedure  was 
followed  the  temperature  dropped  to 
normal  in  30.  The  uterus  should  also  be 
irrigated  with  iodine  of  mercury  solu- 
tion. 1  to  2000.  If  this  does  not  relieve 
the  situation,  or  if  the  infection  appears 
to  be  serious  from  the  beginning,  the 
uterus  should  be  explored  with  the 
finger,  the  patient  being  anaesthetized. 
If  nothing  abnormal  is  found,  the  uterus 


should  be  irrigated  and  then  tamponed 
with  gauze.  If  there  should  be  hyper- 
trophied  or  necrosed  decidua,  it  should 
be  removed  with  the  curette,  bearing  in 
mind  that  danger  attaches  to  such  an  op- 
eration. Posterior  vaginal  section  and 
hysterectomy  are  to  be  considered  in  cer- 
tain cases.  If  serum  is  to  be  injected 
it  should  be  used  early  and  in  large 
doses,  20  cubic  centimeters  being  in- 
jected two  or  three  times  in  twenty-four 
hours.  Lea  ( Fortschritte  der  Medizin, 
May  1,  1905 ;  New  York  Medical  Jour- 
nal and  Philadelphia  Medical  Journal, 
July  1,  1905). 

QUININE.  ADMINISTRATION  OF. 

The  writer  has  compared  the  admin- 
istration of  quinine  by  the  mouth  with 
hypodermic  injection.  In  each  case  the 
quantity  found  in  the  blood  is  very  small 
relatively  to  the  amount  introduced  into 
the  body,  and  reaches  its  maximum  after 
about  an  hour.  The  parasite  of  malaria 
is.  however,,  susceptible  to  a  minute  pro- 
portion of  the  drug.  When  quinine  is 
swallowed,  more  is  found  in  both  the 
blood  and  urine  than  when  it  is  injected 
under  the  skin.  But  experience  has 
shown  that  the  latter  method  of  admin- 
istration is  more  efficacious  in  malaria. 
This  is  due  to  the  prolonged  action  of 
the  drug  in  this  case,  as  it  passes  con- 
tinually, though  slowly,  from  the  tissue? 
into  which  it  has  been  injected  to  the 
blood.  Luca  (Archiv  Ttal.  de  Biol., 
March,  1905;  British  Medical  Journal, 
July  1,  1905). 

RECTAX  SITltr.T-fJTr     

Sii 

plieat 
lated. 
in   pa 


376 


RHEUMATISM,  FORMIC  ACID  IN. 


SCABIES. 


on  with  local  anaesthetics,  of  which  co- 
caine and  eucaine  are  the  best.  In  all 
other  conditions,  including  extensive 
haemorrhoids,  complicated  fissures,  and 
fistulas,  and  always  in  neurotic  hyper- 
aesthetic  individuals,  general  anaesthesia 
should  be  resorted  to.  J.  P.  Tuttle 
(New  York  Medical  Journal  and  Phila- 
delphia Medical  Journal,  June  17, 
1905). 

RHEUMATISM,  FORMIC  ACID  IN. 

The  author  considers  that  formic  acid 
is  little  short  of  a  marvelous  remedy  for 
the  treatment  of  all  rheumatic  condi- 
tions, including  acute  articular  rheuma- 
tism and  arthritis  deformans.  He  has 
cured  acute  inflammatory  articular  rheu- 
matism in  forty-eight  hours,  and  reports 
cases  of  severe  arthritis  deformans  won- 
derfully improved  after  forty-eight 
hours. 

The  following  rules  are  laid  down  for 
using  his  method  of  treatment:  The 
parts  should  always  be  cleansed  thor- 
oughly before  injecting  formic  acid  so- 
lution. A  stronger  solution  than  3  per 
cent,  should  never  be  used,  and  a  2  y2 
per  cent,  solution  is  better.  It  skould 
never  be  used  without  injecting  five  to 
eight  drops  of  a  1  per  cent,  solution  of 
cocaine,  or  other  local  anaesthetic  as  a 
preliminary  to  the  formic  acid  treat- 
ment. The  extensor  or  outer  parts  of  a 
limb  should  be  chosen  for  exhibiting  the 
remedy  and  it  should  be  injected  just 
beneath  the  skin,  though  deep  injections 
may  be  used  when  occasion  demands. 
More  than  eight  drops  should  never  be 
used  in  any  one  place  of  either  cocaine 
1  per  cent,  sortition  or  of  the  formic  acid 
solution.  If  eight  drops  of  the  cocaine 
are  used,  a  similar  amount  of  the  formic 
acid  solution  should  be  employed.  If 
lars;e  doses  are  used  for  formic  acid  so- 


lutions, hard,  painful  lumps  are  formed 
which  are  slow  of  absorption;  whereas, 
if  smaller  doses  are  used  no  destruc- 
tion of  tissue  results,  and  no  hard, 
painful  growths  supervene.  Usually 
the  most  painful  joints  should  be  in- 
jected and  the  injections  made  not  less 
than  two  inches  apart.  No  more  than 
30  injections  should  be  used  at  a  time, 
and  it  is  far  better  to  use  only  12  to  15 
and  repeat  the  following  day  in  another 
place.  All  nerve  trunks  should  he 
avoided,  if  possible,  since  injections  in- 
volving nerves  are  apt  to  be  followed  by 
severe  pains  lasting  for  twenty-four 
hours.  Injections  may  be  given  every 
day,  or  every  other  day,  till  all  the  pain 
has  ceased.  It  will  not  be  apt  to  return 
unless  gross  carelessness  or  willful  dis- 
regard of  plain  directions  exist.  L.  B. 
Couch  (Medical  Eecord,  June  24,  1905). 

SCABIES. 

The  author  alludes  to  the  many  mis- 
takes in  diagnosis.  The  characteristic 
features  are  the  location,  the  presence  of 
burrows,  the  intense  pruritus — worse  at 
night — and  similar  disease  in  associates. 
Treatment  is  easy  and  the  cure  quick. 
A  scrubbing  with  soap  and  hot  water 
should  be  followed  by  an  ointment  of : — 

I£  Napthol  b.,  3j. 
Sulphur,  3ij. 
Balsam  of  Peru, 
Vaseline,  of  each,  3j. 

Well  rubbed  in.  In  infants,  balsam  of 
Peru  is  very  effective.  After  three  days' 
treatment,  soothing  remedies  should  be 
applied,  returning  to  the  first  treatment 
at  the  end  of  the  week  if  itching  con- 
tinues. The  clothing  should  be  boiled 
or  baked.  J.  S.  Howe  (Boston  Medical 
and  Surgical  Journal,  June  22,  1905). 


SPEECH,  RETARDED. 


SUMMER  DIARRHCEAS  IN  INFANCY. 


377 


SPEECH,    RETARDED    DEVELOPMENT    OF, 
IN  YOUNG  CHILDREN. 

Retarded  development  of  speech  in 
young  children  may  be  the  result  of 
structural  irregularities  in  the  periph- 
eral organs,  impaired  respiration  due  to 
nasal,  post-nasal,  and  pharyngeal  ob- 
structions, paresis  of  the  nerves  supply- 
ing the  organs  of  speech,  and  not  infre- 
quently to  some  disturbance  of  hearing 
not  necessarily  amounting  to  absolute 
deafness.  Retarded  development  of 
speech  always  results  in  defective  men- 
tality. 

The  treatment  consists  in  the  removal 
of  any  obstruction  that  may  exist  in  the 
peripheral  organs  and  in  the  systematic 
training  of  the  auditory  and  speech  cen- 
ters by  the  use  of  specially  prepared 
vocal  exercises.  A  child  may  be  taught 
to  hear  in  exactly  the  same  way  as  he  is 
taught  to  read  and  write.  G-.  Hudson- 
Makuen  (Pennsylvania  Medical  Jour- 
nal, June,  1905). 

SUMMER  DIARRHG3AS  IN  INFANCY,  ETI- 
OLOGY AND   CLASSIFICATION   OF. 

The  modern  tendency  toward  classi- 
fying disease  types  upon  an  etiologic 
basis,  which  finds  its  expression  in  the 
continual  attempt  to  separate  such  types, 
by  bacteriologic  proof,  into  the  class  of 
specific  infection,  is  apt  to  lead  to  the 
exaggeration  of  the  role  of  bacteria  in 
all  pathologic  conditions.  Another  ob- 
stacle to  advance  in  the  knowledge  of 
the  infantile  diarrhoeas,  is  the  great  con- 
fusion which  exists  in  their  terminology. 

The  feeding  of  the  child  at  the  time 
of  onset  of  the  diarrhoea  is  important  in 
relation  to  the  question  of  etiology.  A 
certain  type  of  case  stands  out  repeatedly 
from  the  others  as  especially  distinct. 
These  are  the  cases  characterized  by  the 
existence  and  persistence  of  fever.    They 


have  the  recognized  characteristics  of 
true  infections,  with  more  marked  con- 
stitutional symptoms,  and  a  slower  re- 
covery than  the  majority  of  the  cases. 
Persistence  of  fever  seems  to  afford  the 
most  promising  basis  for  a  clinical  di- 
vision of  the  cases,  and  to  these  cases  the 
author  gives  the  name  of  acute  intestinal 
infection.  The  majority  of  the  author's 
cases  being  of  the  indigestion  type,  and 
not  bearing  clinically  the  usual  evidences 
of  true  infection,  he  sees  no  reason  for 
seeking  any  cause  beyond  heat,  and  its 
consequent  indigestion,  as  necessary  to 
explain  their  greater  frequency  during 
the  summer  months.  As  to  the  infec- 
tious cases,  it  seems  probable  that  bac- 
teria do  play  an  important  part  in  their 
etiology.  Nevertheless,  the  heat  is  prob- 
ably the  underlying  cause. 

The  diarrhoeal  diseases  of  infancy  oc- 
curring in  the  summer  months  differ  in 
no  way,  either  clinically  or  anatomically, 
from  the  diarrhoeal  diseases  occurring  in 
the  cooler  months,  except  in  their  much 
greater  frequency.  Classification  on  an 
anatomical  basis,  as,  for  example,  into 
functional  and  organic,  or  non-inflam- 
matory and  ileocolitis,  is  not  convenient 
for  etiologic  study,  owing  to  the  variety 
of  lesions  found  in  cases  of  similar  eti- 
ology and  similar  clinical  course,  and  to 
the  lack  of  correspondence  between  ana- 
tomical and  clinical  picture. 

The  author  suggests  the  following 
clinical  classification :  (a)  Acute  nerv- 
ous diarrhoea,  characterized  by  loose 
stools  of  normal  color  and  odor,  without 
abnormal  constituents.  (b)  Irritative 
diarrhoea.  Acute  intestinal  indigestion 
of  the  irritative  type,  characterized  by 
the  absence  of  persistent  fever,  and  by 
the  presence  of  curds  and  undigested 
masses  in  the  discharges,  (c)  Fermen- 
tal  diarrhoea.     Acute  intestinal  indiges- 


378 


TOXAEMIA  OF  INTESTINAL  ORIGIN  AND  MINOR  INFECTIONS. 


tion  of  the  fermental  type,  characterized 
by  the  absence  of  fever,  and  by  the  green 
stools  of  a  foul  or  sour  odor,  (d)  Infec- 
tious diarrhoea,  characterized  by  the  ex- 
istence and  persistence  of  fever,  and  by 
the  tendency  toward  early  signs  of  ileo- 
colitis, as  shown  by  the  presence  of 
blood,  and  excess  of  mucus  in  the  dis- 
charges. "When  a  specific  organism,  the 
bacillus  dysenteriae,  is  proved  to  be  the 
cause,  the  case  may  be  further  particu- 
larized by  the  term  infantile  dysentery. 
(e)  Rare  cases  occur,  corresponding  to 
the  known  description  of  heat  exhaus- 
tion, and  cholera  infantum. 

Of  the  above  differentiated  types,  the 
indigestion,  including  the  irritative  and 
fermental  cases,  is  by  far  the  commonest. 
The  chief  or  primary  cause  of  all  these 
types  is  the  increased  heat  of  the  weather 
occurring  during  the  summer  months, 
which  probably  acts  in  the  non-infectious 
cases  by  producing  functional  disturb- 
ance either  of  the  nervous  system  or  of 
the  digestion;  and  which  acts  in  the  in- 
fectious cases  by  producing  in  the  intes- 
tine conditions  more  favorable  to  the 
occurrence  of  infection.  The  name 
thermic  diarrhoea  can  be  given  to  the 
entire  group. 

Bacteria  are  the  secondary  cause  of 
a  certain  number  of  cases,  such  cases 
being  mainly,  if  not  wholly,  of  the  type 
classified  clinically  as  infectious.  In- 
fection occurs  by  the  introduction  of 
bacteria  from  without,  or  by  auto-infec- 
tion with  bacteria  already  in  the  intes- 
tine. The  latter  is  probably  the  usual 
method.  The  bacillus  dysenteriae  is  a 
cause  of  most  of  the  infectious  cases. 
Whether  it  is  the  sole  cause  remains  to 
be  determined.  The  bacillus  dysen- 
teric can  often  be  found  in  the  intestine 
in  cases  where  it  probably  has  no  casual 
relation    with    the    pathologic    process. 


Such  cases  are  usually  clinically  of  the 
non-infectious  type.  Other  organisms 
are  probably  a  cause  of  some  infectious 
cases. 

The  anatomical  changes  of  various 
kinds  included  under  the  term  ileoco- 
litis may  occur  in  any  of  the  above  clin- 
ical types,  except  the  acute  nervous. 
Anatomical  changes  of  some  kind  prob- 
ably occur  in  all  infectious  cases.  C.  H. 
Dunn  (Archives  of  Pediatrics,  June, 
1905). 

TOXEMIA  OF  INTESTINAL  ORIGIN  AS 
A  CONDITION  PREDISPOSING  TO 
MINOR    INFECTIONS. 

In  many  cases  of  vital  decrease,  mani- 
fested objectively  by  minor  septic  infec- 
tions, toxaemia  of  intestinal  origin  may 
be  regarded  as  the  predisposing  cause. 
It  may  readily  be  seen  that  the  direction 
toward  which  this  conclusion  points  is 
very  far-reaching.  It  suggests  for  in- 
stance an  explanation  of  the  problem 
met  by  the  surgeon  :  given  two  patients 
of  apparently  similar  vitality,  the  same 
operation  and  a  fixity  of  technique,  why 
is  it  that  one  will  promptly  recover  and 
the  other  perhaps  either  take  longer  to 
recuperate* or  die  of  sepsis?  In  the  do- 
main of  infectious  medical  disease,  why 
is  it  that  one  person  contracts  typhoid 
fever  and  another  does  not?  This  leads 
us,  of  course,  into  that  fascinating  field 
of  study  comprised  within  the  limits  of 
natural  immunity  for  which  the  dawn 
of  knowledge  is  just  beginning.  But  the 
train  of  thought  is  certainly  apparent. 

The  practical  application  of  the  con- 
clusion means  attention  to  the  proteid 
fermentation  taking  place  in  the  bowel, 
particularly  in  those  cases  in  which  the 
urine  presents  a  large  amount  of  indi- 
can.  It  is  not  sufficient  simply  to  pro- 
duce evacuation  of  the  bowels.     The  in- 


TUBERCULAR  PERITONITIS. 


TYPHOID  FEVER,  IODINE  IN. 


379 


dicanuria  must  be  treated  by  diet  and 
other  procedures  looking  toward  its  com- 
plete cessation.  This  will  undoubtedly 
completely  cure  many  troublesome  cases 
of  recurring  minor  infections.  H.  A. 
Houghton  (Medical  Kecord,  May  27, 
1905). 

TUBERCULAR     PERITONITIS,     LAPAROT- 
OMY IN. 

Laparotomy  is  an  efficient  remedial 
measure  in  the  treatment  of  tubercular 
peritonitis  and  should  be  employed  in  all 
cases  where  a  month  or  two  of  medical 
treatment  fails,  except  in  those  cases 
only  of  a  moribund  condition  or  of  such 
an  enfeebled  state  that  the  operation  it- 
self would  be  fatal.  Neither  pyrexia 
nor  tubercular  lesion  elsewhere  than  in 
the  peritoneal  cavity  is  a  contraindica- 
tion unless  the  case  be  an  advanced  one 
and  on  the  border-line  of  being  inoper- 
able. 

The  mortality  is  but  3  per  cent.,  and 
not  as  high  as  Eichberg  places  it,  namely, 
10  per  cent.  A  laparotomy,  if  not  suc- 
cessful, will  not  aggravate  the  condition 
of  the  patient  in  any  sense,  if  the  case 
be  an  operable  one.  Dry  fibrinous  forms, 
and  in  some  cases  the  ulcerative  forms 
are  cured  by  laparotomy  as  well  as  the 
serous  ones,  if  the  operation  be  suffi- 
ciently radical  to  remove  the  primary 
nidus  of  infection.  P.  Y.  Eisenberg 
(Pennsylvania  Medical  Journal,  June, 
1905). 

TUBERCULOSIS,  YEAST  IN. 

The  authors  record  the  results-  of  their 
observations  on  the  effect  of  yeast  taken 
internally  in  tuberculosis.  The  yeast  is 
supposed  to  act  by  means  of  its  nuclein 
causing  a  leucocytosis,  and  further  be- 
cause nuclein  is  bactericidal.  In  almost 
every  case  some  improvement  was  noted. 


In  5  cases  tubercle  bacilli  disappeared 
from  the  sputum  and  the  disease  was 
seemingly  arrested.  In  7  cases  marked 
improvement  took  place.  In  11  cases  of 
medium  severity  and  doubtful  progno- 
sis, all  but  one  showed  improvement. 
Twelve  advanced  cases  of  bad  prognosis 
appeared  to  be  benefited,  at  least  for  a 
time.  A  steady  rise  in  the  opsonic  index 
was  noted  in  21  out  of  25  cases  in  which 
it  was  examined  for.  This  index  shows 
the  degree  to  which  the  serum  of  a  per- 
son's blood  prepares  tubercle  bacilli  for 
being  taken  up  and  digested  by  normal 
white  blood-corpuscles.  The  yeast  em- 
ployed was  of  several  different  kinds, 
the  dose  being  2  or  3  grams  taken  once 
a  day  in  cold  or  tepid  milk  or  water. 
Some  patients  noticed  no  influence;  oth- 
ers felt  a  sense  of  well  being,  while  a  few 
had  a  feeling  of  exhilaration.  It  did 
not  appear  to  have  any  influence  on  the 
temperature  of  febrile  patients.  W.  E. 
Huggard  and  E.  C.  Morland  (Lancet, 
June  3,  1905). 

TYPHOID    FEVER,    IODINE     TREATMENT 
OF. 

The  author  states  that  typhoid  is  en- 
demic where  he  lives,  and  his  cases  were 
always  severe,  the  fever  persisting  high. 
One  patient  succumbed  to  pulmonary 
complications.  Since  he  has  begun  to 
use  iodine  systematically  in  treatment 
his  cases  have  all  been  mild.  Even  when 
the  onset  was  stormy,  the  disease  rap- 
idly assumed  a  mild  course.  He  admin- 
istered 7  centigrams  of  iodine  and  70 
centigrams  of  potassium  iodide  during 
the  day,  fractioncd,  with  a  quantity  of 
water.  He  also  gave  from  15  to  20  centi- 
grams of  quinine  to  retard  the  tissue 
breakdown  -and  50  centigrams  of  sodium 
benzoate  to  favor  elimination  of  waste. 
A.  Ceriolo  (Gazzetta  degli  Ospedali,  vol. 


380 


TYPHUS  FEVER. 


xxvi,  No.  7;    Journal  of  the  American 
Medical  Association,  June  10,  1905). 

TYPHUS  FEVER. 

The  authors  record  the  prominent 
features  in  a  series  of  600  cases  of  ty- 
phus fever  coming  under  their  observa- 
tion in  Liverpool.  All  the  cases  were 
drawn  from  the  poorest  and  most  igno- 
rant classes,  and  often  several  cases  came 
from  the  same  family.  The  greater  pro- 
portion of  cases  occurred  during  the  first 
twenty  years  of  life.  Two-fifths  of  the 
cases  occurred  between  the  ages  of  10 
and  20  years.  The  tendency  to  death 
was,  however,  only  one-tenth  as  great  as 
in  cases  occurring  after  20  years  of  age. 
The  onset  was  not  found  to  be  so  sudden 
and  definite  as  is  usually  believed;  in 
children,  indeed,  the  onset  may  not  be 
noticed,  and  attention  first  called  by  the 
rash.  Severe  headache  is  the  most  prom- 
inent of  the  early  symptoms;  it  is  usu- 
ally frontal  and  may  lead  to  early  in- 
somnia and  delirium.  The  typhus  face 
is  very  significant  to  the  trained  eye, 
congestion  being  a  prominent  feature. 
The  conjunctiva  is  suffused,  the  pupil 
contracted,  and  the  expression  dull.  The 
early  severe  headache  and  delirium  are 
probably  due  to  intercranial  circulatory 
disturbance  rather  than  to  any  toxemia. 
Early  deafness  is  often  present.  The 
tongue  is  at  first  raw  and  "beefy,"  and 
constipation  is  an  early  and  a  persistent 
symptom.  Contrary  to  the  general  ex- 
perience, pneumonia  was  rarely  seen, 
but  a  certain  amount  of  bronchitis  was 
always  present.  Muscular  pain  may  be 
present  and  very  acute;  it  is  usually 
located  in  the  calves,  upper  part  of  the 
chest,  and  in  the  arms.  It  may  be  very 
transient,  almost  paroxysmal.-  The  rash 
makes  its  appearance  fairly  constantly 
on  the  fourth  or  fifth  day,  and  is  all  out 


in  three  days.  It  is  usually  seen  first 
over  the  chest  and  shoulders,  and  then 
spreads  to  the  arms,  the  trunk,  and  the 
limbs.  It  is  rarely  met  with  on  the  face. 
The  severity  of  the  attack  is  usually  di- 
rectly proportionate  to  the  copiousness 
of  the  eruption.  The  eruption  is  at  first 
raised  and  disappears  on  pressure; 
within  a  few  days  there  is  a  definite 
hemorrhagic  stain  which  cannot  be  re- 
moved by  pressure.  In  favorable  cases 
the  hemorrhage  begins  to  clear  up  dur- 
ing the  second  week.  A  characteristic 
feature  is  the  lack  of  definite  outline  to 
the  macula?.  Too  much  stress  has  prob- 
ably been  laid  on  subcuticular  mottling. 
The  mousy  odor,  while  often  present,  is 
not  distinctive.  The  delirium  is  often 
very  active  and  may  require  restraint; 
late  in  the  disease  it  may  give  place  to 
the  low  muttering  of  the  typhoid  state. 

Changes  in  the  heart  muscle  are  spe- 
cially incident  in  cases  occurring  among 
the  better  class  of  patients.  The  tem- 
perature chart  is  that  of  a  lobar  pneu- 
monia prolonged  to  fourteen  days,  the 
range  being  high,  103°  to  105°  F.,  with 
a  remission  frequently  toward  the  tenth 
day.  The  termination,  by  crises  in  most 
cases,  is  very  rapid,  and  a  rise  usually 
occurs  in  the  middle  of  its  course.  There 
is  often  considerable  sweating. 

Eecovery  is  rapid;  the  patients  take 
solid  food  within  two  or  three  days,  and 
leave  their  bed  in  a  week's  time.  The 
authors  have  seen  no  case  of  relapse. 
Alcohol  is  of  great  value  as  a  stimulant 
in  typhus,  especially  for  the  circulatory 
disturbances  which  occur  about  the  tenth 
day.  The  disease  is  very  fatal  in  alcoholic 
subjects"  Complications  and  sequelae 
are  few  in  number;  hypostatic  pneumo- 
nia, meningitis,  retention  of  urine,  sup- 
purative parotidis,  multiple  abscesses, 
and  thrombosis  of  the  veins  of  the  lower 


URINE,  PRESERVATION  OF. 


X-RAY  INJURIES,  PROTECTION  FROM.      381 


extremities  may  be  mentioned.  Abor- 
tion is  almost  inevitable  in  pregnant 
women,  but  seems  to  be  beneficial  rather 
than  otherwise.  Typhoid  fever  is  the 
most  frequent  source  of  incorrect  diag- 
nosis; others  are  pneumonia,  menin- 
gitis, scarlet  fever,  and  measles.  In  con- 
clusion the  authors  lay  great  stress  on 
the  value  of  the  free  use  of  fresh  air  in 
the  management  of  typhus  fever.  No 
cases  occurred  in  the  hospital  force,  this 
result  being  attributed  to  the  treatment 
of  the  cases  in  large  wards  with  plenty 
of  air  space.  F.  Robinson  and  E.  T. 
Potts  (British  Medical  Journal,  May 
27,  1905). 

URINE,  PRESERVATION  OF. 

Boracic  acid  is  the  most  practical  uri- 
nary preservative  that  we  possess  when 
used  in  the  proportion  of  5  grains  to  4 
ounces  (or  2  %  grains  to  2  ounces)  of 
urine.  Formaldehyde  should  be  used 
only  by  the  physician  or  a  responsible 
person.  It  should  be  remembered  that 
1  drop  of  the  solution  will  preserve  a 
pint  of  urine  for  about  a  week,  and  that 
1  drop  can  be  used  in  4  ounces  of  urine 
without  harm.  Other  substances  than 
boracic  acid  and  formaldehyde  should 
not  be  used.  The  name  of  the  preserva- 
tive and  the  quantity  that  has  been  used 
should  always  accompany  the  specimen 
to  be  examined.  J.  B.  Ogden  (Boston 
Medical  and  Surgical  Journal,  June  22, 
1905). 

UTERUS,  MALPOSITIONS  OF. 

The  writer  divides  all  malpositions  of 
the  uterus  into  three  classes:  Operative, 
non-operative,  and  questionable.  The 
operative  class  may  be  further  divided 
into  those  requiring  immediate  atten- 
tion, and  those  in  which  it  is  safe  to 
await  for  a  reasonable  time  the  conven- 


ience of  the  patient.  Under  the  first 
subdivision  come  those  cases  which  may 
be  classed  as  emergency  ones,  namely, 
inversion,  incarceration  and  irreducible 
prolapse  of  the  gravid  uterus,  and  ad- 
herent gravid  retrodisplacements  with 
symptoms  of  threatened  abortion.  In 
the  second  subdivision  are  the  compli- 
cated retrodisplacements  and  hernia  of 
the  uterus,  either  through  the  vagina  or 
through  the  abdominal  wall.  In  the 
non-operative  class  the  author  would  in- 
clude the  uncomplicated  retrodisplace- 
ments, and  reducible  hernia  of  the  gravid 
uterus. 

The  questionable  class  embraces  the 
congenital  type  of  cases  and  retrodis- 
placements with  symptoms  relieved  by 
reduction,  but  where  the  use  of  a  proper 
pessary  fails  to  accomplish  an  anatom- 
ical cure,  or  in  young  virgins  where  its 
use  is  unjustifiable.  The  congenital 
cases  being  errors  in  development  are 
each  a  law  unto  themselves,  and  require 
a  most  thorough  investigation. 

Where  the  retrodisplacement  is  the 
only  abnormality  present,  the  patient  is 
often  greatly  benefited  by  an  early  op- 
eration, but  where  other  marked  evi- 
dences of  maldevelopment  exist  the  prog- 
nosis is  unfavorable.  C.  G.  Child,  Jr. 
(Medical  News,  July  1,  1905). 

VARICOSE  ULCERS,  TREATMENT  OF. 

The  various  more  important  methods 
of  treatment  for  ulcers  and  superficial 
wounds  are  recapitulated  by  the  author, 
and  he  points  out  that  Scott  Schley's 
method  is  the  most  logical  and  the  most 
effectual  for  out-patient  practice.  It 
consists  in  covering  the  surface  thickly 
with  a  layer  of  finely-powdered  boracic 
acid,  and  placing  over  it  a  sheet  of  gutta- 
percha tissue  extending  for  3  to  5  cen- 
timeters beyond  the  margin  of  the  raw 


382 


X-RAY  INJURIES,  PROTECTION  FROM. 


BOOK  REVIEWS. 


area.     This  is  fixed  on  with  bands  of 
strapping,  and  a  gauze  dressing  is  ap- 
plied over  it  with  a  bandage.     This  ap- 
plication is  only  changed  every  five  days ; 
frequently  it  may  be  left  for  a  week. 
The  author  has  tried  this  plan  in  25 
cases.    Every  case  was  first  submitted  to 
a  thorough   disinfection   of   the   wound 
and  the  surrounding  parts  by  washing 
it  with  hot  water  and  soap,  shaving  and 
cleansing  it  with  ether  and  alcohol,  and 
subsequently  disinfecting  it  with  corro- 
sive   sublimate.      Having  -  applied    the 
layer  of  boracic  acid,   an  impermeable 
cover   is   made   by    folding   the    gutta- 
percha in  four;    this  is  covered  with  a 
dressing  of  sterilized  gauze  and  cotton 
wool,  which  is  bandaged  on  firmly,  so  as 
to  keep  the  application  in  place.     The 
interval  between  one  dressing  and  an- 
other was  never  less  than  five  days.    Ten 
of  the  author's  cases  had  ulceration  of  a 
septic  nature,  in  7  it  was  due  to  varicose 
veins,  in  4  to  tubercle,  and  in  2  to  burns. 
The  time  required  for  healing  was  ap- 
preciably short;   in  one  case,  which  had 
a  large   septic   ulcer   on  the  leg,   with 
oedema  and  much  local  irritation,  treat- 
ment   was    necessary    for    twenty-seven 
days;    in  other  cases,  fifteen  to  twenty 
days  was  sufficient.     In  all  the  patients 
the  aspect  of  the  wound  had  changed  at 
the  second  dressing;    the  margins  were 
flattened  and  had  advanced  toward  the 
center,  the  granulations  were  firm  and 
red,  the  secretion  was  simply  serous  or 
else    contained    some    debris   from    de- 
stroyed granulation  tissue.    At  the  third 
and  fourth  dressings  the  surface  was  cov- 
ered by  a  fine  skin,  except  for  a  small 
area  in  the  center;    at  the  fourth  and 
fifth   dressings  the  cure  was  complete. 
Such    surprising    and    beneficial    effects 
are  certainly  due  to  the  bland  and  anti- 
septic action  of  the  boracic  acid,  which 


diminishes  the  secretion  from  the  wound, 
at  the  same  time  preventing  the  forma- 
tion of  luxuriant  granulations;  healthy 
granulations,  when  kept  within  proper 
limits,  favor  the  reproduction  of  skin 
and  the  healing  of  the  ulcer.  The  im- 
permeable layer  hinders  the  formation 
of  crusts  under  which  such  wounds  are 
wont  to  secrete  freely.  The  chief  ad- 
vantage of  this  method  is  the  compara- 
tively rapid  and  easy  cure  obtained,  and 
the  saving  of  time  and  of  dressings  to 
both  doctor  and  patient.  Marchetti 
(Gazzetta  degli  Ospedali  e  delle  Clin- 
iche,  May  21,  1905;  British  Medical 
Journal,  July  1,  1905). 

X-RAY   INJURIES,   PROTECTION   FROM. 

The  writer  calls  attention  to  the  seri- 
ous risk  that  x-ray  operators  undergo, 
especially  if  they  follow  the  practice  ad- 
vised of  testing  the  qualities  of  the  rays 
on    their    hands    with    the    fluorescent 
screen.     The  only  practical  method  is  to 
limit  their  radiated  field  by  covering  the 
Crookes  tube.    For  this  purpose  the  au- 
thor uses  a  pasteboard  box  a  little  wider 
than  the  diameter  of  the  tube  and  cov- 
ered with  x-ray  lead  foil  a  little  heavier 
than  the  ordinary  tea  lead.    This  extends 
two  inches  below  the  bottom  of  the  box, 
and  can  be  adjusted  so  as  to  limit  the 
field  to  any  extent  required.     It  is  not 
necessary  to  cover  the  anode  end,  and 
the  box  is  held  on  a  bracket  over  the  por- 
tion of  the  body  to  be  treated ;  if  a  very 
small  field  is  required,  a  local  shield  may 
also  be   employed.     The   author   thinks 
possibly  .some    effects    are    due    to    the 
strong  induction  field   surrounding  the 
coil  which,  especially  in  large  hospitals, 
should  be  kept  in  another  room,  but  with 
the  controlling  apparatus  within  the  op- 
erator's reach.    For  the  dermatitis  of  the 
operator's  hands,  twice  daily  soaking  in 


X-BAY  INJURIES,  PROTECTION  FROM.                BOOK  REVIEWS.                383 

very   warm   water    and   scrubbing   with  10   per   cent,   ichthyol   is   employed  by 

EichhofFs    superfatted    resorcine    soap,  the  author,  which  he  thinks  acts  as  a 

is  advised,  followed  by  inunction  of  Ian-  prophylactic  against  severe  burns.     This 

oline  containing  half  an  ounce  of  boric  should  not  be  confused  with  stearate  of 

acid  and  a  drachm  of  resorcine  to  the  zinc  ointment,  which  may  do  harm.     C. 

ounce.    For  the  acute  erythema  of  x-ray  L.  Leonard    (Journal  of  the  American 

treatment,  a  stearate  of  zinc  powder  with  Medical  Association.  May  6.  1905). 


f$ool<  Reviews. 


American  Edition  of  Nothnagel's  Practice.  Eleventh  Volume.  Diseases  of  the 
Kidneys,  Diseases  of  the  Spleen  and  Hemorrhagic  Diseases.  By  Drs.  H.  Senator 
and  M.  Litten,  Berlin.  Edited,  with  Additional  Notes,  by  James  B.  Herrick,  M.D., 
Professor  of  Medicine  in  Rush  Melical  College,  Chicago.  Octavo  of  816  pages,  illustrated. 
Philadelphia  and  London  :  TV.  B.  Saunders  &  Company,  1905.  Cloth,  $5.00,  net  ;  Half 
Morocco,  $6.00,  net. 

The  American  edition  of  Nothnagel's  Practice  constitutes  a  most  important  addition  to  our 
medical  referen  e  literature.  The  scientific  position  of  the  authors  causes  the  work  to  be  welcomed 
and  accepted  without  hesitation. 

The  appearance  of  this,  the  next  to  the  last,  volume  brings  the  work  near  to  completion  ;  one 
more  is  now  in  preparation  dealing  with  the  Heart  and  its  diseases.  The  classical  work  of  Senator 
has  been  before  the  public  long  enough  to  be  widely  known  and  appreciated  ;  as  Dr.  Herrick  calls 
it,  "a  model  "  of  its  kind. 

He  has  found  little  to  change,  but  has  enlarged  upon  certain  points  of  value  to  the  clinician, 
on  treatment,  diagnosis,  urinalysis,  etc. 

Surgical  treatment  of  nephritis  is  treated  with  the  courtesy  of  omission  by  Senator  and 
condemnation  by  Herrick. 

The  chapter  on  Diseases  of  the  Spleen  and  Hemorrhagic  Diseases,  by  Litten,  are  scholarly 
and  thorough. 

No  mention  is  made  of  the  use  of  Thyroid  Extract,  which  has  been  shown  by  Sajous  to  be  of 
special  practical  value  in  haemophilia,  and  William  J.  Taylor  has  recorded  cases  recently  wherein 
this  exercised  remark ible  control  of  bleeding. — J.  M.  T. 

The  Pharmacopeia  of  the  United  States  of  America.  Eighth  Decennial  Revision.  By 
Authority  of  the  United  States  Pharmacopceial  Convention,  held  at  Washington,  a.d.  1900. 
Revised  by  the  Committee  of  Revision  and  Published  by  the  Board  of  Trustees.  Philadel- 
phia Agents  :  P.  Blakiston's  Son  &  Co.,  1905. 

The  revised  Pharmacopoeia  will  be  welcomed  by  physicians  and  pharmacists  alike.  It  still 
preserves  its  enormous  bulk  ;  it  is  a  pity  more  omissions  could  not  have  been  made.  Certain 
changes  have  been  introduce!  into  the  strengths  of  Tincture  of  Aconite,  Tincture  of  Veratrum, 
and  Tincture  of  Strophanthus  which  are  of  great  importance  for  the  profession  to  know  and 
remember  : — 

Tincture  of  Aconite  has  been  reduced  from  35  per  cent,  to  10  per  cent. 

Tincture  of  Veratrum  has  been  reduced  from         40        "        "     10       " 
Tincture  of  Strophanthus  has  been  increased  from    5        "        "     10       " 

These  changes  have  been  made  in  order  to  conform  to  the  standards  adopted  by  the  Interna- 
tional Conference  on  Potent  Remedies,  held  in  Brussels  in  September,  1900,  the  object  being  to 
make  uniform  the  strength  of  potent  remedies  in  all  parts  of  the  world. — J.  M.  T. 


384 


BOOKS  AND  MONOGRAPHS  RECEIVED. 


5©ol<s  and  /Vlonographs  Received. 


The  Editor  begs  leave  to  acknowledge  with  thanks,  the  receipt  of  the  following  books"  and 
monographs  : — 

"  The  Pharmacopoeia  of  the  United  States  of  America."  Eighth  Decennial  Revision.  Revised 
by  the  Committee  of  Revision  and  Published  by  the  Board  of  Trustees.     Philadelphia  Agents  : 

P.    Blakiston's  Son   &   Company,    1905. "Handbook   of   Anatomy."     By  James   K.    Young. 

Second  Edition,  Revised  and  Enlarged.   Philadelphia  :  F.  A.  Davis  Company.  1905. "Prognosis 

and  Treatment  of  Urethral  Stricture."  By  E  IwarJ  L.  Keyes,  Jr.,  New  York,  1904. "  Mouth- 
Breathing."     By  W.   H.   Fitzgerald,   Hartford,   Conn.      1905. "  Prostatism  Without  Enlaige- 

ment  of  the  Prostate,  Its  Diagnosis  and  Treatment."    By  Charles  H.  Chetwood,  New  York.     1905. 

"Advice  to  Gonorrhceal  Patients."     By  Ferd.   C.  Valentine,   New  York.     1899. "Oj  the 

Treatment  of  Gonorrhoea."    By  Ferd  C.  Va'entine  and  Terry  M.  Townsend,  New  York.    1905. 

"How  the  General  Practitioner  Should  Treat  Gonorrhoea. "     By  Ferd.  C.  Valentine  and  Terry  M. 

Townsend,  New  York.     1904. "  Some  Forensic  Problems  Concerning  Venereal  Diseases"     By 

Ferd.  C.  Valentine  and  Terry  M.  Townsend,  New  Yoi'k.  1905. "Storrs  Agricultural  Experi- 
ment Station,  Storrs,  Conn.,  Bulletin  No.  31,"  November,  1904. "The  Food  Value  of  a  Pound 

of  Milk  Solids." By  C.  L.  Beach. "The  Mexican  Cotton  Boll  Weevil."     By  W.  D.  Hunter 

and  W.  E.  Hinds.     United  States  Department  of  Agriculture,  Washington,  D.  C,  1905. "The 

Relation  of  Coyotes  to  Stock  Raising  in  the  West."  By  David  E.  Lantz.  United  States  Depart- 
ment of  Agriculture,  Washington,  D.  C,  1905. 


EDITORIAL    STAFF. 

Sajous's  Analytical  Cyclopaedia  of  Practical  Medicine. 


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THE    MONTHLY   CYCLOPEDIA 

OF 

PRACTICAL   MEDICINE 


(Published  the  Last  of  Each  Month) 


Vol.  XVIII. 
Old  Series. 


PHILADELPHIA,  SEPTEMBER,  1905. 


Vol.  VIII,  No.  9. 

New  .Series. 


TABLE   OF  CONTENTS. 


PAGE 

EDITORIALS 

ON    THE    HOME    TREATMENT 
OF  EPILEPSY.     Ch  ,rles  L.Dana  3S5 

suturing:    the  heart  muscle. 

Harry  M.  Sherman 3SS 

the  early  recognition  and 
care  op  mental  defects 

IN  CHILDREN.    Martin  W.  Barr  302 

REMARKS  ON  MUSCULAR  RHEU- 
MATISM AND  ALLIED  PAIN- 
FUL  STATIS.     J.  Madison  Tay 


lor 


394 


CYCLOPEDIA    OF   CURRENT 
LITERATURE 

ACTINOMYCOSIS,  TREATMENT  OF. 

Bevaa 399 

ALBUMINURIA,     PROGNOSIS     AND 

TREATMENT  OF.  Fiirbringer..  399 
ALCOHOL,    EFFECT    OF,   ON   THE 

CIRCULATION.      Martin   Koch- 

mann 400 

ANEMIA,  PERNICIOUS,  ETIOLOGY 
AND  PATHOGENESIS  OF.  C. 
H.  Bunting 40U 

ARTIFICIAL  RESPIRATION.    G. 

Herter 401 

ATROPINE  AND  HOMATROPINE  A8 
CYCLOPLEGICS,  RELATIVE 
ACTIONS  OF.     Oscar  Wilkinson  401 

BLOOD-PRESSURE  OBSERVATIONS. 

C.  E.  Brush 402 

BREATHLESSNEBS,  ESPECIALLY 
IN  RELATION  TO  CARDIAC 
DISEASES.     Lauder  Brunton 402 

BRIGHT'g  DISEASE,  LAVAGE  OF 
RENAL  PELVES  IN.  Winfield 
Ayres  _ 403 

BRONCHITIS,  CAPILLARY,  TREAT- 
MENT OF.     O.  Heubner 403 

BURN8,    TREATMENT     OF.      Haldor 

Shove i.  404 

OEREBELLAR  TVMORS,  SYMPTOMS 

OP.     J.  M.  Clarke 404 

CERVICAL  RIB,  SURGICAL  IMPOR- 
TANCE OF.     Carl  Beck 405 

CUTANEOUS  SYPHILIS.     Fiechkin....  166 

DELIRIUM  TREMENS,  COLD  AF- 
FUSION IN.     William  Broadbent  400 

DELIRIUM  TREMENS,  INJECTION 
OF  SALINE  SOLUTION  IN. 
Qnenu 406 


DENTITION,  THE  MEDICAL 
A8PECT8  OF  THE  SECOND. 
H.  Armstrong 400 

DIABETES,     LOAF     SUGAR    IN. 

Oefele 407 

ERGOT,  INTRAVENOUS  INJECTION 
OF;  EFFECTS  ON  THE  MAM- 
MALIAN   CIRCULATION. 

Torald  Sollmann  and  E.D.  Brown  407 

FRACTURE  OF  THE  NECK  OF  THE 
FEMUR,  TREATMENT  OF. 
R  yal  Whitman 108 

FURUNCLES  AND  CARBUNCLES, 
NEW  LOCAL  TREATMENT 
FOR.     Marcus 40S 

GALL-BLADDER,  RUPTURE  OF  THE. 

B.  M.  Ricketts 4(19 

GASTRIC  INTOLERANCE  IN  TOUNG 

CHILDREN.     M.  E.  Terrien 409 

GA8TRIC  SECRETION.     J.  S.  Edking.  409 

GONORRHOEA  IN  THE  FEMALE.     L. 

Archambault 410 

HYPEREMESIS  GRAVIDARUM. 

TREATMENT  OF.     R.  V.  Uhle..  4i0 

INEBRIATE  MANIAS.    T.D.Crotbers  410 
INFANT  FEEDING.     T.G.Sanderson- 
Wells 411 

IODINE  AND  IODIDES,  CHANGES 
IN  THE  BLOOD  OF  CHILDREN 

DUE  TO.     A.  B.  Gianasso 411 

JOINT  INJURIES,  FUNCTIONAL 
IMPOTENCE    FOLLOWING. 

Mally  and  Richon 412 

LEPROSY,   CURE  OF.     Isadore  Dyer...     12 
LIGATURE    OF    THE    INNOMINATE 

ARTERY.     William  Sheen 413 

MOVABLE     KIDNEY,     TREATMENT 

OF.     Newman 413  I 

MUSCLES,  PRODUCTION  OF  ALCO- 
HOL AND  ACETONE,  BY  THE. 

F.  Maigrian 414 

NASAL  HEADACHE.     Somerg 414  I 

NEPHROPTOSIS.    Earl  Harlan 414 

OPTIC  NERVE,   INJURIEB    OF   THE. 

J.  J.  Evans 415 

PELVIC  OPERATIONS,  INFLAMMA- 
TORY OONDITION8  OF  AP- 
PENDIX IN.     Hunter  Robb Ilfi 

PERINEPHRITIC  AB80E8S.     Bryan..  415 
PERTU88I8,  TREATMENT  OF.     J.B. 

Tyrrell 416 


PAGE 

PNEUMONIA,  LOBAR,  ICE  APPLI- 
CATIONS IN.     P.  A.  Aurness 416 

PNEUMONIA,  LOBAR,   IN  INFANT8 

AND  CHILDREN.     H.  Koplik...;  417 

PNEUMONIA,   PROGNOSTIC  VALUE 
OF      PHOSPHATES     IN      THE 
URINE  IN.     Sicuriani 418 

RHEUMATISM  OF  THE  FEET.     L.W. 

E17 418 

SALT  SOLUTION,  PHYSIOLOGICAL 
VALUE  OF,  IN  CIRCULATORY 
FAILURE.     H.  C.  Wood 419 

SEPTIC  PERITONITIS  DIFFUSE 
DRAINAGE  IN.  Van  Buren 
Knott 419 

STRABISMUS,  CONVERGENT.  Wen- 
dell Reber.„ 420 

TABES,  PRINCIPLES  OF  THE 
EXERCISE  TREATMENT  IN. 
Fraenkel 420 

TETANUS.     J.  M.  Anders   and  A.   C. 

Morgan 21 

TRACHOMA    TREATED    WITH 

RADIUM.     J.  V.  Zelenkovski.....  421 

TUBERCULAR  CERVICAL  LYMPH- 
NODES,  SURGICAL  TREAT- 
MENT OF.     C.  N.  Dowd 422 

TUBERCULOSIS    AND   PREGNANCY. 

G.  E.  Malsbary 422 

TUBERCULOSIS     OF    THE     CECUM. 

R.  A.  Stoney 424 

UREMIC  HEMIPLEGIA,  INTRA- 
CRANIAL PRESSURE  IN.  R. 
N.  Willson 424 

tTRETHRO-RECTAL     FISTULA.       W. 

M.  Beach 425 

UTERINE    CARCINOMA.   EARLY 

DETECTION  OF.     D.  II.  Craig...  420 

UTERINE  HEMORRHAGE,  ARTERI- 
OSCLEROSIS OF  THE  UTERUS 
AS  A  CAUSAL  FACTOR  IN. 
Palmer  Findley 426 

UTERUS,  FIBROID  TUMOR8  OF, 
BURGICAL  TREATMENT.  F. 
H.  Martin 427 

X-RAY    TREATMENT    OF    CANCER. 

William  B.  Coley 428 

YEAST  CELLS,  ACTION  OF.  Wal- 
ter Maiden 428 

CHANGES  IN  THE  PHARM  ACOPCEIA.  429 

THE     INTERNATIONAL     MEDICAL 

CONGRESS 429 

EDITORIAL  STAFF 432 


Editorials. 


DEPARTMENT  IN   CHARGE   OF 

J.  MADISON  TAYLOR,  A.M.,  M.D. 


ON"  THE  HOME  TREATMENT  OF  EPILEPSY. 
I  write  this  article  because  I  find  that  physicians  who  undertake  the  treat- 
ment of  epileptics  often  do  not  realize  the  seriousness  of  their  responsibilities. 
Many,  I  fear,  simply  give  a  little  bromide,  stop  the  meat,  circumcise  the  boy,  and 

i        \  ,  \  •.  i  \  (385) 


336  ON  THE  HOME  TREATMENT  OF  EPILEPSY. 

say  they  think  the  child  will  outgrow  it.  But  children  do  not  outgrow  it;  they 
steadily  get  worse  unless  something  definite  is  done,  and  well  done  for  a  long  time. 
With  proper,  prompt,  and  prolonged  treatment,  the  attacks  can  be  entirely  con- 
trolled in  5  to  10  per  cent,  of  cases,  and  I  believe  more.  They  can  be  greatly  con- 
trolled in  over  one-half  the  cases,  so  that  the  patient  may  be  nble  to  continue  his 
education  and  do  some  work  in  life.  But  this  cannot  be  accomplished  by  any  casual 
dosing  or  occasional  consultation  with  some  high  authority.  The  physician  should 
approach  the  responsibility  of  a  case  of  epilepsy  as  he  would  that  of  a  mortal  sur- 
gical condition,  in  which  much  depends  on  knowledge  and  attention  to  all  the 
details  of  a  long  technique. 

It  is  conceded  that  the  colony  treatment  of  epilepsy  is  the  one  which  approaches 
most  nearly  the  ideal  in  effectiveness,  but  it  cannot  be  applied  to  all  classes— at 
least,  for  a  long  time— and  perhaps  never  to  a  certain  rather  large  percentage. 
There  must  always,  therefore,  be  a  good  many  epileptics  who  have  to  be  treated  at 
their  homes,  and  whose 'care  must  be  directed  by  the  family  physician  or  the  spe- 
cialist. 

For  this  class  of  persons  I  have  gradually  evolved  a  conventional  or,  as  I  have 
termed  it,  a  "formal"  treatment  of  epilepsy,  which  seems  to  produce  the  most  satis- 
factory results  in  those  cases  in  which  a  reasonable  opportunity  for  therapeutic 
effort  exists.  That  is  to  say,  cases  which  are  not  of  very  long  standing,  and  which 
have  not  already  undergone  serious  mental  deterioration,  and  cases  in  which  the  - 
mental  and  physical  degeneration,  at  the  beginning,  is  not  of  a  very  high  grade. 
The  details  of  this  treatment  I  have  already  published,  but  they  only  reached  the 
circle  of  the  readers  of  the  Annual  Eeport  of  the  Department  of  Neurology,  Cornell 
Medical  College,  1904,  hence  some  of  the  principal  points  involved  I  have  thought 
might  be  presented  here. 

The  features  upon  which  emphasis  must  be  laid,  in  the  treatment  of  epilepsy, 

are: — 

First,  the  fact  that  the  course  of  treatment  about  to  be  instituted  is  to  last  for 
at  least  two  years,  and  that  all  measures  prescribed  must  be  carried  out  with  the 
greatest  fidelity  and  exactness  during  that  time,  no  matter  how  well  the  patient 
may  seem,  or  how  unnecessary,  regimen  and  drugs  may  appear  to  be.  The  prepara- 
tion and  outlining  of  treatment  should  receive  the  care  and  attention  such  as  is 
given  to  a  capital  operation. 

Second,  the  use  of  the  pure  bromide  of  sodium  salt,  in  combination  with  the 
glycero-phosphate  of  soda,  so  that  a  patient  takes-  on  an  average  60  grains  of  the 
bromide  of  soda  and  20  to  30  grains  of  the  phosphate,  in  twenty-four  hours.  To 
this  combination  iron  and  a  little  arsenic  may  be  added,  if  needed.  It  has  seemed 
to  me  proved,  beyond  any  question,  that  by  the  combination  of  proper  soluble  phos- 


ON  THE  HOME  TREATMENT  OF  EPILEPSY.  387 

phates  with  bromide,  the  depressing  effect  of  the  bromide  can  be  largely  gotten 
rid  it,  and  the  patient  can  continue  bright  and  active,  and  grow  fat  under  a  fairly 
large  dose  of  the  drug.  This  has  been  tested  by  me  now  for  about  four  years,  mainly 
in  private  practice,  but  also  in  my  dispensary  work.  The  maximum  dose  of  bro- 
mide which  can  be -taken  in  this  combination  is  sometimes  as  high  as  90  grains  a 
day,  but,  rarely,  more,  and  not  often  as  much. 

Third,  1  have  found  it  a  most  efficacious  plan  in  treatment  to  intermit  the 
medication  for  either  one  or  two  days  in  each  seven.  During  these  days,  e.g.,  a 
Wednesday  and  Sunday,  the  drug  is  stopped,  and  in  its  place  is  given,  three  times 
a  day,  before  meals,  a  tumbler  of  hot  water,  and  with  it  an  alkaline  laxative.  The 
ordinary  tablet  of  rhubarb  and  soda,  with  nux  vomica,  usually  answers  this  pur- 
pose. Sometimes  20  grains  of  bicarbonate  of  soda  is  enough.  Its  purpose  is  to  flush 
out  the  stomach  and  bowel  and  cleanse  the  gastro-intestinal  canal  twice  a  week, 
thus  preventing  the  accumulation  of  drugs  and  toxins.  After  meals  on  these  days 
I  sometimes  give  10  drops  of  tincture  of  iron  or  some  needed  tonic.  I  have  not 
seen  any  access  of  convulsion  during  the  day  or  the  day  after  such  intermission. 

Fourth,  an  important  measure  which  I  employ  in  the  treatment  is  the 
securing  of  violent  physical  exercise  for  about  twenty  or  thirty  minutes,  at  least, 
three  times  a  week.  This  must  be  done  either  by  some  active  sport,  like  boxing,  in 
the  gymnasium,  by  tennis,  skating,  or  by  the  simpler  methods  of  chopping  or  saw- 
ing wood  or  punching  the  bag;  but  the  exercise  of  whatever  kind  should  be  short 
and  to  the  point  of  free  perspiration.  After  this  exercise,  the  patient  is  given  a 
cool  bath.  Delicate  persons,  women,  and  those  who  are  unable  to  carry  out  such 
exertion,  I  direct  to  purchase  a  "hot-box"  and  take  a  hot-box  sweat,  followed  by  a 
cool  bath,  three  times  a  week.  These  boxes  are  not  expensive,  and  can  be  set  up  with 
little  trouble. 

Fifth,  the  question  of  diet  is  attended  to,  but  upon  this  I  have  no  regimen 
other  than  that  of  the  moderate,  mixed  diet,  with  the  small  amount  of  meat,  which 
is  usually  recommended. 

I  have  not  collected  my  statistics  as  yet  to  support  the  validity  of  my  belief 
that  this  outline  of  treatment  furnishes  the  best  indications  for  the  home  care  of 
epilepsy,  nor  do  I  claim  that  it  cures  cases.  I  have,  however,  a  good  many  patients 
who  came  to  me  with  attacks  two  or  three  times  a  month,  who,  under  this  treat- 
ment, have  been  able  to  keep  their  attacks  under  control,  so  that  they  have  prac- 
tically none,  or  only  one  or  two  a  year,  and  are  able  to  resume  their  work,  for  it 
has  always  been  my  belief  that  epileptics  should  be  made  to  go  to  work,  and  to  live, 
in  every  way,  as  nearly  like  normal  persons  as  possible. 

It  goes  without  saying  that  there  are  many  epileptics  who  are  too  advanced 
or  too  degenerate  for  treatment  and  who  need  only  custodial  measures. 


388  SUTURING  THE  HEART  MUSCLE. 

I  am  strongly  in  favor,  however,  of  giving  bromide,  guarded,  as  indicated,  by 
measures  which  keep  open  the  skin,  cleanse  the  bowels,  and  invigorate  the  circulation. 
The  dose  should  not  be  large.  Not  much  can  be  done  if  60  or  80  grains  will  not 
do  it.  There  is  no  merit  in  mixing  bromides,  and  the  sodium  salt  is  as  good  as  any. 
The  dose  should  be  increased  as  the  patient  gets  better;  he  should  take  more,  if 
possible,  at  the  end  of  the  second  year  than  at  the  beginning  of  the  first,  if  the 
attacks  are  controlled.  After  four  years  one  can  feel  safe,  not  before.  There  are 
no  other  drugs  of  any  importance  in  epilepsy,  though  freak  cures  happen  under  all 
kinds  of  measures.  Looking  over  the  histories  of  twenty  cases  which  I  have  followed 
in  private  practice  in  the  last  four  years,  I  find  in  5  no  help  at  all;  in  3  attacks 
stopped  for  2  to  4  years;  in  12  attacks  reduced  from  ^  to  1/12,  i.e.,  from  1  every 
two  to  six  weeks,  to  1  every  six  to  eighteen  months,  the  patients  all  being  well, 
feeling  well,  and  doing  their  work  like  other  people. 

Charles  L.  Dana. 


SUTURING  THE  HEAET  MUSCLE. 


In  1896  was  recorded  the  first  suture  of  the  heart  muscle  to  close  a  wound, 
and  in  1902  I  collected  34  cases  which  had  been  reported  in  the  intervening  six 
years.  In  September,  1904 — a  little  more  than  two  years  after  these  34  cases  were 
collected — Stewart  collected  60  cases,  showing  in  general  that  surgeons  had  learned 
the  lesson  from  the  statistics,  were  on  the  lookout  for  the  cases,  and  were  submit- 
ting the  patients  to'  operation.  I  have  made  no  search  for  cases  reported  since  last 
September,  but  the  assumption  that  there  are  some  such  is  surely  not  far  fetched. 

Now  60  cases  is  a  large  number  if  one  thinks  of  them  as  representing  a  series 
of  recent  operations  on  a  rare  condition,  which  was  untreated  up  to  the  time  of 
the  series.  But  60  cases  are  hardly  enough  to  supply  all  necessary  facts  so  that 
reliable  general  inferences  may  be  drawn  and  safe  general  rules  formulated.  Fur- 
thermore, it  is  not  to  be  expected  that  in  the  short  time  of  two  years  there  should 
have  come  any  marked  changes  in  the  statistics  of  recovery  and  death  between  the 
first  and  the  last  half  of  the  60,  especially  as  the  operators  have. been  so  many,  for 
only  eleven  men  have  had  the  opportunity  of  repeating  the  operation  once,- and  only 
three,  Ninni,  Giodorno,  and  Barth,  have  done  it  three  times.  In  the  1902  list  38 
per  cent,  of  the  patients  recovered,  counting  all  the  cases;  in  the  1904  list  38  1/3 
per  cent,  recovered,  showing  that  there  was  a  remarkable  average  struck  in  the  four 
contributing  elements,  the  patient,  the  wound,  the  infection,  and  the  operator.  It 
hardly  seemed  fair,  in  discussing  the  1902  list,  to  count  as  against  the  operation  those 
cases  in  which  hopeless  conditions  were  disclosed,  and  those  patients  who  died  of  the 
haemorrhage  from  the  original  wound  in  spite  of  the  operation.    Eliminating  these 


SUTURING  THE  HEART  MUSCLE.  389 

and  considering  only  those  patients  who  had  a  chance,  which  was  given  them  by  the 
operation,  the  percentage  of  recoveries  was  nearly  doubled.  Much  the  same  is  true 
of  the  60  cases.  Stewart  notes  a  mortality  of  over  76  per  cent,  in  those  patients 
operated  upon  within  four  hours,  and  in  those  whose  wound  did  not  kill  within  that 
time  and  who  had  the  operation  later,  the  mortality  was  30  per  cent.  In  regard  to 
the  other  two  matters  of  infection  and  drainage  there  is  such  a  close  similarity  in  the 
60  cases  as  in  the  34  that  we  have  to  say  that  the  increase  in  the  cases  and  the 
operations  has  not  as  yet  taught  anything  new  or  definite,  and  the  same  may  be 
expected  to  be  true  of  the  next  60  cases,  unless  it  chances,  which  is  unlikely,  that 
many  operations  can  be  done  by  one  operator  and  give  him  special  opportunities  for 
observation. 

There  has  come,  however,  a  suggestion  of  an  extension  of  the  application  of 
the  operation.  Guibal,  in  the  Revue  de  Chirurgie,  1905,  suggests  suture  of  the 
heart  in  those  cases  of  rupture  in  which  the  pericardium  is  intact,  a  rupture 
that  is  produced  by  traumatism  and  is  not  a  pathologic  end  product.  Guibal  says 
the  operation  has  not  yet  been  done  for  this  condition,  but  that  the  condition  at 
times  is  met.  The  traumatism  to  the  heart  may  be  by  fractured  ribs  or  sternum,  or 
a  blunt  missile;  it  may  make  a  contused  wound  in  the  heart  penetrating  to  the 
endocardium  or  not,  but  not  tearing  the  pericardium.  Or  the  rupture  may  be  due 
to  compression,  in  which  case  the  incompressible  blood  in  the  heart  bursts  the 
organ  in  its  thinnesf  parts,  that  is,  in  the  auricles,  and  the  tear  may  even  extend  into 
the  large  veins.  Given  a  rupture  of  the  heart  with  intact  pericardium,  the  condi- 
tions under  which  the  heart  works  differ  from  those  in  which  the  pericardium  is 
torn.  In  the  former  case  a  certain  amount  of  blood  escapes  from  the  ventricle  into 
the  pericardial  sac  at  each  systole,  and  in  time  the  pressure  of  blood  in  the  sac 
approximates  and  then  equals  the  pressure  in  the  ventricle.  When  this  state  is 
reached  blood  cannot  enter  the  auricles  from  the  large  veins,  for  they  are  subjected 
to  an  external  pressure  equal  to  the  systolic  ventricular  pressure ;  the  heart  is  prac- 
tically strangulated,  for  its  own  blood  supply  is  cut  off ;  it  may  not  be  inapt  to  say 
it  is  drowned  in  its  own  blood.  This  does  not  occur  if  there  be  a  wound  in  the 
pericardium  associated  with  that  in  the  heart ;  blood  poured  into  the  pericardium 
can  escape  into  the  pleura,  or  mediastinum  or  on  the  surface.  If  death  comes  from 
the  haemorrhage  it  is  due  to  the  general  acute  anaemia.  If  it  comes  in  the  ease  of 
the  intact  pericardium  with  the  wounded  heart,  it  is  due  to  the  compression  and  the 
anaemia  of  the  heart  alone. 

The  supervention  of  this  haemopericardium  may  be  quick  or  slow.  Guibal  refers 
to  two  cases  in  men;  one,  that  of  Podrez,  took  but  three  days  to  attain  a  critical 
stage ;  the  other,  that  of  Mansel-Moullin,  required  three  weeks.  That  it  may,  how- 
ever, be  much  quicker  than  in  either  of  these  cases  is  evident  from  laboratory  work, 


390  SUTURING  THE  HEART  MUSCLE. 

and  this  has  shown  that  the  deaths  due  to  heart  trauma  which  occur  from  a  few 
minutes  to  a  few  hours  after  the  injury  are  due  to  acute  hsemopericardium. 

It  will  not  be  wise  to  pass  this  suggestion  lightly  by.  It  is  more  than  likely 
that  patients  with  this  injury  are  in  the  hands  of  surgeons  at  this  very  moment. 
Probably  the  heart  injury  is  one  of  a  number  of  associated  lesions,  and  if  it  is  it 
is  surely  the  one  of  maximal  importance.  If  the  patient  dies,  it  is  not  at  all  im- 
probable that  the  heart  injury  cuts  a  figure  next  in  causal  importance  to  injuries 
of  the  central  nervous  system,  and  if  that  be  so  we  have  the  satisfaction  of  knowing 
that  the  heart  is  accessible,  that  its  injuries  can  be  repaired,  and  that  healing  may 
be  expected. 

The  appreciation  of  the  condition  does  not  seem  to  be  difficult.  The  history 
and  character  of  the  general  injury  would  be  suggestion,  and  shortly,  that  is,  within 
a  few  minutes,  or  a  few  hours,  or  a  few  days,,  would  supervene  the  symptoms  of 
embarrassed  heart  action,  and  the  rapidity  of  its  action  would  not  be  an  element 
of  the  symptom  complex  of  an  infection.  At  this  time  the  area  of  cardiac  dullness 
should  be  much  increased.  In  the  case  of  Podrez,  Guibal  states  that  the  cardiac 
dullness  extended  from  the  third  to  the  sixth  rib,  and  from  the  right  border  of  the 
sternum  to  the  left  anterior  axillary  line. 

If  we  can  recognize  the  gradual  supervention  of  compression  of  the  brain  due 
to  a  slowly  forming  extravasation  of  blood,  if  we  can  locate  the  clot  and  operate  for 
its  removal,  we  should  be  able  to  recognize  this  compression  of  the  heart.  In  the 
case  of  the  brain  we  only  get  those  symptoms  which  come  to  us  through  the  nervous 
system,  while  in  the  case  of  the  heart  we  can  use  the  ordinary  methods  of  physical 
examination,  and  no  operation  should  be  undertaken  unless  the  physical  signs  show 
that  the  pericardium  is  distended  far  beyond  its  usual  limits.  If  it  is  so,  and  the 
heart  is  working  rapidly  and  ineffectively,  the  inference  must  be  that  something 
i<  distending  the  pericardium  and  interfering  with  heart  action;  that  this,  after 
a  trauma  of  the  thorax,  and  in  the  absence  of  symptoms  of  infection,  is  most  likely 
to  be  a  hemorrhage,  and  that  to  permit  the  condition  to  go  unrelieved  will  be  quite 
as  reprehensible  as  it  would  be  to  permit  a  patient  to  die  of  compression  of  the  brain 
without  opening  the  skull. 

Mansell-Moullin  operated  on  his  patient,  relieved  the  haemopericardium,  and 
later  on  the  man  resumed  foot-ball,  in  playing  which  he  had  gotten  his  injury. 
1  think  that  surely  others  of  us  must  have  the  same  opporhmity  presented  sooner 
or  later,  and  the  only  way  to  adequately  meet  the  contingency  will  be  to  prepare  to 
recognize  it. 

It  is  hardly  practical  to  enter  into  technical  operative  details  in  this  place,  but 
thero  are  some  points  which  merit  brief  mention.  The  suture  material  of  choice 
for  the  heart   muscle  is  still  silk,  though  long-lived  catgut  is  permissible.     The 


SUTURING  THE  HEART  MUSCLE.  39I 

refinement  of  placing  the  suture  during  diastole,  and  tying  in  a  succeeding  diastole 
is  abandoned.  Operators  on  human  hearts  find,  as  I  found  on  dog's  heart,  that  the 
rhythm  of  heart  action  continues  even  though  the  organ  be  hanging  from  a  string, 
and  so  the  first  suture  is  tied  and  the  ends  left  long  and  used  to  hold  and  steady 
the  organ  during  the  placing  of  the  other  sutures.  This  is  really  a  manoeuver  of 
considerable  value,  especially  as  the  heart  might  otherwise  require  to  be  lifted  from 
the  pericardium  for  each  suture  and  be  thus  subjected  to  an  unnecessary  amount 
of  handling.  Finally  the  fear  of  subsequent  ills  such  as  from  wounding  and  tying 
the  coronary  arteries  is  abolished.  Eicketts  showed  that  either  coronary  might  be 
tied  in  the  dog,  without  harm,  and  it  had  been  the  same  in  my  dog  work.  In  addi- 
tion Stewart  wounded  the  coronary  artery  in  placing  a  suture  in  a  human  heart 
and  tied  it,  and  his  patient  recovered.  So  that  the  fact  that  the  coronary  arteries 
may  be  treated  as  other  arteries  if  they  are  cut,  seems  to  have  a  good  foundation  in 
experience. 

There  is  naught  more  disheartening  to  a  surgeon  than  to  have  an  otherwise 
exemplary  technique  stultified  by  infection.  The  operator  on  emergency  cases  has 
this  saving  clause  in  the  face  of  this  mischance:  that  he  may  divide  the  respon- 
sibility with  the  original  wounding  instrument,  even  though  he  has  no  way  of 
definitely  knowing  that  the  infection  really  occurred  before  his  operation.  Basing 
conclusions  on  a  most  meager  list  of  cases  I  found  that  in  heart  wounds  infection 
was  caused  in  one-third  of  the  cases  by  the  wounding  instrument.  This,  I  think, 
makes  it  incumbent  on  every  operator  to  consider  every  such  wound  as  probably 
infected  and  to  arrange  for  drainage. 

The  merest  glance  at  the  list  will  show  the  need  of  this,  for  almost  all  the 
cases  that  lived  long  enough  for  infection  to  develop,  exhibited  it,  and  it  cut  a 
decided  figure  in  the  mortality,  being  the  cause  of  death  in  all  the  fatal  cases  that 
did  not  die  of  hemorrhage  or  of  the  shock  of  the  primary  operation.  But  there 
seems  to  be  a  difference  in  the  susceptibility  to  the  infection  of  the  two  serous  sacs 
involved.  The  pericardium  is  much  less  frequently  affected  than  is  the  pleura,  ana 
this  makes  it  probably  correct  practice  to  close  the  pericardium  without  drainage, 
and  probably  wrong  to  do  that  with  the  pluera.  Indeed  one  must  expect,  if  one  does 
not  drain  the  pleura  primarily,  to  have  to  do  so  secondarily,  and  surely  in  the  face 
of  this  contingency  one  should  always  choose  the  practice  that  exposes  the  patient 
to  the  least  risk,  and  that  must  lie  in  the  placing  of  a  precautionary  drain.  Further 
than  this  one  might,  with  reason,  strap  the  left  side  of  the  chest  to  limit  motion, 
lessen  the  amount  of  effusion,  and  give  the  pleura  a  chance  to  dispose  of  what  was 
inevitably  present.  It  is  not  likely  that,  with  a  pneumo-luemothorax  present  the 
left  lung  will  be  of  much  practical  value  to  the  patient,  even  though  his  acute 
ainc  1  nia  makes  him  suffer  some  from  air  hunger. 


392  RECOGNITION  AND  CARE  OF  MENTAL  DEFECTS  IN  CHILDREN. 

It  hardly  seems  likely  that  any  of  the  lesions  of  the  heart  which  interest  the 
physician  will  be  amenable  to  surgical  intervention,  even  though  an  English  phy- 
sician did  suggest  that  mitral  insufficiency  might  be  remedied  by  contracting  the 
orifice.  The  pathologic  heart  is  already  potentially,  if  not  actually,  incompetent, 
hence  does  not  invite  one  to  add  to  its  load,  and  the  explorer  in  this  field  will  have 
to  be  either  a  preternaturally  wise  or  a  very  venturesome  man. 

Harry  M.  Sherman.* 


THE  EAELY  KECOGNITION  AND  CAEE  OF  MENTAL  DEFECTS 

IN  CHILDEEN. 

The  early  recognition  of  mental  defect  in  children  and  its  mitigation  is  a 
crying  need  of  the  day,  for  the  untrained  adult  imbecile  stands  the  most  helpless, 
often  the  most  dangerous,  type  of  a  dependent  class.  If  there  be  an  appearance 
of  intelligence  which  he  does  not  possess,  and  he  looks  brighter  than  he  really  is, 
just  in  the  same  proportion  is  more  expected  of  him  than  he  is  capable  of  fulfilling, 
and  to  those  who  do  not  understand  him  he  is  consequently  most  irritatingly  disap- 
pointing. Should  he  have  attained  the  stature  and  physical  development  of  a  man, 
and  yet  be  of  low  mental  grade,  incapable  of  self-help,  he  becomes  naturally  a  greater 
care  to  those  in  charge  of  him  than  the  child  who  can  be  handled  with  more  ease. 
Again,  if  he  be  possessed  of  a  high  or  middle  grade  of  intelligence,  which  yet  has 
not  been  directed  by  training  into  some  channel  of  usefulness,  indolence  and  that 
susceptibility  to  suggestion  peculiar  to  his  class  will  render  him,  if  he  be  not  under 
constant  guardianship,  the  tool  or  the  victim  of  vicious  persons  who  will. quickly 
gather  him  into  the  criminal  ranks.  Most  generally  ignorance  of  true  conditions, 
or  a  futile  hoping  against  hope,  has  kept  him  in  the  home  untrained  and  untaught 
until  degeneration  from  lack  of  stimulation  has  atrophied  his  meager  faculties. 
Then,  when  too  late,  and  the  burden  has  become  insupportable,  the  training-school 
is  invoked  to  do  the  impossible — to  train  the  untrainable — and  too  often,  where 
influence  can  accomplish  it,  such  cases,  properly  subjects  for  mere  asylum  care,  are 
forcing  out  the  young  trainable  children,  who  might  be  brought  to  a  condition  of 
fair  responsibility  or  even  semi-self-support.  Thus  we  find,  as  links  in  a  chain, 
wrongs  affecting  the  home,  the  school,  the  individual,  and  his  neighbor,  following  in 
natural  sequence;  all  traceable  too  often  to  the  ignorance  of  the  parents  and  the 
family  physician. 

The  strenuous  quality  of  our  modern  life  creating  a  highly  nervous  race,  result- 
ing naturally  in  an  increase,  marked  and  rapid,  of  mental  defect,  psychosis,  and 
nervous  disease,  presents,  as  does  the  much-talked  of  race  suicide,  a  wide  field  of 


Professor  of  Surgery  in  the  University  of  California. 


RECOGNITION  AND  CARE  OF  MENTAL  DEFECTS  IN  CHILDREN.  393 

research  to  the  student  of  to-day,  who  finds  therein  that  over-much  zeal  has  not 
always  for  its  goal  the  ultimate  good,  no  more  than  is  "race  suicide,"  so  called,  an 
unmitigated  evil,  since  only  by  the  elimination  of  the  strain  that  threatens  race 
degeneration,  may  we  hope  for  a  survival  of  the  fittest. 

In  view  of  the  overwhelming  evidence  which  statistics  present  of  the  far-reach- 
ing power  for  ill,  of  accident,  of  disease,  and  of  hereditary  transmission  as  seen  in 
unlooked  for  lapses  into  idiocy,  imbecility,  epilepsy,  sudden  outbreaks  into  insanity, 
and  their  recurrence  in  generations  through  latent  or  combined  neuroses,  it  would 
seem  that  these  subjects  should  achieve  a  greater  prominence  in  the  lectures  of  our 
medical  colleges,  so  that  the  young  physician  shall  be  early  led,  while  yet  a  student, 
to  search  out  and  consider  such  influences  before  making  a  positive  diagnosis. 
Ability  to  recognize  defect  and  to  affirm  its  absolute  incurability;  to  diagnose  and 
to  explain  the  special  forms  of  defect;  to  discriminate  between  the  hopelessness  of 
idiocy  and  the  possibilities  of  amelioration  for  the  imbecile;  to  outline  the  measures 
indicated,  and  furthermore,  exhibit  courage  to  give  repeated  and  emphatic  warning 
as  to  the  danger  of  delay,  are  responsibilities  confronting  to-day  almost  every  gen- 
eral practitioner;  and  yet  how  few  are  prepared  to  meet  it. 

The  student,  if  he  is  to  be  successful  in  meeting  all  the  demands  of  the  day, 
must  be  brought  to  realize  that  books  are  but  feeble  guides  and  aids  to  that  higher 
study  found  beyond  the  limits  of  the  lecture-room,  the  dissecting-room,  and  the  bed- 
side clinic.  He  will  need  to  prepare  himself  to  discriminate  intuitively  between 
disease  and  defect — which  constitutes  the  real  difference  between  insanity  and  im- 
becility— and  to  recognize  readily  the  stigmata  of  degeneration;  and  this  power  is 
best  gained  through  repeated  observation  and  association  with  the  living  mass  of 
humanity,  twisted,  delimited,  and  askew,  found  in  asylums,  institutions,  and  sani- 
toria.  Here,  while  familiarizing  himself  with  many  types,  he  can  also  compare  their 
present  with  their  past — the  living  fact  with  its  unquestioned  history  gathered  from 
data  compiled — and  in  arriving  at  a  knowledge  of  cause  and  effect,  as  is  possible  in 
no  other  way,  he  will  learn  also  the  value  of  formulating  his  own  tables  of  etiology. 
These  the  note-book  of  every  practitioner  should  show,  and  by  them  and  through 
them  he  should  be  able  to  maintain  a  certain  oversight  of  the  families  in  his  care, 
somewhat  similar  to  that  of  the  chief  of  a  Large  ins!  itution,  while  exercising  a  salutary 
influence  in  his  community — dependent  of  course  upon  the  personality  of  the  man — 
infinitely  more  far-reaching.  For  he  conies  in  time  to  be  the  mentor  and  guardian 
of  its  children;  his  mission  not  alone  to  minister  to  physical  ailments,  but  by  sug- 
gestion as  to  treatment  and  training,  changing  often  the  whole  current  and  des- 
tinies of  their  lives,  or  by  well-timed  caution  safeguarding  from  permanent  misfor- 
tune. Maki-iv  \V.  Barr.* 


•Chief  Physician  to  the  Pennsylvania  School  for  the  Feeble-minded  atElwyn,  Pa. 


394  MUSCULAR  RHEUMATISM  AND  ALLIED  PAINFUL  STATES. 

REMARKS  ON  MUSCULAR  RHEUMATISM  AND  ALLIED 
PAINFUL  STATES. 

The  physician  is  constantly  confronted  with  a  variety  of  sensory  problems, 
many  of  which  resist  treatment  to  such  a  degree  that  dissatisfaction  follows  and, 
too  often,  a  change  of  medical  adviser.  A  large  proportion  of  these  are  due  to 
what  are  called  the  acid  intoxications.  The  nature  of  the  processes  involved  have 
provoked  such  a  vast  amount  of  controversy,  discussion,  scientific  and  pseudo- 
scientific,  with  conclusions  so  widely  at  variance  with  each  other,  and,  indeed,  with 
common  sense,  that  we  are  often  compelled  to  fall  back,  in  our  treatment,  upon 
empiricism,  illumined,  it  is  true,  by  incidental  exact  findings  and  conclusions. 

Moreover,  the  underlying  factors  are  so  complex — of  bio-chemism,  katabolism, 
suboxidation,  the  status  of  the  regulative  mechanisms,  the  ductless  glands,  the 
circulatory  organs,  the  blood,  especially  the  plasma,  with  consequent  morphologic 
changes  in  affected  structures — that  practical  findings  are  obscured  by  their  very 
mass.  It  is  not  feasible  for  the  busy  practitioner  to  keep  in  review  all  the  patho- 
logic data,  hence  he  should  strive  to  secure  a  practical  summary  of  acceptable  prin- 
ciples which  he  can  use  clinically.  He  can  fix  his  mind  at  least  upon  those  points 
which  ought  to  aid  the  cure. 

The  causes  of  muscular  rheumatism  arise  chiefly  in  states  of  faulty  oxygena- 
tion and  oxidation  resulting  in  disorders  of  metabolism. 

Hence,  in  devising  means  of  cure,  we  cannot  go  amiss  in  following  a  broad 
general  plan  of  bodily  hygiene,  beginning  with  a  revision  of  digestion,  elaboration, 
and  elimination.  Then  should  follow  a  thorough  search  into  individual  suscepti- 
bilities, peculiarities,  habits,  tastes,  and  previous  derangements.  To  secure  best 
results  these  peculiarities  demand  radical  correction,  involving  personal  direction, 
with  dominant  and  consistent  control  of  contributory  circumstances. 

Unless  this  be  done,  the  results  are  chaotic,  inexact;  many  conditions  misun- 
derstood or  unrevealed  remain  as  contributory  causes.  Actual  harm  may  be  done 
as  well  as  failures  of  relief  follow  zealous  blundering,  guessing,  meddling,  firing  of 
chance  shots  with  inaccurate  or  ill-timed  aim.  How  can  we  arrive  at  such  a  degree 
of  professional  efficiency?  Not  by  searching  for  new  and  wonder-working  remedies 
to  combat  obvious  but  unappreciated  functional  derangements;  not  by  assuming 
the  potency  of  change  of  scene,  climate,  spas,  novel  systems  of  treatment,  but  by 
a  rational  comprehension  of  the  factors  present,  adopting  fundamental  principles 
for  the  elucidation  of  concrete  puzzlements.  The  writer  does  not  pretend  that  he 
has  attained  such  wisdom,  only  that  he  is  an  earnest  student  on  these  lines. 

Much  is  to  be  learned ;  many  essential  facts  must  yet  -be  learned  before  full 
control  is  attainable.    Among  modern  writers  are  many  who  offer  deeply  significant 


MUSCULAR  RHEUMATISM  AND  ALLIED  PAINFUL  STATES.  395 

hints,  pertinent,  helpful  conclusions.  The  present  communication  is  too  brief  to 
be  scholarly.  It  must  be  left  to  a  future  occasion  to  review  these,  even  the  chief 
of  them.  Here  only  such  acceptable  points  can  be  offered  as  have  illumined  our 
mind,  borrowing  freely  from  these  authors,  and  adding  the  fruits  of  experience. 

These  acidoses,  or  intoxications,  as  they  show  themselves,  are  clinically  rec- 
ognizable chiefly  by  their  effects,  in  perversions  of  function,  degeneration  of  tis- 
sues, notably  the  blood ;  in  subversions  of  oxidation  and  oxygenation  processes, 
katabolic  stasis,  many  digestive  and  some  respiratory  disorders — asthma,  chronic 
bronchitis,  and  certain  infections,  such  as  pneumonia  and  tuberculosis. 

Again,  a  group  of  common  phenomena  result  in  subkatabolism,  with  the  pro- 
duction of  excess  of  sarcolactic  acid,  e.g.,  fatigue,  traumata  from  pressure  or  irri- 
tations. From  such  causes,  as  Wakefield  says,  the  circulation  is  deranged,  blood- 
vessels being  occluded  in  part,  producing  cell  asphyxiation,  resulting  in  gelatini- 
form  tissue  changes  of  a  benign  character,  possibly  passing  on,  under  certain  cir- 
cumstances, to  malignancies* 

A  large  number  of  unclear  painful  states,  variously  labeled,  have  their  origin 
in  acid  intoxications.  So,  too,  of  many  depressive  states,  neurasthenias,  psychoses, 
hallucinations,  gloom. 

They  are  more  commonly  evinced  by  sensory  derangements,  often  passing  into 
exquisitely  painful  conditions,  headaches,  migraine,  neuralgias,  myalgias,  neuritis 
or  simulations  of  neuritis,  recurring  often  in  such  degrees  as  to  render  life  wretched, 
disabling,  all  but  enforcing  permanent  invalidism.  By  reason  of  the  morbid  fac- 
tors at  work,  whatever  they  may  be,  certain  parts  are  rendered  useless,  more  or  less 
permanently. 

Although  not  of,  or  by,  themselves  threatening  death,  yet  they  so  derange  the 
rhythm  of  life  as  to  produce  serious  changes  in  the  conduct  of  life,  curtailing  nor- 
mal activities,  diverting  energies  from  normal  channels,  inducing  psychoses,  aggra- 
vating neuroses,   spoiling  dispositions,   embittering  existence. 

Few  problems  confronting  the  clinician  justify  closer  study  as  to  causes. 
prevention,  and  means  for  more  than  temporary  relief.  So  varied  are  the  phe- 
nomena, yet  so  constant  are  the  major  features,  that  it  is  obvious  we  must  look 
for  some  common  points  of  origin  and  relief. 

Studying  the  results  of  these  from  their  clinical  manifestations,  deductively 
elaborate  differentiations  are  made,  articular  rheumatism,  chronic  rheumatism  or 
myalgia,  lumbago,  neuralgia  of  varied  local  ion,  migraine,  neuritis,  multiple  and 
local,  etc.  Perhaps  a  larger  array  of  conditions  could  be  arranged  etiological  ly 
under  the  acidoses,  when  contributing  causes  are  included,  such  as  diabetes  mellitus, 
spasmodic  disorders,  puerperal  eclampsia,  epileptics,  certain  forms  of  anaemia,  espe- 
cially those  of  bulk;   hydremia. 


396  MUSCULAR  RHEUMATISM  AND  ALLIED  PAINFUL  STATES. 

Upon  a  basis  of  acidosis,  decreased  alkalinity  of  the  blood,  cellular  resistance 
often  so  impaired  as  to  furnish  the  origin  for  many  serious  diseases,  among  which 
are  septic,  tubercular,  and  gonorrhceal  arthritis. 

The  principles  of  treatment  of  the  acidoses  involve  attention  to  the  sys- 
temic perversions  and  sensory  disturbances.  Suggestion  is  necessary  to  secure 
cooperation  which  is  by  no  means  easily  attained.  So  varied  are  the  symptoms, 
persistent  the  recurrences  of  discomfort,  so  protracted  the  disabilities,  that  it  is 
a  matter  of  surprise  to  the  physician  to  find  so  little  consistent  help  afforded  by 
science.  Once  earnest  personal  cooperation  is  promised,  the  recommendations 
should  include  most  of  those  precautions  which  apply  with  equal  force  to  the  attain- 
ment of  health  and  longevity.  Eevision  of  habits  is  essential,  wherein  the  physician 
needs  to  be  thorough,  judicious,  and  dominant.  The  digestive  organs  will  be  some- 
where at  fault,  notwithstanding  the  fact  that  the  ordinary  symptoms  may  be  absent 
or  found  only  on  critical  search.  Alkalies  before  meals  are  generally  useful  to  cor- 
rect the  organic  acid  formation,  to  remove  gastric  mucus,  especially  to  cleanse  a 
catarrhal  duodenum,  relieve  the  outlet  to  the  common  gall  duct,  etc.  Remedies  are 
indicated  to  overcome  attacks  of  biliousness;  laxatives  are  required  occasionally 
even  where  actual  constipation  is  not  present,  but  to  promptly  remove  the  intes- 
tinal accumulations,  among  which  are  the  milder  morbific  bacteria  and  their  toxins, 
especially  the  end  products,  organic  acids,  acetic,  butyric,  lactic,  succinic,  valerigenic, 
caprionic,  etc.  Also  other  remedies  may  be  indicated  to  expedite  the  action  of  the 
eliminating  organs  according  to  the  needs  of  the  case. 

The  most  universal  fault  will  be  found  in  the  manner  of  eating,  the  combina- 
tions of  food  and  drink.  Many  of  these  errors  are  primarily  mechanical,  inducing 
errors  of  chemism,  directly  and  indirectly.  As  to  choice  of  articles  of  food  which 
should  be  avoided  or  limited,  this  is  within  the  powers  of  any  competent  -physician. 
It  is  wise  to  steer  clear  of  irrational  prejudices  which  have  become  current  and 
always  to  bear  in  mind  the  dictum  of  Maxon  (quoted  in  this  connection  by  Roberts, 
Osier,  Woods  Hutchinson)  :  "It  is  quite  as  important  to  know  what  kind  of 
patient  the  disease  has  got,  as  to  know  what  sort  of  disease  the  patient  has  got." 

Woods  Hutchinson  says  wisely:  "The  question  of  our  ability  to  relieve  our 
patients  from  the  tortures  of  toxaemia  has  depended  on  our  ability  to  correct  some 
vice  of  bodily  habit.  It  may  be  in  exercise,  in  bathing,  in  sleep,  in  mental  stress, 
in  hurry  after  meals,  even  in  errors  of  refraction,  that  the  crux  of  the  lithasmic 
problem  may  lie." 

Further,  many  of  the  remedies,  vaunted  as  specifics  for  rheumatic  and  gouty 
states,  will  be  found  to  act  more  directly  upon  the  digestion,  alkalies  to  correct 
acidities,  fermentation,  laxation,  kidney  elimination,  and  the  Tike. 


MUSCULAR  RHEUMATISM  AND  ALLIED  PAINFUL  STATES.  397 

Researches  on  status  of  alkalinity  and  specific  gravity  of  the  blood  have  been 
recently  emphasized  as  of  direct  practical  importance.  This  normal  alkalinity  is 
due  chiefly  to  the  carbonate  and  phosphate  of  sodium  present.  Saturation  of  the 
blood  with  CO,  causes  the  plasma  to  become  more  alkaline  and  the  corpuscles  less  so. 
"Therapeutically,  it  is  of  importance  that  both  the  specific  gravity  and  the 
alkalinity  of  the  blood  should  be  kept  at  normal.  In  many  pathologic  conditions 
there  are  deviations  from  the  normal  which  produce  more  or  less  marked  symptoms; 
in  fact,  anaemia  of  bulk  and  hydremia,  the  result  of  the  increase  and  decrease  of 
the  specific  gravity,  and  acidosis,  the  result  of  decreased  alkalinity,  are  conditions 
producing  a  complicated  array  of  symptoms  which  might  almost  be  classed  as 
definite  diseases."     (Hubert  Richardson.) 

"Acidosis,  a  decreased  alkalinity  of  the  blood,  can  be  brought  about  either 
by  the  administration  of  acids  or  from  their  formation  in  the  system,  or  by  de- 
creased intake  of  alkalies."     (Op.  cit.) 

"In  acidosis  the  elimination  by  the  lungs  is  increased  and  that  of  the  kidneys 
.is  decreased."     (Op.  cit.) 

Certain  organic  acids  formed  in  the  stomach  and  intestines  produce  a  variety 
of  symptoms,  mostly  neurotic;  not,  however,  if  they  were  unabsorbed  and  voided. 
The  worst  of  these  are  the  acetone  bodies,  viz.,  acetone,  diacetic  acid,  oxybutyria 
acid. 

Other  acids,  often  in  small  amounts,  yet  can  produce  acidosis  and  can  be 
detected  in  the  urine.  The  formation  of  these  acids  takes  place  chiefly  in  the 
stomach  and  intestines,  neutralizing  the  alkaline  media  necessary  to  oxidation  and 
tryptic  digestion.  Failure  of  elimination  of  acids  and  other  excretions  by  bowels, 
kidneys,  and  skin  may  be  responsible  for  hyperacidity  and  toxaemia  by  accumula- 
tion (Wakefield).  Obviously,  intestine  putrefaction  forms  the  foundation  of  many 
disorders,  mainly  by  irritation,  whereby  tissue  resistance  is  lowered,  pathogenic 
bacteria  parasites  and  toxins  are  invited  to  enter  the  circulation. 

Personal  experience  in  recurring  conditions,  especially  painful  ones,  educates 
a  physician  and  enables  him  to  offer  advice  with  peculiar  conviction. 

Muscular  rheumatism  is  common  enough,  but  ought  to  be  less  so.  It  is 
entirely  preventable;  it  is  amenable  to  cure,  but  it  is  seldom  possible  to  command 
all  the  conditions  of  life  necessary  to  achieve  either.  It  is  relievable  by  simpler 
means  than  are  usually  employed,  and  to  a  far  more  perfect  degree  than  is  often 
obtained.  When  once  established  it  is  liable  to  remain  with  one  till  death.  Eternal 
vigilance  is  the  price  of  relative  emancipation.  However,  their  fate  is  not  so  pitiful 
when  it  is  reflected  that  by  following  the  rules  whereby  these  discomforts  are 
alleviated  or  eliminated,  many  other  desirable  effects  are  also  attained;  among 
them  passports  to  longevity.     As  Oliver  Wendell  Holmes  said:    "Nothing  so  con- 


398  MUSCULAR  RHEUMATISM  AND  ALLIED  PAINFUL  STATES. 

duces  to  a  long  life  as  an  incurable  malady."  This  is  eminently  true  of  the  acidoses, 
notwithstanding  the  incidental  annoyances  and  dolors,  and  the  actual  perils  of 
possible  consequences  if  suffered  to  go  on  unchecked. 

Contributory  causes  are  many,  but  we  may  focus  our  attention  upon  that  which 
underlies  our  conditions  most,  if  not  all,  viz.,  errors  in  diet.  If  the  digestive  func- 
tion be  wisely  conserved  from  earliest  infancy,  it  is  scarcely  conceivable  that  the 
"diathesis"  habit  of  body,  katabolic  status,  can  become  established.  The  problem 
presenting  is  usually  to  overcome  the  effects  of  reprehensible  abuse,  especially  per- 
nicious habits  and  vitiated  tastes.  The  deranged  walls  of  the  stomach  or  bowel 
become  permeable  for  germs  to  pass  into  the  general  circulation.  Biliousness  shows 
that  the  normal  guardianship  of  the  liver,  its  function  as  poison  filter,  is  im- 
paired. 

As  the  subject  of  digestive  derangements  is  so  vast,  it  will  be  sufficient  here 
to  outline  briefly  the  principles  upon  which  I  have  been  able  to  secure  the  most 
conspicuous  results.  The  choice  of  foods  is  of  less  significance  than  the  manner 
of  eating.  The  thorough  mastication  of  food,  whether  it  be  dense  or  fluid,  is  the 
"sine  qua  non;"  permitting  no  mass  to  be  swallowed  until  completely  comminuted. 
Even  milk  and  raw  eggs  should  be  held  in  the  mouth  till  insalivated.  Fluids,  water, 
decoctions  of  tea  or  coffee,  should  never  be  taken  into  the  mouth  unless  then  empty. 
Soups,  broths,  purees,  should  be  taken  alone  and  slowly,  held  in  the  mouth  for  an 
appreciable  time.  As  to  choice  of  foods,  it  will  be  found  that,  as  Fletcher  has  so 
wisely  pointed  out,  once  the  sanity  of  taste  is  restored  by  careful  mastication,  the 
impulse  to  select  a  suitable  dietary  will  soon  be  restored  by  a  return  of  normal 
wholesome  instincts. 

It  is  obvious  that  if  the  intake  of  foods  be  above  reproach,  not  only  will 
digestion  proceed  normally,  but  the  great  elaborating  agencies  will  not.be  over- 
taxed, fewer  and  simpler  poisons  will  be  formed  and  more  perfectly  disposed  of, 
eliminated,  or  destroyed.  The  dejecta  must,  of  course,  be  extruded  from  bowels, 
skin,  kidneys,  and  lungs.  It  may  be  necessary  occasionally  to  specify  the  articles 
of  diet  permissible,  but  as  a  general  rule  the  safeguards  outlined  above  are  of  vastly 
greater  efficacy  than  the  most  thorough  chemical  adaptation.  In  any  event  they 
must  also  be  enforced. 

My  experience  leads  me  to  advise  limiting  the  amount  of  food  in  most  cases, 

although  where  exhaustion  be  recognized,  hyperalimentation  is  required.     For  this 

purpose  the  use  of  raw  eggs,  especially  yolks,  as  pointed  out  by  Ilcinrich  Stern, 

serves  admirably.1 

J.  Madison  Taylor.* 


Formerlj    Neurologist  to  the  I  low  n  id  Hospital,  Philadelphia,  Pa.  - 
1  This  article  will  be  concluded  in  the  next  issue,  outlining  the  more  efficacious  forms  of 
treatment. 


ACTINOMYCOSIS. 


ALBUMINURIA. 


399 


Cyclopaedia  of  Current  fciteratur?. 


ACTINOMYCOSIS,   TREATMENT   OF. 

Six  cases  of  actinomycosis  are  report ed 
by  the  writer  which  he  has  recently  had 
under  observation,  and  he  states  that 
treatment  is  of  absolute  and  demon- 
strated value  in  this  disease.  It  should 
consist,  in  the  first  place,  in  the  opening 
of  the  focus  and  in  drainage,  and  in  the 
second  place  in  removal  by  a  sharp  spoon 
of  the  granulation  tissue  produced  by 
the  lesion.  The  fungi  remaining  in  the 
tissues  should  be  destroyed  by  nitrate  of 
silver  in  stick  or  solution,  or  by  iodine. 
The  drainage  should  be  maintained  by 
iodoform  packing.  Iodide  of  potassium 
should  be  used  either  internally  or  as  a 
1  per  cent,  injection  introduced  into  the 
tissues  surrounding  the  focus.  The 
drug,  it  is  suggested,  may  be  given  in 
interrupted  doses.  It  may  be  adminis- 
tered for  a  week  and  its  use  be  discon- 
tinued then  for  three  to  five  days.  This 
practice  is  based  on  the  theory  that  the 
spores  are  more  resistant  than  the  adult 
thread  forms,  and  that  when  the  drug 
is  not  given  the  spores  find  an  opportu- 
nity to  develop  into  the  adult  forms, 
which  are  more  easily  destroyed  by  the 
iodide. 

The  x-rays,  it  is  held,  are  of  distinct 
value  in  the  treatment  of  actinomycosis. 
Some  experiments  made  by  the  author 
and  two  assistants  showed  that  the  rays 
liberate  free  iodine  in  solutions  of  iodide1 
of  potash,  and  he  believes  that  it  is  fair 
to  conclude  that  given  a  patient  suffer- 
ing from  actinomycosis,  who  lias  been 
'freely  dosed  with  iodide  of  potassium, 
the  exposure  of  the  local  lesion  to  the 
x-rays  favors  to  a  considerable  degree  the 
liberation  of  free  nascent  iodine.  The 
author  states  that  he  has  obtained   ap- 


parently striking  results  from  this  com- 
bination of  therapeutical  methods.  Bevan 
(Annals  of  Surgery,  May,  1905). 

ALBUMINURIA,  PROGNOSIS  AND  TREAT- 
MENT  OF. 

Dietetic  treatment  of  nephritic  albu- 
minuria is  more  important  than  phys- 
ical measures,  while  medicine  is  of  com- 
paratively slight  benefit  except  against 
the  underlying  cause.  Cyclic  albumin- 
uria is  always  of  pathologic  origin,  and 
may  be  the  manifestation  of  an  insidious 
nephritis.  When  this  can  be  excluded, 
physical  measures  will  be  found  the  best 
means  of  restoring  conditions  to  normal. 
Strengthening  the  heart  by  muscular  ex- 
ercise is  useful  if  overexertion  be  avoided. 
The  author  prefers  cold  and  tepid  to  hot 
baths,  but  the  proper  reaction  with 
warmth  and  rewarming  of  the  surface 
must  be  obtained  or  they  do  more  harm 
than  good.  One  of  the  principal  bene- 
fits of  the  cold  baths  is  the  stimulation 
of  the  appetite.  The  clothing  must  pro- 
tect thoroughly  against  cold  and  damp- 
ness. Massage  and  elastic  compression 
of  the  legs  never  did  any  good  in  the  au- 
thor's experience. 

The  diet  in  nephritic  albuminuria 
should  seek  to  compensate  the  losses  of 
albumin.  Cooked  eggs,  meat,  both  dark 
and  light,  fish,  and  vegetable  albumin 
should  be  taken  in  abundance.  Milk  is 
less  a  strengthener  of  the  heart  than 
meat,  and  its  frequent  drawbacks  of 
dyspepsia  and  urinary  and  intestinal  dis- 
turbances have  dethroned  it  from  its 
former  exalted  position,  although  the  ab- 
sence of  elements  that  irritate  the  kid- 
ney and  ils  "rinsing"  properties  theo- 
retically rank  it  above  meat.     The  more 


400 


ALCOHOL,   EFFECT   ON  CIRCULATION. 


ANEMIA,  PERNICIOUS. 


varied  the  combinations  of  the  above 
articles  of  diet,  the  better  and  stronger 
the  patient  will  feel.  The  fear  of  in- 
creasing the  albuminuria  by  the  copious 
intake  of  albumin  will  be  found  to  have 
no  basis  in  fact.  Fiirbringer  (Deutsche 
medizinische  Wochenschrift,  Bd.  xxxi, 
Nu.  20 ;  Journal  of  the  American  Med- 
ical Association,  July  8,  1905). 

ALCOHOL,    EFFECT    OF,    ON    THE    CIRCU- 
LATION. 

The  author  reports  the  results  of  his 
experiments  with  alcohol.  From  40  to 
60  centimeters  of  10  per  cent,  to  18  per 
cent,  alcohol  caused  a  rise  in  the  blood- 
pressure  in  twenty  to  thirty  minutes 
after  ingestion,  which  disappeared  in 
sixty  to  seventy-five  minutes.  The  in- 
crease in  pressure  was  15  millimeters  of 
mercury  in  most  cases,  reaching  30  mil- 
limeters of  mercury  in  others.  A  few 
showed  only  5  millimeters-  mercury  rise. 
Doses  of  60  to  80  cubic  centimeters  of 
20  per  cent,  alcohol  or  50  to  60  cubic 
centimeters  of  30  per  cent,  alcohol 
caused,  first  a  slight  rise,  then  a  fall  to, 
and  slightly  below,  the  pressure  at  the 
beginning  of  the  experiment.  Fifty  cen- 
timeters of  50  per  cent,  alcohol  cause  a 
lowering  of  the  blood-pressure  from  the 
beginning.  The  lowering  of  the  blood- 
pressure  with  100  cubic  centimeters  of 
50  per  cent,  alcohol  did  not  exceed  10 
millimeters  of  mercury.  Persons  accus- 
tomed to  using  alcohol  do  not  react  with 
the  small  doses,  but  require  greater 
amounts.  It  was  found  that  when  the 
pressure  had  been  raised  by  small  doses, 
it  could  be  maintained  by  giving  re- 
peated doses  at  thirty-minute  intervals. 

Regarding  the  pulse  wave,  it  was  found 
that  the  catadi erotism  became  very  pro- 
nounced. With  large  doses  of  alcohol, 
the  frequency  increased.  The  pulse 
wave  was  fuller  than  normal  with  mod- 


erate doses.  The.  skin  on  the  hands  and 
face  became  red,  and  an  increased  per- 
spiration was  noticeable.  Animal  ex- 
periments showed  that  the  cardiac  vas- 
cular supply  was  bettered  under  the  in- 
fluence of  alcohol  and  the  heart  muscle 
contracted  more  vigorously. 

The  writer  concludes  that  the  blood- 
pressure  is  increased  by  alcohol  in  proper 
doses;  that  the  rise  in  blood-pressure  is 
due  to  a  vasoconstriction  in  the  splanch- 
nic system,  associated  with  a  peripheral 
vasodilatation;  and  that  increased  car- 
diac action  is  due  to  a  better  circulation 
in  the  cardiac  vessels.  Martin  Koch- 
mann  (Deutsche  medizinische  Wochen- 
schrift, No.  24,  1905 ;  St.  Louis  Medical 
Eeview,  July  8,  1905). 

ANiEMIA,    PERNICIOUS,    ETIOLOGY    AND 
PATHOGENESIS   OF. 

In  haemorrhage  there  is  created  a  de- 
ficiency in  circulating  red  cells,  which  is 
met  by  the  marrow  with  the  mature  red 
cells  lying  close  to  the  capillaries  at  the 
periphery  of  the  erythrogenetic  groups. 
In  large  haemorrhages  with  exhaustion 
of  the  supply  of  mature  red  cells  a  cer- 
tain number  of  normoblasts  are  called 
out  to  supply  the  deficiency. 

On  the  other  hand,  with  a  circulating 
toxin,  there  is  destruction  not  only  of 
red  cells  in  the  circulation,  but  also  of 
some,  at  least,  in  the  marrow,  even  of 
normoblasts  as  suggested  by  the  large 
number  of  naked  nuclei  found  later  in 
the  circulation.  The  marrow  responds, 
in  this  emergency,  with  nucleated  red 
cells  of  normoblastic  or  megaloblastic 
type,  depending  upon  the  extent  of  the 
destruction.  The  experiment  of  the  re- 
peated dose  of  ricin  where  megaloblasts 
appeared  only  after  the  second  dose 
would  seem  to  confirm  this  idea,  as  well 
as  the  observation  as  to  the  arrangement 
of  the  cells  in  the  erythrogenetic  groups 
in  the  marrow. 


ARTIFICIAL  RESPIRATION. 


ATROPINE  AND  HOMATROPINE. 


401 


Applying  these  conclusions  to  perni- 
cious anasmia,  it  seems  possible  that  an 
analagous  toxin  may  be  present,  destroy- 
ing red  cells  both  in  the  circulation  and  in 
the  marrow,  so  that  in  the  reaction  nucle- 
ated red  cells  are  used  to  supply  the  defi- 
ciency— that  further  action  of  the  toxin 
reduces  the  erythrogenetic  groups  more  or 
less  to  the  megaloblastic  centers,  dimin- 
ishing greatly  the  regenerating  power  of 
the  marrow  and  resulting  in  a  discharge 
of  megaloblastic  cells  in  the  hasty  effort 
to  supply  the  needs  of  the  circulation. 
Thus,  the  regular  orderly  development 
of  the  groups  of  the  marrow  cells  is  in- 
terfered with  and  a  short  cut  is  taken 
from  the  megaloblast  to  the  macrocyte, 
an  imperfect,  immature  cell,  as  shown 
by  its  polychromatophilia  and  granular 
basophilia.  In  this  light  it  is  not  diffi- 
cult to  see  why  cases  of  pernicious  anae- 
mia with  few  normoblasts  and  more 
megaloblasts  in  the  circulation  are  of 
graver  prognosis  than  those  with  a  large 
number  of  normoblasts  and  few  megal- 
oblasts. And  again,  if  the  presence  of 
nucleated  cells  in  the  circulation  is  re- 
garded as  evidence  of  injury  to  the  bone 
marrow,  the  "nucleated  red  cells  crises" 
of  pernicious  anaemia  and  leukaemia  in 
which  the  blood  picture  resembles  much 
that  shown  in  ricin  intoxication  is  ex- 
plained. C.  H.  Bunting  (Bulletin  of 
the  Johns  Hopkins  Hospital,  June, 
1905). 

ARTIFICIAL  RESPIRATION. 

The  writer  recommends  a  combination 
of  the  Marshall  Hall,  Sylvester,  Howard, 
and  Brosch  methods  of  artificial  respira- 
tion, which  are  described  in  detail,  stress 
being  laid  on  the  importance  -of  keeping 
the  tongue  drawn  out  of  the  mouth.  The 
ideal  method  is  to  seize  the  tongue  with 
a  Pean  forceps  and  draw  it  out  of  the 
mouth,  letting  it  hang  down  on  one  side, 


the  forceps  being  fastened  to  the  bodv 
by  a  band  passed  around  the  head.  If 
forceps  are  not  at  hand,  one  person  must 
hold  with  his  fingers  the  tip  of  the 
tongue  in  the  corner  of  a  handkerchief. 
A  person  kneeling  at  the  head  of  the 
subject  should  devote  his  entire  atten- 
tion to  the  tongue,  while  counting  aloud 
his  own  breathing  rate.  An  aid  on  each 
side  makes  the  Sylvester  movements  for 
the  arms,  while  the  fourth  aid,  kneeling 
astride  of  the  subject,  makes  the  Howard 
movements,  not  removing  his  hands  dur- 
ing the  intervals,  but  merely  suspending 
pressure  with  them,  carefully  avoiding 
any  pressure  of  the  abdomen  that  might 
force  stomach  contents  into  the  throat, 
with  consequent  aspiration.  This  dan- 
ger is  a  real  one;  aspiration  is  rendered 
less  imminent  by  having  the  head  low. 
If  only  three  assistants  are  at  hand,  the 
one  kneeling  astride  must  take  charge  of 
the  tongue,  as  well  as  of  the  Howard 
movements,  and,  if  there  are  only  two, 
one  must  make  the  Sylvester  movements 
for  both  arms.  If  only  one  is  present, 
the  arm  movements  should  not  be  at- 
tempted, and  the  assistance  should  be  re- 
stricted to  holding  the  tongue  and 
the  Howard  movements.  G.  Herter 
(Deutsche  medizinische  Wochenschrift, 
Bd.  xxxi,  Nu.  20;  Journal  of  the 
American  Medical  Association,  July  8, 
1905). 

ATROPINE  AND  HOMATROPINE  AS  CY- 
CLOPLEGICS,  RELATIVE  ACTIONS 
OF. 

From  a  clinical  study  of  the  relative 
actions  of  atropine  and  homatropine  as 
cycloplegics,  the  author  concludes  that 
homatropine  is  not  in  any  way  as  effi- 
cient a  cycloplegic  as  atropine.  The  so- 
lution of  1  grain  to  the  drachm,  1  drop 
in  each  eye  every  three  to  five  minute 
until  eight  to  ten  instillations  are  made, 


402 


BLOOD-PRESSURE. 


BREATHLESSNESS  IN  CARDIAC  DISEASES. 


seems  to  be  as  efficient  and  safe  a  solu- 
tion as  any.  Homatropine  usually,  if 
not  always,  is  inefficient  in  cases  that 
suffer  a  great  deal  from  eye-strain, 
whether  there  be  any  indication  of  re- 
tinal or  choroidal  congestion  or  not. 

It  is  advisable  to  use  homatropine  in 
cases  between  the  ages  of  20  and  40 
where  a  cycloplegic  is  used  (and  this 
should  be  the  rule),  provided  there  are 
no  marked  symptoms  of  eye-strain,  but 
at  the  same  time  it  is  advisable  to  inform 
the  patient  that  the  examination  may  be 
only  tentative,  and  they  may  have  to 
return  for  further  treatment  under  atro- 
pine. The  use  of  homatropine  is  espe- 
cially indicated  in  cases  that  do  not 
suffer  severely,  and  have  no  time  to  lose 
from  their  work. 

Homatropine  is  not  efficient  in  chil- 
dren. Atropine  is  the  most  desirable 
cycloplegic  to  use  with  children,  and 
should  be  employed  in  most  cases.  It  is 
by  giving  accurate  corrections  in  these 
cases  that  intraocular  diseases  can  be 
prevented  that  might  incapacitate  the 
patient  for  life. 

Homatropine  has  an  unrivaled  field  in 
elderly  subjects  for  dilating  the  pupils 
for  more  perfect  fundus  examination. 
It  is  also  to  be  commended  in  trouble- 
some cases  near  or  above  the  age  of  40' 
in  which  a  long  cycloplegic  action  is  not 
desirable,  to  enable  one  to  detect  slight 
degrees  of  astigmatism  by  means,  of 
retinoscopy.  Oscar  Wilkinson  (Thera- 
peutic Gazette,  July  15,  1905). 

BLOOD-PRESSURE    OBSERVATIONS. 

Both  systolic  and  diastolic  pressures 
should  be  taken,  if  any  are  taken,  the 
method  of  Strassburger  being  sufficiently 
accurate  for  any  but  scientific  investiga- 
tions. The  cuff  on  the  instrument 
should  be  at  least  12  centimeters  wide. 
With  the  wide  cuff,  the  normal  systolic 


blood-pressure  for  the  healthy  adult  male 
is  nearer  to  110  millimeters  than  it  is 
to  130  millimeters  Hg — this  represent- 
ing the  normal  in  a  patient  who  has  been 
in  bed  for  twenty-four  hours  or  more. 
The  chief  value  of  blood-pressure  ob- 
servations lies  in  the  lead  they  give  in 
regard  to  indications  for  and  results  of 
treatment.  In  a  few  conditions  they 
are  of  diagnostic  value.  In  many  con- 
ditions blood-pressure  observations  are 
of  no  practical  value.  C.  E.  Brush 
(American  Medicine,  July  15,  1905). 

BREATHLESSNESS,  ESPECIALLY  IN  RE- 
LATION TO  CARDIAC  DISEASES. 
The  author  begins  his  paper  by  nar- 
rating a  case  in  which  he  made  the  un- 
usual diagnosis  of  atheroma  of  the  right 
coronary  artery  tracing  the  conditions 
which  led  to  this  conclusion.  The  au- 
topsy verified  his  argument.  Aeration 
of  the  blood  requires  (1)  that  fresh  air 
should  freely  enter  the  lungs;  (2)  that 
the  blood  should  flow  readily  through 
the  lungs,  to  be  exposed  in  sufficient 
quantity  to  the  air  before  it  enters  the 
circulation.  If  either  process  is  stopped 
asphyxia  may  be  produced;  if  either  is 
interrupted  the  result  will  be  breathless- 
ness.  The  latter  may  signify  either  too 
frequent  breathing,  or  painful  breath- 
ing. Imperfect  aeration  leading  to 
dyspnoea  may  be  due  to  hindrance  to 
the  free  passage  of  the  air  to  and  from 
the  lungs  or  to  hindrance  to  the  free 
circulation  of  the  blood  through  the 
lungs.  Dyspnoea,  like  pain  and  fatigue, 
consists  of  two  elements,  the  peripheral 
condition  and  the  central  sensation,  and 
they  generally  bear  a  definite  relation- 
ship to  each  other.  These  elements  are 
probably  chemical  rather  than  mechan- 
ical. If  they  are  produced  too  quickly 
or  are  imperfectly  oxidized,  hyperpncea 
or    dyspnoea    results    according   to    the 


BRIGHT'S  DISEASE. 


BRONCHITIS,  CAPILLARY. 


403 


quantity  of  the  stimulant.  With  dysp- 
noea there  is  a  tendency  to  diminish  pul- 
monary circulation  and  to  distention  of 
the  right  side  of  the  heart. 

To  facilitate  the  pulmonary  circula- 
tion and  thus  lessen  cardiac  dyspnoea, 
the  first  essential  is  absolute  rest.  Next 
in  importance  is  massage.  This  with  the 
Nauheim  baths  is  a  most  useful  agent. 
A  pill  containing  1  grain  each  of  dig- 
italis, squill,  and  blue  mass  is  very  effec- 
tive. Two  grains  of  hyoscyamus  are 
often  added  with  advantage.  Further, 
strychnine  or  strophanthus  may  be  given, 
also  oxygen,  caffeine,  and  diuretin.  Free 
purgation  will  often  bring  great  relief 
by  diminishing  congestion,  especially  in 
the  liver.  If  fluid  has  accumulated  in 
the  peritoneal  or  pleural  cavities,  or 
within  the  tissues,  abstraction  by  needle 
punctures  or  by  small  incisions  should 
be  practiced.  Opium  is  one  of  the  most 
valued  means  of  relieving  dyspnoea.  The 
diet  should  be  such  that  fermentation 
will  not  occur.  Lauder  Brunton  (Prac- 
titioner, June,  1905). 

BRIGHTS  DISEASE,  LAVAGE  OF  RENAL 
PELVES  IN. 
The  writer  considers  that  not  enough 
importance  has  been  given  to  the  prob- 
ability that  a  large  percentage  of  cases 
of  chronic  nephritis,  in  whom  no  dis- 
coverable cause  for  the  inflammation  can 
be  found,  are  really  due  to  extension  of 
inflammation  from  the  renal  pelves. 
Lavage  of  the  renal  pelves  is  only  ap- 
plicable in  selected  cases  of  nephritis,  but 
it  will  certainly  cure  a  beginning  nephri- 
tis that  is  due  to  extension  of  inflam- 
mation from  the  renal  pelves.  Lavage 
of  the  renal  pelves  in  subchronic  and 
chronic  parenchymatous  nephritis  will 
check  the  disease  and  markedly  improve 
the  general  condition  of  the  patient  in 
those  cases  that  have  not  reached  the 


stage  known  as  cirrhotic  kidney.  Lav- 
age of  the  renal  pelves  for  nephritis  by 
one  who  is  not  properly  trained  in  the 
technique  cannot  possibly  improve  the 
condition  of  the  kidney  and  may  do 
harm.  Winfield  Ayres  (Medical  News, 
July  1,  1905). 

BRONCHITIS,     CAPILLARY,     TREATMENT 
OF. 

The  author  ascribes  a  life-saving  value 
to  mustard  water  packs  in  many  cases  of 
capillary  bronchitis  where  pulmonary 
circulation  and  the  ingress  of  air  is  hin- 
dered by  the  swelling  of  the  mucous 
membrane  and  the  accumulation  of  in- 
flammatory products  in  the  bronchi. 
The  remedy  acts  by  drawing  the  blood 
to  the  surface,  thus  lessening  the  amount 
of  blood  to  be  moved  and  diminishing 
the  obstacle  due  to  swelling  of  the  mu- 
cous membrane.  The  technique  is  de- 
scribed as  follows :  Five-tenths  of  a  kilo- 
gram or  more  of  mustard  flour  are  sifted 
into  an  open  dish  containing  1.5  liters 
of  warm  water  at  40°  C.  until  irritating 
vapors  are  given  off.  (This  is  a  little 
more  than  a  pound  of  mustard  in  three 
pints  of  water  at  104°  F.)  A  linen  cloth 
large  enough  to  envelop  the  child  is 
soaked  in  the  liquid,  wrung  out,  and 
spread  out  on  a  blanket  of  the  same  size. 
The  naked  child  is  laid  on  the  mustard 
sheet,  the  upper  edge  on  a  level  with  the 
neck.  It  is  drawn  up,  and  over  it  the 
blanket  is  rapidly  tucked  around  the 
neck  and  wrapped  around  the  feet.  This 
pack  is  left  from  ten  to  twenty  minutes, 
according  to  the  vitality  of  the  child. 
When  removed  from  the  pack,  the  whole 
body  is  red.  The  child  is  quickly  placed 
in  a  warm  bath  or  sponged  with  warm 
water  in  order  to  remove  the  particles  of 
mustard  still  adhering  to  the  skin.  It 
is  then  put  in  a  second  pack  of  lukewarm 
water  and  left  from  one  to  two  hours, 


404 


BURNS,  TREATMENT. 


CEREBELLAR  TUMORS,  SYMPTOMS. 


if  possible,  in  order  to  maintain  as  long 
as  possible  the  hyperemia  of  the  skin 
which  has  been  secured.  In  many  suc- 
cessful cases,  the  child  looks  like  a  scar- 
let-fever patient  all  day.  While  in  the 
second  pack,  the  temperature  is  liable 
to  rise,  and  the  child,  therefore,  should 
be  under  constant  supervision,  in  order 
to  interrupt  the  process  if  its  head  and 
face  become  red  or  as  soon  as  it  sweats 
thoroughly.  A  second  warm  bath  is  then 
given,  and,  in  case  the  child  is  very  hot, 
cold  water  may  be  quickly  poured  over 
it.  The  child  is  then  wiped  dry  and  left 
undisturbed  for  the  rest  of  the  day. 
Sometimes  the  crisis  follows,  with  rapid 
convalescence,  but  more  frequently  a  re- 
petition of  the  process  is  required  on 
the  second  or  third  day  or  later.  It 
should  not  be  applied,  however,  more 
than  once  in  twenty-four  hours.  This 
process,  like  all  others,  fails  in  some 
cases.  Where  it  is  not  successful  in  pro- 
ducing reddening  of  the  whole  surface 
of  the  skin  it  is  better  not  to  attempt 
to  repeat  it.  0.  Heubner  (Therapie  der 
Gegenwart,  Bd.  xlvi,  Nu.  1 ;  Journal  of 
the  American  Medical  Association,  July 
22,  1905). 

BURNS,  TREATMENT  OF. 

A  large  number  of  burns  have  been 
treated  by  the  author  by  the  "open 
method,"  that  is,  by  leaving  them  ex- 
posed to  the  air.  The  healing  occurs  in 
one-third  the  time  required  by  the  oc- 
clusive method,  the  scars  are  not  so  dis- 
tressing in  appearance,  and  the  patient 
does  not  suffer  nearly  so  much  pain. 
The  author  divides  burns  into  four 
classes:  Hyperemia  of  the  skin  is  con- 
sidered a  burn  of  the  first  degree;  de- 
struction of  the  epidermis  shown  by 
vesicatio ii.  second  degree;  destruction  of 
the  derma,  third  degree;  and  of  the 
deeper  tissues,  fourth  degree.     The  au- 


thor summarizes  his  advice  as  follows : 
First,  the  shock  should  be  treated.  Sec- 
ond, the  pain  should  be  controlled  as 
necessary  and  everything  kept  from  con- 
tact with  the  burned  areas.  Third,  the 
patient  should  be  kept  surgically  clean. 
Ordinary  surgical  principles  govern  here 
as  elsewhere;  bichloride  of  mercury, 
carbolic  acid,  and  other  strong  antisep- 
tics are  to  be  avoided  when  possible,  be- 
cause they  are  such  powerful  cell  poisons 
that  toxic  effects,  both  general  and  local, 
are  to  be  feared;  the  delicate  covering 
of  granulations  will  not  stand  escharotic 
action  without  interfering  with  the  pro- 
duction of  smooth,  flexible  scars.  Fourth, 
frequent  cold  sponge  baths  should  be 
given  to  the  sound  skin  with  frictions, 
and  the  room  temperature  kept  high. 
Fifth,  the  blisters  should  be  cut  away, 
cleansed  with  normal  salt  solution,  thor- 
oughly dried,  and  all  second  degree 
burns  dusted  with  stearate  of  zinc,  care- 
fully wiping  away  serous  exudate  until 
dry,  brown,  adherent  crusts  are  formed. 
Sixth,  third  degree  burns  should  be  left 
exposed  without  powder  and  the  surface 
kept  clean  until  granulations  are"  ready 
for  skin  grafting.  Seventh,  to  maintain 
and  to  preserve  function,  body  and  limbs 
should  be  exercised  as  much  as  possible; 
the  eschars  of  burns  to  fourth  degree 
should  be  removed  when  Nature  so  indi- 
cates and  amputation  should  be  per- 
formed when  needed.  Haldor  Sneve 
(Journal  of  the  American  Medical  Asso- 
ciation, July  1,  1905). 

CEREBELLAR  TUMORS,  SYMPTOMS  OF. 

The  author  lays  emphasis  on  two 
symptoms  which  he  thinks  are  over- 
looked as  symptoms  of  cerebellar  tumors. 
These  are  deafness  and  tremor.  Deaf- 
ness in  these  cases  generally  takes  the 
form  of  impairment  of  hearing  only  and 
is  unilateral,  or  at  least  more  marked  on 


CERVICAL  RIB,  SURGICAL  IMPORTANCE. 


CUTANEOUS  SYPHILIS. 


405 


the  side  of  the  lesion.  Deafness  may 
also  be  associated  with  tinnitus  aurium. 
These  auditory  symptoms  may  precede 
by  many  months  the  pathognomonic 
symptoms  of  cerebellar  tumor.  In  re- 
gard to  tremor,  the  cerebellum  is  one 
part  of  the  brain  in  which  a  tumor  may 
give  rise  to  an  intentional  tremor.  The 
author  gives  the  history  of  an  interesting 
case  in  which  there  was  a  peculiar  tremor 
which  resembled  that  of  disseminate  scle- 
rosis in  being  absent  when  the  limb  was 
at  rest  and  supported,  and  becoming  very 
evident  on  motion.  J.  M.  Clarke  (Bris- 
tol Medico-Chirurgical  Journal,  June, 
1905). 

CERVICAL   RIB,   SURGICAL  IMPORTANCE 
OF. 

While  the  supernumerary  ribs  of  the 
lumbar  vertebras  have  only  an  academic 
interest,  those  of  the  cervical  region  have 
a  real  practical  importance.  The  ob- 
servations of  disturbances  due  to  a  cer- 
vical rib  are  multiplying  every  year. 
The  anomaly  may  vary  from  a  slight 
growth  just  extending  beyond  the  trans- 
verse process  to  a  complete  rib  with  a 
cartilage  uniting  with  that  of  the  first 
rib.  It  is  bilateral  in  two-thirds  of  the 
cases,  but  a  complete  rib  on  both  sides 
is  a  rarity.  When  not  complete,  or 
nearly  so,  it  may  give  rise  to  no  special 
symptoms,  and  before  the  use  of  the 
Roentgen  ray  it  was  comparatively  sel- 
dom diagnosed  during  life,  and  most  of 
the  reported  cases  were,  therefore,  acci- 
dentally discovered  at  autopsy.  Even 
when  it  caused  trouble,  the  symptoms 
were  often  credited  to  tumor  or  other 
causes  than  cervical  rib.  It  is  probably, 
therefore,  a  more  common  anomaly  than 
might  appear  from  the  small  number  of 
cases  reported.  Though  of  congenital 
origin,  it  does  not  cause  trouble  until 


about  the  twentieth  year,  a  fact  that  is 
hard  to  explain. 

The  principal  symptoms  of  the  anom- 
aly are  a  hump-like  prominence  in  the 
lateral  cervical  region,  a  superficial  pul- 
sation of  the  subclavian  artery,  and  the 
appearance  of  pressure  symptoms  in  the 
brachial  plexus.  The  trouble  is  mechan- 
ical, and  the  treatment,  when  required, 
must  be  surgical.  The  author  finds  that 
a  triangular  flap  incision,  running  di- 
rectly downward  along  the  trapezius  and 
then  conducted  toward  the  sternum  about 
an  inch  above  the  clavicle,  fully  exposes 
the  field  of  operation.  If  the  trapezius 
cannot  be  sufficiently  retracted  with  a 
broad  retractor,  a  transverse  incision 
must  be  made  into  the  muscle,  for  next 
to  a  strict  asepsis,  the  success  of  the  op- 
eration depends  on  extensive  exposure  of 
its  field.  The  brachial  plexus,  which 
usually  runs  across  the  rib,  can  be  pushed 
aside;  the  subclavian  artery  is  best 
pulled  forward.  The  scaleni  are  care- 
fully divided  at  their  points  of  insertion, 
and  this  is  best  done  by  using  a  Cooper 
shears  and,  advancing  layer  by  layer, 
lifting  the  several  muscle  fibers  with  the 
flat  of  the  scissors  and  using  the  instru- 
ment like  a  grooved  director.  By  means 
of  a  ring-shaped  periostcotome,  the  rib 
is  then  freed  of  any  small  muscular  ap- 
pendages. The  division  is  easy  with 
Beck's  beak-shaped  rib  shears,  but  some 
may  prefer  the  Gigli  saw.  Any  remains 
are  nipped  off  with  rongeur  forceps. 
Carl  Beck  (Journal  of  the  American 
Medical  Association,  June  17,  1905). 

CUTANEOUS   SYPHILIS. 

A  number  of  cases  are  reported  by  the 
author  which  go  to  show  that  cutaneous 
syphilis  may  be  closely  simulated  by  a 
number  of  skin  diseases.  There  are  no 
absolutely  characteristic  syphilitic  skin 
lesions.     The  elements  of  diagnosis  in 


406 


DELIRIUM  TREMENS,  COLD  AFFUSION  IN. 


DENTITION,  SECOND. 


cutaneous  syphilis  have  only  an  arbitrary 
value.  The  element  of  time  is  an  un- 
reliable factor  in  the  diagnosis  of  syph- 
ilis. It  may  happen  that  simple  sores 
with  consequent  swelling  of  the  glands 
will  develop  in  intervals  corresponding 
to  the  periods  of  syphilis.  The  region- 
ary  lymphadenitis  is  not  absolutely 
pathognomonic  for  syphilis.  Adenitis 
of  inguinal  and  cubital  glands  following 
infection  of  simple  wounds  may  be  seen 
which  have  the  characteristics  of  syph- 
ilis, viz.,  they  are  indolent  and  indurated. 
The  ensemble  of  all  syphilitic  symp- 
toms, in  exceptional  cases,  may  be  closely 
imitated  by  non-specific  dermatoses.  The 
diagnosis  of  syphilis  can  be  made  with 
absolute  certainty  only  when  based  on 
positive  as  well  as  on  negative  findings, 
that  is,  when  the  characteristic  elements 
of  syphilis  are  not  only  found,  but  when 
all  other  skin  diseases  which  may  appear 
under  the  similar  symptoms  can  be  ex- 
cluded with  certainty.  Fischkin  (Jour- 
nal of  the  American  Medical  Associa- 
tion, July  8,  1905). 

DELIRIUM     TREMENS,     COLD     AFFUSION 
IN. 

The  author  describes  the  treatment 
that  he  uses  in  cases  of  delirium  tremens. 
The  patient  is  stripped  naked  and  lies 
on  a  blanket  over  a  waterproof  sheet. 
A  copious  supply  of  ice-cold  water  is 
provided,  and  a  large  bath  sponge  drip- 
ping with  the  iced  water  is  dashed  vio- 
lently on  the  face,  neck,  chest,  and  body 
as  rapidly  as  possible.  He  is  then  rubbed 
dry  with  a  rough  towel,  and  the  process 
is  repeated  a  second  and  a  third  time 
The  patient  is  now  turned  over,  and  the 
wet  sponge  is  dashed  on  the  back  of  the 
head  and  down  the  whole  length  of  the 
spine  two  or  three  times,  vigorous  fric- 
iion  with  a  bath  towel  being  employed 
between  the  cold-water  applications.    By 


the  time  the  patient  is  dried  and  made 
comfortable,  he  will  be  fast  asleep. 
William  Broadbent  (British  Medical 
Journal,  July  1,  1905). 

DELIRIUM  TREMENS,  INJECTION  OF   SA- 
LINE SOLUTION  IN. 

In  discussing  the  treatment  of  post- 
traumatic delirium  in  alcoholic  subjects, 
the  writer  states  that  the  administration 
of  wine  or  spirits  in  such  cases  can  do 
very  little  good,  and  may  even  do  harm. 
He  is  strongly  opposed  to  the  use  of 
opiates  or  chloral  in  cases  of  delirium 
tremens,  as  such  treatment  really  con- 
sists in  adding  one  poison  to  another. 
Holding  that  the  patient  is  under  the 
influence  of  poisoning  due  either  to  the 
direct  effect  of  alcohol  or,  as  is  more 
likely,  to  disturbance  of  the  secretory 
functions  caused  by  defective  nervous 
action,  it  would  seem  more  logical,  the 
author  suggests,  to  base  the  therapeutics 
of  delirium  tremens  on  the  principle  of 
eliminating  the  poisonous  products. 
During  the  past  eight  years  he  has  in- 
variably treated  his  cases  of  delirium 
tremens  by  the  subcutaneous  injection 
of  saline  solution,  and  his  clinical  ex- 
perience of  this  method  has  convinced 
him  of  its  superiority  over  other  plans 
of  treatment.  All  depressing  narcotics, 
such  as  opium,  morphine,  and  chloral, 
should  be  rejected,  and  the  only  addition 
to  the  injections  of  artificial  serum 
should,  in  cases  of  cardiac  weakness,  be 
an  occasional  injection  of  sulphate  of 
strychnine.  Quenu  (Bull,  et  Mem.  do  la 
Soc.  de  Chirurgie  de  Paris,  No.  IS,  1905  ; 
British  Medical  Journal,  July  29,  1905). 

DENTITION,    THE    MEDICAL    ASPECTS    OF 
,  THE  SECOND. 

Rickets  delays  the  eruption  not  only 
of  the  milk  teeth,  but  also  of  their  suc- 
cessors, in  addition  to  frequently  causing 


DIABETES,  LOAF  SUGAR  IN. 


ERGOT-,  INTRAVENOUS  INJECTION.        407 


overgrowth  of  the  jaw,   with   resulting 
malposition.     A  similar  retarding  influ- 
ence is  also  exerted  hy  cretinism.     It  is 
not  probable  that  hereditary  syphilis  has 
any  effect  in  hastening  the  advent  of  the 
second  teeth,  though  all  text-books  gen- 
em  I  ly   assert  that  it  has   this  effect  on 
both  sets  of  teeth.    "Eventually  bad   re- 
sults as  to  integrity  of  the  enamel  often 
follow     the     exanthemata,     bronchitis, 
pneumonia,   and   the   nutritive   disturb- 
ances which  result  from  improper  feed- 
ing.     Alveolar   abscesses   in   connection 
with  the  first  teeth  may  lead  to  irregu- 
larities  of   their  permanent   successors. 
A  frequent  source   of  ill   health  is  the 
incomplete  detacbment  of  the  remnants 
of  the  first  dentition.     The  teeth  retain 
their   adhesion   to   the   alveolar   mucosa 
long   after   the   supplanting  teeth   have 
arrived.     Food  accumulates  and  decom- 
poses at  these  points  and  sepsis  results, 
the  neighboring  glands  become  swollen, 
though    suppuration    is    rare.      Possible 
outcomes  are  necrosis  and  cancrum  oris. 
As  to  the  influence  of  dentition  upon 
concurrent  general  disease,  it  may  be  said 
that  the  most  obvious  example  seen  is 
epilepsy  in  which  tooth  eruption  initiates 
the  onset  and  may  increase  the  frequency 
of    the    attacks.      Hysterical    conditions 
and   chorea    may  also  be  aggravated   by 
coincident     dentition.      H.    Armstrong 
(Lancet,  June  :!,   L905). 

DIABETES,   LOAF   SUGAR   IN. 

The  writer  slates  thai  for  some  time 
he  has  been  allowing  the  more  intelligent 
of  his  diabel  ic  patients  to  take  a  certain 
amount  of  loaf  sugar,  with  very  good 
results.  In  ss  per  cent,  of  the  cases  it 
was  found  that  after  the  regular  con- 
sumption of  :;:>  grams  or  over  of  sugar 

daily,  the  amount  of  glucose  in  t  he  urine 

either  did  not  increase  or  ever  decrease, 

while    the   general    condition    of    the    pa- 


tients was  much  improved.  Not  only  is 
the  subjective  effect  on  the  patient  ex- 
cellent, but  as  the  diabetic  organism  is 
deficient  in  albumins  and  fats,  it  is  ad- 
vantageous to  have  the  carbohydrate 
metabolism  increased  as  much  as  pos- 
sible. A  diet  restricted  to  albumins  and 
fats  involves  risk  of  insufficient  oxida- 
tion of  nitrogen  and  fats,  with  its  danger 
of  oxybutyria  acid  intoxication,  and  the 
possibility  of  coma,  and  the  administra- 
tion of  sugar  does  much  to  avoid  these 
perils.  The  sugar  is  best  given  in  the 
form  of  sugar  water  or  in  coffee,  shortly 
before  muscular  exertion,  the  rule  being, 
no  sugar  without  exercise  and  no  exercise 
without  a  preceding  sugar  feeding.  The 
author  believes  that  the  administration 
of  large  amounts  of  sugar  under  suitable 
precautions,  is  advantageous,  if  not  in 
all  cases,  in  at  least  95  per  cent,  of 
diabetics.  Both  the  actual  strength  and 
the  feeling  of  energy  are  increased  by 
this  addition  to  the  dietary.  Oefele 
(Miinchener  medizinische  Wochen- 
schrift,  May  23,  190:> ;  Medical  Rec- 
ord, June  17,  1905). 

ERGOT,  INTRAVENOUS  INJECTION  OF; 
EFFECTS  ON  THE  MAMMALIAN  CIR- 
CULATION. 

From  experiments  made  by  the  au- 
thors, chiefly  on  dogs,  the  following  con- 
clusions were  reached  :  The  typical  ef- 
fects of  the  intravenous  injection  of 
ergot  consist  in  a  large  and  abrupt  fall 
of  blood-pressure,  followed  by  a  prompt 
recovery,  and  generally  by  a  slight  and 
short  rise.  The  volume  of  the  organs 
varies  generally  in  the  same  direction  as 
the  blood-pressure.  The  changes  in  tin1 
latter  are  mainly  cardiac.  This  is  con- 
firmed by  myocardiograms  from  the  in- 
tact and  excised  heart.  Ergot  causes 
first   a   lessening  and   then  an   increase  of 

the   excursions;    both    phenomena   may 


408      FRACTURE  OF  NECK  OF  FEMUR. 


FURUNCLES  AND  CARBUNCLES. 


occur  while  the  ergot  is  being  injected. 
The  rate  of  the  heart  is  but  little  al- 
tered. The  effect  of  ergot  must  be  ex- 
erted directly  on  the  cardiac  muscle. 
There  is  some  oncometric  evidence  that 
ergot  has  a  slight  vasoconstrictor  action, 
but  this  is  inconstant  and  inconsiderable. 
There  was  no  evidence  of  strong  con- 
striction or  of  a  high  rise  of  blood-pres- 
sure. The  preliminary  fall  of  blood- 
pressure  is  absent  if  the  ergot  is  given 
by  intramuscular  injection. 

The  action  of  ergot  is  independent  on 
the  dose,  within  wide  limits.  The  rela- 
tive predominance  of  the  fall  and  rise 
differ  somewhat  in  different  ergot  prepa- 
rations; age,  however,  does  not  impair 
the  efficiency  of  their  action  on  the 
mammalian  circulation.  The  effects  are 
greatly  diminished  by  lowering  the 
blood-pressure,  by  any  method.  Shortly 
after  the  destruction  of  the  spinal  cord, 
however,  ergot  produces  a  relatively 
good  rise  of  pressure. 

Large  doses  of  ergot  depress  the  vagus 
center  and  the  vasomotor  endings.  It 
is  not  acutely  fatal,  even  in  very  large 
doses.  Torald  Sollmann  and  E.  D. 
Brown  (Journal  of  the  American  Med- 
ical Association,  July  22,  1905). 


The  first  essential  in  the  treatment  of 
complete  fracture  is  to  appose  the  frag- 
ments. For  this  purpose,  direct  trac- 
tion under  anaesthesia  followed  by  fixa- 
tion in  the  attitude  of  abduction  seems 
to  present  certain  advantages  over  the 
methods  ordinarily  employed.  If  union 
has  not  followed  routine  treatment,  the 
open  operation  is  indicated  in  suitable 
cases.  Support  and  protection  by  prop- 
erly adjusted  apparatus  is  of  great  ad- 
vantage during  the  period  of  repair,  and 
in  any  event  weight-bearing  should  not 
be  permitted  until  the  symptoms  indi- 
cate that  the  consolidation  is  complete. 
The  distinction  between  the  two  forms  of 
fracture  that  occur  in  young  subjects  is 
of  importance  as  influencing  treatment. 
It  seems  probable  that  in  the  majority 
of  cases  treatment  may  be  applied,  ten- 
tatively at  least,  with  advantage.  The 
standard  of  success  in  treatment  of  the 
most  favorable  cases  should  be  restora- 
tion of  normal  function,  and  in  all  one 
should  at  least  attempt  to  apply  the 
principles  that  are  recognized  as  essen- 
tial to  success  in  the  treatment  of  frac- 
tures in  other  situations.  Royal  Whit- 
man (American  Journal  Medical  Sci- 
ences, July,  1905). 


FRACTURE  OF  THE  NECK  OF  THE  FEMUR, 
TREATMENT  OF. 
Fracture  of  the  neck  of  the  femur 
occurs  at  any  age,  even  in  childhood. 
An  injury  at  the  hip,  followed  by  per- 
sistent disability,  should  always  suggest 
fracture,  and  if  one  is  not  expert  in  the 
details  of  physical  examination,  an  x-ray 
picture  should  be  procured  if  possible. 
As  an  impacted  fracture 'must  of  itself, 
cause  disability,  one  should  attempt  to 
reduce  it. in  the  manner  described  by  the 
author,  provided  efficient  support  can  be 
assured. 


FURUNCLES  AND  CARBUNCLES,  NEW  LO- 
CAL TREATMENT  FOR. 

The  use  of  the  electric  current,  is  ad- 
vised in  the  treatment  of  furuncles  and 
carbuncles.  If  no  pus  formation  has 
taken  place  the  opening  of  the  infected 
follicle  is  sought  for  with  a  magnifying 
glass,  and  when  found,  an  opi latins; 
needle,,  forming  the  minus  pole  and  car- 
rying a  current  of  12  milliamperes  is 
introduced  into  it.  The  current  is  grad- 
ually increased  up  to  10  milliamperes 
and  the  opening  enlarged  by  moving  the 
needle  about  so  that  the  hydrogen  gen- 
erated can  wash  out  all  bits  of  necrotic 


GALL-BLADDER,  RUPTURE  OF. 


GASTRIC  SECRETION. 


409 


tissue,  pus,  etc.  The  needle  is  then  re- 
moved and  reintroduced  after  reversal 
of  the  current,  so  that  the  oxygen  which 
is  now  generated  shall  thoroughly  disin- 
fect the  follicle,  after  which  a  final 
cleansing  of  the  cavity  is  carried  out  by 
means  of  another  minus  treatment. 
Every  suspicious  follicle  is  treated  in 
this  way  and  the  development  of  true 
furuncles  is  aborted.  If  pus  has  already 
formed  the  cavity  is  explored  with  a 
larger-  needle  until  the  entire  necrotic 
plug  has  been  broken  up  and  expelled 
by  the  nascent  hydrogen.  As  long  as 
suppuration  keeps  up,  the  procedure 
must  be  repeated  twice  a  day.  Wet 
dressings  of  plain  water  are  applied,  and 
it  is  surprising  to  see  even  large  furun- 
cles clear  up  under  five  or  six  days  of 
this  treatment.  Of  course,  if  there  is 
extensive  swelling  or  phlegmonous  in- 
flammation, incision?  must  be  made  as 
usual.  Marcus  (Miinchener  medicinische 
Wochenschrift,  May  23,  1905;  Medical 
Record,  June  17,  1905). 

GALL-BLADDER.    RUPTURE    OF    THE. 

Rupture  of  the  gall-bladder  should  be 
suspected  in  all  abdominal  injuries  and 
localized  tendencies  about  the  hepatic 
tract.  When  there  is  any  indication  of 
such  condition  the  abdomen  should  be 
opened  as  soon  as  possible.  Concretion? 
and  abdominal  fluid  should  be  removed 
from  the  peritoneal  cavity,  preferably 
will]  gauze.  Cases  in  which  the  peri- 
toneal cavity  should  be  irrigated  with 
water  alone  or  in  combination  with  salt 
or  other  medicaments,  are  few,  if  indeed 
they  ever  exist.  The  condition  of  the 
common  duct  should,  if  possible,  be  de- 
termined a1  t  [me  the  abdomen  is  opened. 
Tf  the  common  duct  is  occluded  by  neo- 
plasm the  frail-bladder  should  be  sutured 
to  the  duodenum.  If  a  concretion  is 
found  in  the  common  duct  it  should  be 


removed  at  the  primary  operation,  and 
drainage  provided  for.  Free  drainage 
should  be  resorted  to  by  suturing  the 
-all-bladder  to  the  abdominal  wall,  or, 
if  this  cannot  be  done,  by  inserting  gauze 
packing.  B.  M.  Ricketts  (St.  Louis 
Medical  Review,  July  8,  1905). 

GASTRIC  INTOLERANCE  IN  YOUNG  CHIL- 
DREN. 

The  writer  remarks  the  occurrence  of 
marked  gastric  disturbances  in  children 
without  intestinal  manifestations.  Three 
causes  are  distinguished :  dyspepsia,  ace- 
tonemia, pyloric  stenosis.  The  thera- 
peutic indications  are  nearly  the  same 
in  all.  To  arrest  the  emesis  only  water 
should  be  allowed  at  first — ice-water — a 
teaspoonful  every  half-hour,  and  hot 
applications  to  the  epigastrium.  Lavage 
may  sometimes  be  necessary,  and  injec- 
tions of  artificial  serum  may  be  em- 
ployed. When  vomiting  has  become  fre- 
quent, vegetable  broths,  salted,  are  al- 
lowed. When  emesis  has  ceased,  a  bouil- 
lon, containing  a  coffeespoonful  of  far i  in 
to  each  three  ounces,  is  given,  to  which, 
after  a  few  days,  a  little  milk  may  be 
added,  and  if  well  borne  it  may  be  grad- 
ually substituted  for  bouillon.  The 
quantity  of  sugar  in  the  milk  must  he 
carefully  regulated.  Tf  the  milk  is  not 
tolerated,  the  vegetable  broth  must  be 
returned  to,  and  after  a  few  days  but- 
termilk tried.  If  these  means  fail  and 
pyloric  stenosis  is  suspected,  the  case 
becomes  one  for  the  surgeon.  M.  E3. 
Terrien  (Le  Bulletin  Medical.  No.  11. 
190.V). 

GASTRIC    SECRETION. 

The  writer's  observations  show  thai  it 
is  probable  that,  in  the  process  of  al>- 
sorpl  ion  of  digested  food  in  the  stomach, 
a  substance  may  be  separated  from  the 
cells   of   the  mucous   membrane  which. 


410 


GONORRHOEA  EN  THE  FEMALE. 


INEBRIATE  MANIAS. 


passing  into  the  blood  or  lymph,  later 
stimulates  the  secretory  cells  of  the  stom- 
ach to  functional  activity.  An  extract 
of  the  fundus  mucous  membrane  in  5 
per  cent,  dextrin  injected  into  the  jugu- 
lar  vein  docs  not  cause  any  secretion  of 
gastric  juice,  while  a  similar  extract  of 
tbc  pyloric  membrane  does  cause  such 
a  secretion.  Boiling  tbc  extract  has  no 
effect  on  the  action  of  this -gastric  secre- 
tion. Such  absorption  as  occurs  in  the 
stomach  apparently  takes  place  in  the 
pyloric  end.  J.  S.  Edkins  (Lancet, 
July  15,  1905). 

GONORRHOEA   IN   THE   FEMALE. 

In  vulvo-vaginitis  the  author  recom- 
mends copious  injections  twice  a  day  of 
1  to  2000  to  1  to  4000  potassium  per- 
manganate, or  of  mercury  bichloride  1 
to  2000,  followed  by  a  dressing  of  5 
per  cent,  ichthyol  or  25  per  cent,  thigenol 
in  glycerine.  Resorcin,  in  doses  of  15 
grains,  may  be  given  internally.  Twice 
a  week  silver-nitrate  solution  should  be 
used  to  swab  the  inflamed  mucous  mem- 
brane, and  following  tins,  a  powder  of 
alum.  3  parts;  tannin.  2  parts,  should 
be  insufflated,.  Frequent  bathing  and 
other  hygienic  means  should  be  em- 
ployed. If  there  is  complicating  metri- 
tis, dressings  of  ichthyol,  10  parts;  io- 
doform, 5  parts;  glycerine.  200  parts, 
should  be  used.  Local  applications  of 
tincture  of  iodine  or  of  zinc  chloride.  1 
to  50,  may  be  employed,  and  intra- 
uterine injections  of  about  1  1/1»  ounces 
of  either  of  the  following  solution-: 
alumnol,  2%  parts;  tincture  of  iodine 
and  alcohol,  each  25  parts;  or  dermatol 
and  gum  arabic,  each  2  parts;  water,  25 
parts.  I  nl  I'ii-uterine  bougies  of  derma- 
tol, 8  grains;  lanolin,  150  grains;  while 
wax.  30  grains,  are  useful,  as  are  tam- 
pons of  deer  yeast,  which  acl  by  libera- 
tion  of   lactic  acid.     Urethritis  should 


be  treated  by  the  balsams,  thealkalines, 
and  by  irrigations  of  silver-nitrate  or 
protargol  solutions,  a  1  per  cent,  aqueous 
solution  of  thallin  sulphate.  L.  Archam- 
bault  (Journal  de  Medecine  de  Paris, 
Xo.  9,  1905). 

HYPEREMESIS      GRAVIDARUM,      TREAT- 
MENT   OF. 

The  writer  reports  a  case  of  protracte  1 
incoercible  vomiting  during  the  third 
month  of  pregnancy,  persisting  for  weeks 
even  after  entire  suspension  of  food  or 
medicines  by  the  mouth.  The  uterus 
was  in  pronounced  ante-flexion.  After 
failure  of  all  other  measures,  and  as  a 
partial  preliminary  to  artificial  abortion. 
a  colpeurynter  was  placed  in  the  vagina 
just  beyond  the  entrance  and  moderately 
filled,  thus  lifting  the  uterus  by  pressure 
from  below.  The  result  was  the  imme- 
diate suspension  of  the  vomiting:  the 
patient  was  soon  able  to  take  a  little 
milk.  The  colpeurynter  was  removed'at 
night,  hut  on  recurrence  of  the  vomit- 
ing was  replaced  the  next  morning,  with 
the  same  successful  result.  It  was  re- 
moved again  at  night  and'  there  was  no 
further  trouble,  the  pregnancy  progress- 
ing to  a  normal  termination.  R.  V. 
Uhle  (Centralblatt  fur  Gynaekologie,  Bd. 
xxix,  Xu.  24,  1905;  Journal  of  the 
American  Medica]  Association,  July  15, 
1905). 

INEBRIATE    MANIAS. 

The  continuous  drinker  of  spirits  in 
active  life  is  cultivating  a  soil  for  the 
growth  and  development  of  distinct  psy- 
choses, which, may  break  out  at  any  time. 
One  of  the  most  common  of  these  symp- 
toms is  delusions  of  infidelity.  They  are 
practically  symptomatic  of  the  partic- 
ular cause,  alcohol.  Delusion  of  perse- 
cution and  delusions  of  grandeur,  to- 
gether   with     mania-    of    various    kind.-. 


INFANT  FEEDING. 


IODINE  AND  IODIDES. 


411 


are  natural  sequels  of  alcoholic  degenera- 
tion and  should  receive  the  most  careful 
study.  All  such  persons  are  irresponsible 
— to  what  degree  the  facts  of  each  case 
will  determine.  The  medical  man  should 
recognize  this  condition  and  be  emphatic 
in  his  statements,  and  never  minimize  or 
neglect  to  recognize  the  gravity  of  these 
states.  T.  D.  Crothers  (Medical  Becord, 
July  1,  1905). 

INFANT    FEEDING. 

Mother's  milk  is  the  only  proper  food 
for  an  infant,  and  should  he  used  when- 
ever available.  All  forms  of  proprietary 
foods  are  had  and  to  be  avoided.  Wet- 
nursing  is  rarely  permissible.  The  proper 
substitute  food  for  an  infant  is  some 
form  of  modified  cows'  milk.  The  stand- 
ard to  be  aimed  at  is  the  child's  natural 
food — mother's  milk.  Careful  attention 
must  be  paid  to  each  of  the  constituent- 
— proteid,  fat,  sugar,  and  salts.  The 
proteid  of  cows'  milk  is  less  digestible 
than  that  of  human  milk,  and  requires 
over-dilution  compared  with  the  stand- 
ard. The  whole  of  this  indigestible  pro- 
teid (caseinogen)  may  be  removed,  leav- 
ing the  more  easily  digestible  proteid 
(lactalbumin)  as  in  whey  mixtures,  or 
the  proteid  content  may  be  completely 
or  partially  peptonized.  Cows'  milk  di- 
luted sufficiently  to  bring  the  proteid 
into  line  with  the  standard  ( from  I  per 
cent,  to  1..")  per  cent.)  is  deficient  in  fat 
and  sugar,  and  these  must  he  subse- 
quently added.  Fat  may  he  added  in  the 
form  of  cream,  either  separated  and  of 
standard  strength,  or  by  using  gravity 
creams.  Lactose  is  the  proper  sugar  to 
add.  Cows'  milk,  although  neutral  or 
alkaline  when  drawn,  owing  to  its  cer- 
tain   illfect  inn    ;l-   ;lt     present    obtained    ;l  IK  I 

to  the  rapid  growth  of  germs  it  allows, 
becomes  acid,  and  this  acidity  must  he 
neutralized  hv  bicarbonate  of  sodium  or 


lime  water.  Human  milk  is  sterile. 
therefore  some  attempt  must  be  made  to 
kill  germs  always  present  in  large  quan- 
tities in  cows'  milk.  Boiling  does  this 
most  effectually  and  rapidly,  is  much  the 
easier  method,  and,  in  the  hands  of  the 
poor,  often  the  only  method  available, 
hut  certain  injurious  changes  result,  to 
be  avoided  if,  possible.  These  changes 
can  best  be  avoided  at  70°  C.  (158°  F.) 
for  half  an  hour  (pasteurization).  All 
infants'  food  should  therefore  undergo 
this  process  when  possible.  T.  G.  San- 
derson-Wells (British  Medical  Journal. 
July  8,  1905). 

IODINE  AND  IODIDES,  CHANGES  IN  THE 
BLOOD  OF  CHILDREN  DUE  TO. 
Injections  of  a  solution  of  iodine  and 
potassium  iodide  according  to  the  method 
of  Durante  have  not  only  a  local  effect 
upon  tuberculosis  processes,  but  have  a 
general  action  upon  the  blood-forming 
organs.  These  injections  give  rise  to  a 
leucocytosis  in  which  the  mononuclear 
form  prevails.  This  lymphocytosis  rep- 
resents the  reaction  of  the  organism 
which  defends  itself  by  means  of  the 
phagocytic  action  of  the  white  cells.  The 
latter  act  directly  upon  the  tubercle  ba- 
cilli, hindering  the  spread  of  the  infec- 
tion and  neutralizing  the  action  id'  the 
toxin.  The  author,  therefore,  advises 
the  use  of  Durante's  method  of  injecting 
iodine  and  potassium  iodide  in  the  re- 
gion of  tuberculous  glands,  etc..  in  chil- 
dren. The  blood  of  each  child  was  ex- 
amined before  and  after  the  injections. 
The  treatment  consisted  of  daily  injec- 
tions of  1  cubic  centimeter  of  the  Men- 
tion of  potassium  iodide  and  iodine,  as 
recommended  by  Durante,  thirty  injec- 
tions consl  it  id  ing,  as  a  rule,  a  course  of 

treatment,  after  which  the  blood  was 
once  more  examined.  A.  B.  Gianasso 
<  Riforma  Medica,  May  2,1,  L905;    New 


412 


JOINT  INJURIES. 


LEPROSY,  CURE  OF. 


York  Medical  Journal  and  Philadelphia 
Medical  Journal,  July  15,  1905). 

JOINT  INJURIES,  FUNCTIONAL  IMPO- 
TENCE FOLLOWING. 
In  every  case  of  functional  impotence 
consecutive  to  a  traumatism  of  the  joints, 
it  is  necessary  to  remember  that  spinal 
disease  may  be  associated  with  the  disease 
of  the  joints,  reflex  amyotrophy  being 
the  manifestation  which  is  the  most  ap- 
parent and  the  best  known.  To  the 
well-known  symptoms  of  reflex  atrophy, 
including  atrophy,  paresis,  spasmodic 
phenomena,  diminution  of  galvanic  and 
faradic  excitability  without  the  reaction 
of  degeneration,  must  be  added  diminu- 
tion of  electrical  resistance  in  compari- 
son with  the  unaffected  side.  Keflex 
amyotrophy  is  usually  fatal  in  its  results 
when  an  effusion  of  the  joints  is  devel- 
oped. All  degrees  of  involvement  are 
possible,  from  simple  paresis  to  complete 
paralysis.  Pathological  anatomy  as  well 
as  experimentation  have  demonstrated 
that  the  principal  medullary  lesion  con- 
sists in  a  diminution  of  the  large  motor 
cells  in  the  anterior  horns.  In  the  nerves 
and  muscles,  in  the  midst  of  healthy  ele- 
ments there  may  be  degenerated  sensory 
nerve  cords  pertaining  to  the  joints,  de- 
generated motor  fibers,  atrophied  mus- 
cular fibers,  forming  the  lesions  of  the 
reflex  arc,  and  sustaining  the  theory  of 
Vulpian  and  Charcot.  Centripetal  ex- 
citation referred  to  the  joints,  which 
may  change  the  motor  cells  of  the  ante- 
rior horns,  may  also  change  the  other 
trophic  centers  which  preside  over  the 
nutrition  of  the  other  tissues  or  circum- 
articular organs.  The  medullary  lesions 
arc  in  two  different  forms  or  degrees. 
The  idea  of  reflex  amyotrophy  of  artic- 
ular origin  should  hold  an  important 
place  in  general  surgical  pathology,  for 
it  explains  the  pathogenesis  of  a  great 


number  of  joint  diseases.  There  is  no 
necessary  relation  between  the  intensity 
of  the  articular  affection  and  the  gravity 
of  the  reflex  amyotrophy  which  it  causes, 
but  the  more  articular  irritation  is  pro- 
longed, the  more  incurable  are  the  med- 
ullary lesions.  Eeflex  amyotrophy  is  al- 
ways more  severe  in  its  significance  for 
the  lower  extremity.  The  more  curable 
the  articular  lesion,  the  more  curable  the 
reflex  amyotrophy.  Should  the  former 
become  chronic  the  latter  will  be  incur- 
able. 

Electrical  exploration  enables  one  to 
determine  the  prognosis  of  reflex  amyo- 
trophy. It  becomes  the  more  grave  as 
the  galvanic  excitability  is  diminished, 
comparing  it  with  the  unaffected  side. 
The  benign  form  of  reflex  amyotrophy 
may  be  treated  by  faradism  or  static 
electricity.  Should  the  spasmodic  phe- 
nomena become  prominent,  localized 
faradization  would  be  injurious.  Static 
electricity  in  its  sedative  form  would  be 
more  appropriate.  In  the  incurable 
forms  static  electricity  is  useful  to  re- 
lieve the  spasmodic  and  painful  symp- 
toms. Such  symptoms  contraindicate  all 
treatment  which  may  be  violent  or  forci- 
ble. The  spasmodic  phenomena,  includ- 
ing exaggerated  tendon  reflexes,  exag- 
gerated mechanical  excitability  of  the 
muscles,  rapid  fatigue  with  contractures, 
form  the  practical  guide  to  the  proper 
direction  of  treatment.  Mally  and  Eichon 
(Eevue  de  Chirurgie,  May,  1905;  New 
York  Medical  Journal. and  Philadelphia 
Medical  Journal,  June  24,  1905). 

LEPROSY,   CURE   OF. 

The  writer  believes  leprosy,  like  syph- 
ilis and  .tuberculosis,  is  curable,  accord- 
ing to  the  degree  of  infection  and  body 
resistance.  No  early  case  has  failed  to 
respond  to  his  treatment  and  a  certain 
number  have  recovered.    The  only  reme- 


LIGATURE  OF  INNOMINATE  ARTERY. 


MOVABLE  KIDNEY. 


413 


dies  which  have  given  him  results  arc 
strychnine,  antivenomous  serum,  chaul- 
moogra  oil,  and  chlorate  of  potash.  The 
oil  more  nearly  approximates  a  specific 
for  leprosy  than  any  treatment  as  yet 
suggested.  Full  diet  is  best,  restricting 
only  indigestible  foods.  Hot  baths  twice 
daily,  with  or  without  soda,  are  essen- 
tial. Tonics  and  febrifuges  are  needed. 
The  patient  should  be  watched  for  inter- 
current affections.  Strychnine  is  a  sine 
qua  non.  Chaulmoogra  oil  is  better  en- 
dured before  than  after  meals  and 
should  be  given  in  capsules,  hot  milk,  or 
milk  of  magnesia,  beginning  with  3 
drops  and  slowly  increased  to  120  or 
150  drops.  It  may  be  combined  in  pill 
with  nux  vomica  and  ordinary  excipients. 
One  patient,  now  well,  did  not  show  im- 
provement for  two  years.  Treatment 
should  be  continued  after  all  evidence 
of  disease  is  gone.  Isadore  Dyer  (Med- 
ical Xews,  July  29,  1905). 

LIGATURE  OF  THE  INNOMINATE  AR- 
TERY. 

In  properly  selected  cases  ligature  of 
the  innominate  is  a  reasonably  safe  and 
undoubtedly  useful  operation.  Suitable 
cases  arc  those  in  which  the  aneurism 
is  of  a  circumscribed,  globular  character. 
ami  the  general  condition  of  the  patient 
is  otherwise  good.  Unsuitable  eases  are 
those  in  which  the  aneurism  is  what  is 
commonly  called  fusiform,  but  is  really 
often  nothing  more  than  part  of  a  gen- 
eral arterial  dilatation,  and  in  which 
there  are  marked  signs  of  general  arterio- 
sclerosis with  accompanying  visceral  dis- 
ease. 

The  maintenance  of  asepsis  is  the 
main  factor  in  obtaining  a  successful 
result.  The  incision  should  be  central 
with  horizontal  and  vertical  division  of 
the  manubrium,  if  necessary.  The  ca- 
rotid should  be  tied  as  well  as  the  in-' 
nominate.    Silk  is  the  best  ligature  mate- 


rial. Some  amount,  of  injury  to  the  in- 
ner coats  is  probably  necessary  to  insure 
occlusion,  but  with  aseptic  conditions 
such  injury  does  not  matter. 

Two  ligatures  should  if  possible  be 
placed  round  the  vessel,  the  first  turn 
of  the  proximal  ligature  being  held  tight, 
so  as  to  keep  back  the  blood  while  the 
distal  ligature  is  completely  tied.  The 
use  of  a  drainage-tube  is  inadvisable. 

As  a  study  of  the  recorded  cases  shows 
that,  next  to  sepsis,  some  cerebral  lesion 
has  been  the  most  frequent  cause  of  death 
after  operation,  it  would  be  well  for 
future  operators  to  consider  the  advis- 
ability of  tying  the  carotid  about  a  fort- 
night before  the  innominate.  "Valsal- 
van"  methods  of  treatment  immediately 
prior  to  operation  are  inadvisable.  Will- 
iam Sheen  (Annals  of  Surgery,  July. 
1905). 

MOVABLE    KIDNEY,    TREATMENT    OF. 

Nephrorrhaphy  should  not  be  recom- 
mended in  cases  in  which  the  symptoms 
referable. to  the  mobility  of  the  kidney 
are  a  small  part  of  the  trouble.  In  mov- 
able kidney  complicated  by  enteroptosis 
an  operation  should  not  be  recommended 
unless  it  can  be  shown  that  serious  symp- 
toms are  directly  due  to  the  displacement 
of  the  kidney.  Tf  movable  kidney  is  as- 
sociated with  a  nervous  temperament, 
palliative  measures  should  be  exhausted 
before  an  operation  is  suggested.  If  dys- 
pepsia, constipation,  uterine  or  ovarian 
disease,  or  chronic  disease  of  the  kidney 
have  long  coexisted  with  the  mobility, 
nephrorrhaphy  should  not  be  performed. 
Tf  the  displacement  does  not  cause  much 
discomfort  or  functional  disturbance, 
nephrorrhaphy  should  not  be  recom- 
mended. 

Nephrorrhaphy  should  be  recom- 
mended in  uncomplicated  cases  in  which 
the  pair  is  distinctly  renal,  and  in  which 


414         MUSCLES,  PRODUCTION  OF  ALCOHOL,  ETC.,  BY. 


NEPHROPTOSIS. 


there  are  definite  renal  crises;  if  there 
is  evidence  of  twisting  of  the  pedicle  as 
shown  by  paroxysmal  renal  pain,  and 
albumin,  pus,  blood,  or  tube  casts  in  the 
urine;  if  gastro-intestinal  symptoms  are 
pronounced  while  the  patient  is  active, 
but  are  relieved  during  periods  of  rest. 
Newman  (Glasgow  Medical  Journal, 
July,   1905). 

MUSCLES,  PRODUCTION  OF  ALCOHOL  AND 
ACETONE,   BY   THE. 

An  explanation  of  a  possible  source  of 
some  of  the  acetone  that  may  accumulate 
in  the  blood  in  pathological  conditions. 
is  afforded  by  the  research  of  the  writer, 
who  finds  that  a  muscle  removed  from 
an  animal  and  placed  under  conditions 
favorable  for  survival,  produces  both  ace- 
tone and  alcohol.  The  former  con- 
stantly increases,  but  the  latter  increases 
only  for  the  first  few  days,  and  then 
diminishes.  The  tissues  are  able  to  de- 
stroy alcohol  after  it  is  formed,  but  have 
no  influence  over  the  molecule  of  ace- 
tone. The  alcohol  is  probably  trans- 
formed into  acetic  acid  by  a  direct  or  an 
indirect  oxidation.  The  acetic  acid  then 
undergoes  the  fate  of  all  other  organic 
acids  in  the  body,  namely,  a  transforma- 
tion by  oxidation,  into  carbon  dioxide 
and  water.  The  transformation  of  glu- 
cose into  alcohol  may  be  considered  a 
mode  by  which  the  body  is  aide  to  de- 
stroy glucose.  F.  Maignan  (Comptes 
Rendus,  April  IT.  1905;  Medical  News. 
August  12,  1905). 

NASAL   HEADACHE. 

Two  general  causes  of  headache,  par- 
tial or  complete  stenosis,  and  acute  or 
chronic  sinusitis,  are  considered  by  the 
author.  In  intractable  headache  of  any 
form  the  nose  should  be  carefully  in- 
spected. In  acute  empyemas  headache 
is  almost  always  present  ;    in  the  chronic 


forms  it  is  less  frequent.  The  order  of 
frequency  is  frontal,  occipital,  vertical. 
The  varieties  are  similar  to  those  from 
other  causes,  neuralgia  or  hemicrania 
predominating.  Usually  the  pain  is  con- 
stant in  its  relation,  changing  its  posi- 
tion when  other  intranasal  tissues  are 
consecutively  involved.  The  intensity 
varies  with  the  severity  of  the  local  dis- 
order and  the  general  'condition  of  the 
patient.  If  portions  of  the  nasal  interior 
are  in  contact,  neuralgic  headache  re- 
sults. Stenosis  produces  frontal  pain 
and  weight,  while  the  most  violent  and 
constant  pains  result  from  pressure  in 
the  accessory  sinuses.  In  chronic  ob- 
struction from  any  cause,  especially  hy- 
pertrophy of  the  turbinates,  headache  is 
a  common  symptom.  Severe  epistaxis 
is  often  preceded  by  congestive  headache. 
If  the  bleeding  is  profuse  the  headache 
may  follow  it.  In  headache  from  sinu- 
sitis in  general  more  than  one  cavity  is 
usually  involved.  There  may  also  be 
nasal  disease,  with  or  without  suppura- 
tion and  with  intermittent  headache,  to 
which,  however,  it  has  no  direct  relation. 
Somers  (Medicine,  July,  1905). 

NEPHROPTOSIS. 

Dislocated  kidney  is  of  far  -more  fre- 
quent occurrence  than  ordinarily  sup- 
posed or  diagnosed.  It  should  be  care- 
fully searched  for  in  all  cases  complain- 
ing of  abdominal  symptoms.  It  is  a  po- 
tent factor  in  the  causation  of  neurosis 
and  is  the  cause  of  many  cases  of  obsti- 
nate indigestion.  It  is  a  prime  factor  in 
the  production  of  various  bodily  crises, 
the  latter  being  the  result  of  toxic  ab- 
sorption from  imperfect  elimination,  and 
having  their  origin  from  either  the  stom- 
ach, intestines,  kidneys,  or  liver.  It  may 
be  the  result  of  any  lesion,  either  local  or 
general,  which  will  vitiate  the  vitality  of 
the  peritoneum,  thereby  weakening  that 


OPTIC  NERVE,  INJURIES  OF. 


PERINEPIIRITIC  ABSCESS. 


415 


organ  so  that  there  is  continued  loss  of 

peritoneal  tone  and  therefore  a  decrease 
in  intra-abdominal  resistance,  tension, 
and  support.  It  produces  ulcer  of  the 
stomach  and  duodenum ;  it  handicaps 
the  activity  of  the  eholecyst  and  obstructs 
the  duct  of  the  latter;  it  produces  typh- 
ilitis,  perityphlitis,  appendicitis,  colitis, 
and  localized  or  general  peritoneal  in- 
flammations, with  adhesions;  it  is  a 
powerful  factor  in  the  production  of  a 
general  loss  of  vitality.  Obstinate  con- 
stipation, with  the  accompanying  trau- 
matism produced  by  the  violent  peri- 
stalsis of  drastic  catharsis,  is  one  of  the 
chief  causes  of  dislocated  kidney. 

Any  operative  interference  calculated 
to  correct  a  dislocated  kidney  must  be 
one  which  has  for  its  primary  objed  a 
reattachment  of  the  peritoneum  to  the 
back,  a  shortening  of  peritoneal  elonga- 
tions, and  a  reestablishment  of  the  nor- 
mal anatomical  relations  and  positions 
of  the  abdominal  viscera.  Earl  ITarlan 
(  Lancet-Clinic,  July  '2-?.  1905). 

OPTIC  NERVE.  INJURIES  OF  THE. 

Five  cases  of  indirect  injury  of  the 
optic  nerve  are  reported  by  the  writer. 
The  sequence  of  events  was  as  follows: 
A  more  or  less  severe  Mow  in  the  region 
of  the  external  angular  process  of  the 
frontal  hone.  Sudden  impairment  of 
vision  on  the  side  of  injury.  Loss 
of  the  greater  part  of  the  temporal  Held 
of  vision  on  the  same  side.  Absence  of 
ophthalmoscopic  changes  for  the  firsl 
\'r\v  weeks,  followed  by  atrophy  of  the 
nerve  head  on  the  injured  side.  <  lentral 
vision  may  be  almosl  completely  re- 
stored, hni  the  limitation  in  the  field  of 
vision  remains  practically  and  perma- 
nently the  same.  The  nature  of  the  le- 
sion is  very  problematical,  hut  it  is  prob- 
ably one  of  limited  contusion  of  the  nasal 
fibers  of  the  optic  nerve  by  contrecoup. 


The  nerve  on  the  side  of  the  injury  is 
driven  against  the  inner  boundary  of 
the  optic  foramen. 

The  treatment  should  consist  of  rest 
and  quiet  in  a  darkened  room,  light  diet. 
and  aperients  for  a  week  or  two.  and 
avoidance  of  work  and  mental  excite- 
ment for  a  further  period  of  two  or  three 
weeks.  J.  J.  Evans  (British  Medical 
Journal,  July  8,  1905). 

PELVIC     OPERATIONS.      INFLAMMATORY 
CONDITIONS    OF   APPENDIX    IN. 
In   a    large   number — in    the   present 
series  in  323  out  of  370 — of  pelvic  eases 
no  inflammatory  changes  in  the  appendix 
are  found,  even  microscopically.     When 
a  normal  appendix  is  found  in  conjunc- 
tion with  disease  of  the  pelvic  organs,  it 
is  improbable  that  the  latter  condition 
has  been  brought  about  by  a  perforation 
of   the   appendix   which    had    afterward 
healed.     On  the  other  hand,  an  old  peri- 
appendicitis and  adhesions  may  often  he 
looked  upon  as  the  result  of  a  septic  in- 
fection,   originating    in,    and    spreading 
from  the  organs  of  general  ion.     An  ap- 
pendix which  looks  abnormal  macroscop- 
ieally  does  not  always  show  inflammatory 
changes   on    microscopical    examination. 
Nevertheless,   when   the   removal    of   the 
appendix  adds  veiw  little  to  the  gravity 
of  the  abdominal  operation,  for  the  bene- 
fit of  the  patient   il  should  he  taken  away. 
In  the  writer's  series  of  370  cases  there 
were   four  deaths,  hut    a  careful   analysis 
goes  to  show  that    the   fatality  could   in 
no  instance  he  attributed  to  the  removal 
of    the    appendix.      Hunter    Robb    (St. 
Louis  Medical  Review,  July  8,  L905 ). 

PERINEPHRITIC    ABSCESS. 

This  disease  is  frequently  caused  by 
pyonephrosis,  pyonephritis,  or  -tone  in 
I  he  pe|\  is  or  the  parenchyma  of  the  kid- 
ney.   It  may  also  resuH  from  inflamma- 


416 


PERTUSIS,  TREATMENT. 


PNEUMONIA,  LOBAR,  ICE  IN. 


tory  processes  of  the  stomach,  duodenum, 
small  intestines,  or  colon.  Disease  of 
the  liver  and  gall-bladder,  or  of  the  bile 
ducts  may  also  act  as  a-  cause.  Inflam- 
mation of  the"  psoas  muscle  and  vertebral 
column  causing  this  form  of  abscess  are 
usually  of  a  tuberculous  nature.  Other 
causes  are  perimetritis  or  parametritis, 
appendicitis,  oophoritis,  cystitis,  orchi- 
tis, inflammation  of  the  vas  deferens, 
inflammatory  processes  in  the  lower  ex- 
tremities, or  ruptured  empyema.  Acute 
infectious  diseases,  in  which  the  bacteria 
are  in  the  blood,  or  are  capable  of  in- 
vading the  body,  as  a  whole,  through  the 
blood  or  lymphatic  circulation,  have  im- 
portant causative  relations  to  this  dis- 
ease. The  infecting  agent  may  be  car- 
ried by  the  urine  in  scarlet  fever,  in  re- 
current, relapsing,  or  typhoid  fever,  and 
malaria.  Within  four  hours  after  ex- 
perimental injections  containing  bacteria 
the  latter  may  be  found  in  the  urinary 
tract.  This  has  been  found  true  of 
coli  communis,  staphylococcus  pyogenes, 
streptococcus,  pyocyaneus,  proteus,  gon- 
ococcus.  typhosus,  tetragenus.  and  diplo- 
coccus  of  Friedlander.  Therefore,  any 
germ  capable  of  producing  inflammation 
or  pus  when  it  has  entered  the  blood  may 
be  eliminated  by  the  kidney,  and  may 
produce  lesions  of  the  kidney  substani  e, 
or  of  the  mucous  lining  of  the  pelvis, 
ureters,  and  bladder.  They  are  thus 
brought  into  proximity  with  the  peri- 
nephric fat,  into  a  region  directly  con- 
nected by  lymphatics  with  this  fat. 
Perinephrilie  abscess  has  beeD  found 
after  small-pox,  typhoid  fever,  scarlet 
fever,  puerperal  (r\rv.  diphtheria,  acti- 
nomycosis, metastatic  infected  wounds, 
and  abscesses  in  various  parts  of  the 
body.  The  symptoms  are  those  of  sepsis 
and  vary  with  the  type  of  the  infection. 
There  may  be  difficult  defecation,  gen- 
eral debility,  dyspnoea,  vomiting,  and  a 


mass  in  the  lumbar  region  unaffected  by 
respiration.  The  urine  is  unchanged. 
It  is  more  frequent  in  males  than  in 
females,  and  there  may  be  fluctuation. 
It  should  be  differentiated  from  nephritic 
abscess,  hydronephrosis,  appendicitis, 
and  hip  disease.  The  treatment  consists 
in  incision,  and  cleaning  and  draining 
the  cavity.  Bryan  (International  Jour- 
nal of  Surgery,  June,  1905). 

PERTUSSIS,  TREATMENT  OE. 

Prophylaxis  is  believed  by  the  author 
to  he  the  first  essential,  and  entails 
avoidance  of  contact  with  whooping- 
cough  patients,  schools  and  kindergar- 
tens being  closed  during  severe  epidem- 
ics. Disinfection  of  sputa  and  excreta  is 
advisable,  and  good  results  in  cutting 
short  the  disease  have  been  reported  by 
fumigation  of  the  patient's  room  with 
sulphurous  acid.  Of  the  drugs  to  be 
used,  quinine  stands  foremost,  and  it 
may  be  given  three  times  a  day,  as  many 
decigrams  as  it  is  months  old.  Camphor 
is  useful,  but  the  coal-tar  products  are 
less  favorable  than  quinine  and  are  fre- 
quently dangerous.  Careful  dieting  is 
necessary,  and  it  is  desirable  to  give 
small  amounts  of  concentrated  food  at 
short  intervals  to  avoid  overflowing  the 
stomach.  For  the  paroxysms,  belladonna 
and  opium,  and  moral  suasion  are  advo- 
cated. The  author  reports  encouraging 
results  attending  the  use  of  the  elastic 
abdominal  belts  recommended  by  Kilner 
for  the  purpose  of  controlling  the  vomit- 
ing and  reducing  the  number  and  vio- 
lence of  the  paroxysms.  J.  B.  Tyrrell 
(Medical  Record,  July  2?,  1905). 

PNEUMONIA,   LOBAR,   ICE   APPLICATIONS 
IN. 

The  writer  outlines  as  follows  a 
method  of  treatment  Fhat  he  claims  to 
have  used  for  a  number  of  years  with 
great  success  in  lobar  pneumonia:    As 


PNEUMONIA,  LOBAR,  IN  INFANTS  AND  CHILDREN. 


417 


soon  as  a  diagnosis  is  made,  the  patient 
is  given  a  full  warm  bath  for  cleansing 
purposes,  put  to  bed,  and  given  a  laxa- 
tive dose  of  calomel  and  soda.  The  chest 
area  of  the  lung  tissue  involved  is  care- 
fully outlined,  and  one  or  more,  as  re- 
quired, specially  constructed  ice-bags 
are  moderately  but  evenly  filled  with 
crushed  ice  and  applied  accurately  over 
the  parts  inflamed.  Each  bag  is  wrapped 
in  a  thin  layer  of  gauze  and  is  furnished 
with  a  drainage  pipe,  the  lower  end  of 
which  empties  into  a  basin  below  the 
bed.  The  main  and  important  feature 
is  this  draining  off  the  water  as  fast  as 
it  is  formed,  thereby  establishing  con- 
stant and  uniform  ice  application  and 
utilizing  the  remarkable  heat-absorbing 
quality  of  melting  ice.  Examinations 
are  made  each  morning  and  evening,  and 
the  ice  applications  adapted  to  the  chang- 
ing areas  of  involved  lung.  There  is  no 
danger,  the  author  claims,  to  the  vitality 
of  the  parts,  and  the  ice  applications  are 
kept  up  as  long  as  the  disease  appears 
to  be  progressing  and  no  threatening 
signs  of  collapse  appear.  In  the  latter 
event,  ice  applications  are  promptly  re- 
moved, and  stimulation  is  at  once  re- 
sorted to.  The  internal  treatment 
throughout  the  disease,  aside  from  stim- 
ulants, includes  free  use  of  some  milk, 
alkaline  mineral  water,  and  5  to  15-drop 
doses  of  creosote  every  four  hours.  The 
bowels  are  regulated  by  saline  laxatives 
and  enemas,  the  diet  is  guided  by  the 
digestive  capacity,  and  free  ventilation 
of  the  sick  room  Is  secured.  It  isclai] 
that  this  treatment  lowers  the  pulse  while 
regulating  rnd  strengthening  11k1  heart, 
relieves  respiratory  difficulty  and  chest 
pains,  and  shortens  the  duration  of  the 
disease  in  the  majority  of  cases.  If 
begun  within  the  first  twelve  hours,  the 
disease  may  be  aborted.  P.  A.  Am 
(American  Medicine,  June  3,  1905). 


PNEUMONIA,    LOBAR,    IN    INFANTS    AND 
CHILDREN. 

The  pneumonia  of  infancy  and  child- 
hood as  compared  to  that  of  the  adult 
presents  certain  differences  in  its  course 
which  should  impress  the  physician.  In 
certain  epidemics,  meningeal  symptoms 
seem  to  predominate,  especially  in  those 
cases  in  which  the  apices  of  either  lung 
are  involved.  In  other  epidemics,  pneu- 
monia with  meningeal  symptoms  is  not 
so  frequent.  In  children,  pneumonia  is 
more  apt  to  be  followed  by  purulent  pleu- 
risy, especially  below  the  age  of  4  years, 
than  by  pleurisy  with  effusion,  as  in  the 
adult.  During  fifteen  years  the  author 
saw  839  cases  of  pneumonia  of  all  kinds 
and  types.  Of  these  cases  582,  or  69 
per  cent.,  occurred  before  the  end  of  the 
first  two  years  of  life.  Of  the  839  cases 
mentioned  436  occurred  in  male  and  403 
in  female  children.  The  right  lung  is 
most  affected,  and  the  upper  lobe  of  the 
right  lung,  rather  than  the  lower  lobe  of 
the  left  lung,  is  mostly  involved. 

The  prognosis  of  lobar  pneumonia  in 
infants  and  children  will  vary  as  to  the 
age.  severity,  and  kind  of  infection,  as 
to  the  amount  of  lung  involved,  and  the 
presence  or  absence  of  complications. 
Generally  speaking,  the  prognosis  a 
age  is  best  below  10  years.  The  younger 
the  child,  the  greater  the  danger.  The 
season  of  the  year  also  influences  mor- 
tality. Tn  the  winter  months,  when  the 
epidemic  is  at  its  height,  the  mortality 
is  greatest,  and  in  the  spring  and  sum- 
mer months  it  is  lowest.  This  is  due, 
possibly,  to  the  great  virulence  of  the 
infection.  Complications  also  influence 
the  prognosis.  Tn  infants  and  children 
a  complicating  pericarditis  is  i 
Other  complications,  such  as  otitis,  pleu- 
risy, empyema,  do  not  materially  influ- 
ence the  prognosis  in  infants  and  chil- 
dren  if   recognized   early   and   treated  on 


418       PNEUMONIA,  PHOSPHATES  IN  URINE  IN.  RHEUMATISM  OF  FEET. 


sound  principles.  Lobar  pneumonia,  be- 
ing an  acute  infectious  disease,  abso- 
lutely  self-limited  in  its  course,  unin- 
fluenced by  any  mode  of  specific  treat- 
ment that  is  known  of,  it  should  be  the 
duty  of  the  physician  to  manage  a  case 
of  lobar  pneumonia  in  an  infant  or  child 
very  much  on  the  same  principles  as  he 
would  manage  a  case  of  any  other  in- 
fectious disease,  such  as  typhoid  fever, 
with  a  certain  allowance  for  the  duration 
of  the  disease  and  the  severity  of  the 
infection.  H.  Koplik  (Boston  Medical 
and  Surgical  Journal,  June  29,  1905). 

PNEUMONIA,  PROGNOSTIC  VALUE  OF 
PHOSPHATES  IN  THE  URINE  IN. 
The  author's  researches,  involving  a 
study  of  25  cases  of  pneumonia  in  both 
sexes,  showed  that  in  almost  all  of  these 
patients  there  was  a  more  or  less  marked 
diminution  of  the  total  amount  of  phos- 
phates in  the  urine.  The  earthy  phos- 
phates did  not  suffer  such  a  marked 
diminution,  and  of  these,  magnesium 
phosphate  was  diminished  in  amount, 
although  it  never  disappeared  entirely, 
while  calcium  phosphates  remained  un- 
altered. The  alkaline  phosphates,  how- 
ever, were  subject  to  variations  parallel 
with  those  of  the  disease.  During  the 
first  few  days  they  diminished,  and  they 
almost  disappeared  during  the  most 
acute  stage  in  most  patients.  When 
resolution  began,  the  phosphates  again 
increased  gradually  until  recovery  was 
complete.  This  return  of  the  phosphates 
preceded  the  crisis  by  half  a  day  or  a 
day.  while  the  absence  of  chlorides  still 
persisted.  Tn  three  of  the  cases  observed, 
this  diminution  of  phosphates  was  ab- 
-< -n t .  Of  these  patients,  two  died,  and  in 
one  resolution  was  retarded  for  some 
time.  II  seems  that  the  diminution  of 
phosphates  is  a  normal  occurrence  in 
the  course  of  pneumonia,  and  that  in 


these  cases  the  course  was1  abnormal. 
The  persistence  of  phosphaturia  during 
the  acute  stage  of  pneumonia  may  have 
the  opposite  meaning  from  that  occur- 
ring after  the  crisis.  A  large  number 
of  cases  must  be  observed  in  order  to 
establish  this  law,  but  it  is  worth  while 
investigating  this  question  further. 
Sicuriani  (Gazzetta  degli  Ospedali  e 
delle  Cliniche,  April  9.  1905  ;  New  York 
Medical  Journal  and  Philadelphia  Med- 
ical Journal,  July  8,  1905). 

RHEUMATISM  OF  THE  FEET. 

The  author  states  that  among  the  pa- 
tients seeking  relief  at. an  orthopaedic 
clinic,  probably  the  most  frequent  com- 
plaint is  "rheumatism  of  the  feet." 
There  is  no  "rheumatism  of  the  feet." 
One  of  the  commonest  affections  giving 
rise  to  pain  in  the  feet  is  flat  foot.  An- 
other is  anterior  metatarsalgia,  or  Mor- 
ton's toe.  Gonorrhceal  arthritis  or  peri- 
arthritis of  the  ankle  has  often  been  ob- 
served, and  the  author  says  that  there  is 
a  form  of  gonorrhceal  infection  charac- 
terized by  extreme  sensitiveness  about 
the  sole,  to  which  he  gives  the  name  of 
gonorrhceal  foot,  The  pathology  of  this 
affection  is  still  a  matter  of  doubt. 

Hysteria  may  simulate  rheumatism  of 
the  feet,  and  tuberculosis  of  the  ankle 
and  tarsus  must  also  he  carefully  ex- 
cluded, as  any  circumscribed,  persistent, 
painful  swelling  in  the  foot,  especially 
of  a  child,  is  to  be  viewed  with  extreme 
suspicion.  The  sequelae  of  fractures,  and 
the  pains  of  late  syphilis  or  of  locomotor 
ataxia  must  also  be  kept  in  mind.  Gout 
and  acute  rheumatism  itself  close  the  list 
of  such  affections,  and  it  is  pointed  out 
that  acute  articular  rheumatism  never 
leaves  behind  it  a  damaged  joint.  The 
treatment  of  these  conditions  is  briefly 
outlined,  the  chief  adjuvants  required 
being  zinc  oxide  plaster,  plaster  of  Paris. 


SALT  SOLUTION  IN  CIRCULATORY  FAILURE.        STRABISMUS,  CONVERGENT.     419 


a  few  drugs,  and  some  assistance  from 
the  bracema^er  and  shoemaker.  L.  W. 
Ely  (Medical  Record,  August  5,  1905). 

SALT   SOLUTION,   PHYSIOLOGICAL  VALUE 
OF,    IN    CIRCULATORY   FAILURE. 

From  an  experimental  study  of  the 
subjecl  of  the  use  of  physiological  salt 
solution  in  therapeutics,  the  following 
conclusions  appear  to  the  author  to  be 
justified  by  the  evidence  obtained:  The 
injection  of  a  .7  per  cent,  solution  of 
sodium  chloride  in  any  quantity  up  to 
four  times  the  total  volume  of  the  blood 
has  no  effect  upon  the  blood-pressure  in 
the  normal  animal.  When  the  quantity 
of  fluid  injected  is  not  more  than  the 
total  volume  of  the  blood,  the  greater 
proportion  of  the  fluid  apparently  re- 
mains in  the  vessels  for  a  considerable 
period  of  time,  the  pressure  in  the  ar- 
teries being  kept  at  the  normal  height 
probably  by  vascular  dilatation.  When 
tbe  quantity  of  injected  fluid  is  greater 
than  the  total  volume  of  the  circulation, 
the  excess  escapes  very  rapidly  from  the 
vessels.  This  excess  does  not  pass  out 
through  the  kidney,  at-  least  for  some 
time  after  the  injection.  A  very  large 
amount  of  the  fluid  escapes  into  the 
gastro-intestina]  tract;  some  apparently 
also  leaks  through  the  vessel  walls,  (■spe- 
cially into  the  lungs,  giving  rise  to  pul- 
monary (edema.  In  conditions  of  low 
pressure,  due  either  to  haemorrhage  or  to 
vasomotor  paresis,  and  sometimes  in  that 
caused  by  depressant  poisons,  the  injec- 
tion of  physiological  Ball  solution  is  ca- 
pable of  increasing  the  arterial  pressure 
to  a  point  approximately  normal.  In  the 
great  majority  of  instances  Ibis  pise  is 
permanent,  although  in  one  or  two  cases, 
for  Borne  reason  nol  determined,  il  lasted 
but  a  \'rw  minutes.  The  vise  produced 
by  salt  solution  is  broughl  about  through 
purely  mechanical   influence.     The  bud- 


cutaneous  injection  produces  an  eleva- 
tion of  blood-pressure  in  conditions  of 
circulatory  depression,  but  it  is  much 
slower  in  its  action  than  the  intravenous 
infusion.  An  effed  from  hypodermo- 
<  lysis  may  be  expected  in  about  half  an 
hour. 

No  distinct  difference  in  the  imme- 
diate effects  are  demonstrable  between 
solutions  containing  .5  per  cent,  or  .1  per 
cent,  of  sodium  chloride,  nor  do  varia- 
tions in  temperature  between  86°  to  112° 
F.  apparently  affect  the  results.  H.  C. 
Wood  (Transactions  American  Thera- 
peutic Society;  Boston  Medical  and 
Surgical  -Journal,  July  6,  190.")). 

SEPTIC  PERITONITIS,  DIFFUSE,  DRAIN- 
AGE IN. 
Operations  for  diffuse  septic  perito- 
nitis should  be  made  as  quickly  and  with 
as  little  manipulation  as  is  compatible 
with  thoroughness.  Evisceration,  par- 
tial or  complete,  greatly  increases  shock 
and  the  prospects  of  a  fatal  result.  The 
generous  use  of  clean,  hot  water  will 
most  thoroughly  cleanse  the  infected 
cavity  with  the  least  traumatism.  Drain- 
age is  simplified  by  collecting  the  peri- 
toneal fluid  at  one  point  where  drains 
may  be  easily  placed.  The  elevated  bead 
and  trunk  posture  followed  by  the  gravi- 
tation of  fluid  to  the  lower  pelvis  best 
accomplishes  this.  Results  following  the 
surgical  i  real  men!  of  diffuse  septic  peri- 
tonitis will  be  improved  should  each  in- 
dividual operator  adopt  some  definite 
form  of  procedure  in  such  cases,  which, 
being  well  understood  by  operator  and 
assistants,  may  be  methodically,  speedily. 

and  thoroughly  carried  out.    Van  Buren 
Knott  (Annals  of  Surgery,  July,  1905). 

STRABISMUS.    CONVERGENT. 

From  a  careful  ^ln<\\  of  150  records, 
the  author  concludes  thai   esotropia   is 


420 


TABES,  PRINCIPLES  OF  EXERCISE  TREATMENT  IN. 


most  likely  to  manifest  itself  before  the 
end  of  the  third  year.  It  cannot  yet  be 
said  whether  any  of  the  various  reasons 
assigned  by  parents  for  the  appearance 
of  strabismus  have  aught  whatever  to  do 
with  it.  Whooping-cough  may  be  related 
to  it,  Heredity  certainly  plays  a  part  in 
bestowing  upon  some  children  a  con- 
genitally  deficient  visual  apparatus.  The 
degree  of  deviation  will  average  about 
30°  in  a  large  number  of  cases.  It  is 
in  no  special  way  bound  up  with  the 
degree  of  refractive  error. 

The  amblyopia  of  esotropia  is  pre- 
sumably an  amblyopia  exanopia,  the 
present  day  evidence  being  against 
Schweigger's  theory  of  a  congenital  am- 
blyopia. The  degree  of  amblyopia  in- 
creases with  the  length  of  time  elapsing 
between  the  appearance  and  the  time  of 
treatment;  especially  is  this  true  after 
the  seventh  year. 

Improvement  may  be  expected  in  the 
amblyopic  eye  in  50  to  60  per  cent,  of 
cases  by  properly  adjusted  glasses.  This 
improvement  varies  from  20  per  cent,  to 
ninefold  betterment. 

While  a  defectively  developed  fusion 
apparatus  has  much  to  do  with  the  gene- 
sis of  esotropia,  the  influence  of  hyper- 
metropia  and  its  allied  states  seems  al- 
most as  important  as  in  the  days  of  Don- 
ders.  The  part  played  by  astigmatism  is 
no  little  one.  There  seems  to  be  no 
special  relation  between  the  degree  of 
it  Tractive  error  and  the  degree  of  devia- 
tion. 

Hypermetropic  conditions  of  from  one 
to  four  diopters  seem  most  commonly 
associated  with  estropia.  A  very  high 
degree  of  hypermetropia  does  not  n 
sarily  exclude  strabismus,  as  three 
in  the  present  series  were  of  11  D.  and 
over. 

If  taken  before  the  fifth  year,  there 
us    no    reason    why    the    strabismus 


should  not  be  cured  by  non-operative 
methods  in  70  per  cent,  of  cases.  This 
percentage  will,  in  all  probability,  be 
increased  to  80  per  cent,  in  the  next 
ten  years.  The  results  of  non-operative 
treatment  in  children,  if  adhered  to  with 
any  persistence,  are  infinitely  better 
than  any  "scissors"  statistics  thus  far 
offered.  Wendell  Eeber  (Pennsylvania 
Medical  Journal,  July,  1905). 

TABES,    PRINCIPLES    OF    THE    EXERCISE 
TREATMENT   IN. 
The  greatest  discrimination  is  neces- 
sary in  the  application  of  this  form  of 
treatment  for,  improper^  used,  it  is  a 
source  of  more  harm  than  good.     The 
mistake  must  not  be  made  of  confusing 
simple  muscular  exercise  with  the  prac- 
tice of  coordination,  and  the  author  also 
warns   against  the  use  of  massage   for 
tabetics.     All  coordinated  actions  must 
be  learned  by  the  individual,  and  if  the 
power    of    coordination    has   been    lost, 
every  muscular  act  must  be  learned  over 
again  just  as  a  child  does  it.    The  usual 
steps  of  each  movement  must  be  sepa- 
rately rehearsed  until  the  ataxia  is  re- 
duced sufficiently  to  permit  the  whole  to 
be  attempted.    As  the  ataxia  is  due  not 
to  loss  of  muscular  power,  but  to  defi- 
cient sensibility,  if  a  tabetic  learns  to 
perform  a  coordinated  action  which  had 
become  impossible,  it  means  that  the  cen- 
ters have  become  educated  to  get  along 
with  a  subnormal  degree  of  sensibility. 
In  teaching  a  tabetic  to  walk,  for  exam- 
ple, a  great  deal  of  practice  is  needed  to 
produce   the   proper   coordinated   move- 
ments of  'the  trunk  muscles  which  pre- 
cede every  step.    As  the  sense  of  fatigue 
is  greatly  diminished,  the  patient's  sen- 
sations are  no  guide  as  to  the  length  of 
the  time  exercises  may  be  kept  up,  and  it 
is  well  to  restrict  them  to  two  sessions  a 
day  each,  of  not  more  than  five  to  fif- 


TETANUS. 


TRACHOMA  TREATED  WITH  RADIUM. 


421 


teen  minutes.  The  pulse-rate  also  rises 
rapidly  during  the  exercise,  and  it  is 
advisable  to  wait  after  each  movement 
until  the  rate  has  become  normal  again 
before  going  on  to  the  next  exercise. 
The  prognosis  of  the  disease  is  greatly 
improved  by  the  judicious  employment 
of  the  principle  of  reduction,  and  the 
author  believes  that  the  atony  of  the 
abdominal  muscles  and  intestine,  cysti- 
tis, paraplegic  forms,  etc.,  have  been  re- 
duced in  frequency  since  its  introduc- 
tion. Fraenkel  (Berliner  klinische 
Wochenschrift,  June  5,  1905;  Medical 
Eecord,  July  1,  1905). 

TETANUS. 

The  authors  give  a  preliminary  report 
of  their  statistical  study  of  1201  cases 
of  tetanus,  collected  from  the  literature 
and  by  direct  correspondence,  with  spe- 
cial reference  to  the  incidence  of  the  dis- 
ease in  the  United  States.  They  find 
convincing  proof  that  tetanus  is  invari- 
ably the  result  of  the  introduction  of  the 
germ,  and  that  the  so-called  rheumatic 
and  idiopathic  tetanus  does  not  exist. 
They  also  find  that  it  is  endemic  in  all 
large  centers  of  population,  that  in  some 
localities  where  it  was  formerly  common, 
it  has  become  rare,  and  that  occasional 
small  epidemics,  traceable  to  a  definite 
source,  occur  in  limited  localities.  Teta- 
nus is  more  prevalent  in  the  hotter  part 
of  the  year,  males  are  more  subject  to  it 
than  females,  and  it  is  less  frequent  in 
advanced  age.  The  robust  are  more  sus- 
ceptible than  the  weak,  and  the  nervous 
than  the  lymphatic.  There  is  much  evi- 
dence that  the  disease  is  transmissible 
and  may  give  rise  to  epidemics.  The 
germ,  Nicolaier's  bacillus,  is  rarely  in- 
troduced by  the  alimentary  tract,  but 
usually  through  open  wounds,  all  parts 
of  the  body  being  very  susceptible.  The 
diagnostic  imporlnnce  of  the  tonic  con- 
5 


tractions  as  opposed  to  the  intermittent 
ones  in  certain  other  conditions  that 
simulate  tetanus,  such  as  strychnine  poi- 
soning, is  emphasized. 

The  study  showed  clearly  the  value  of 
immediate  radical  local  treatment,  and 
that  the  most  important  thing  is  to  open 
the  wound  freely  in  all  directions  under 
general  ansesthesia.  Many  patients  were 
more  or  less  benefited  by  the  local  car- 
bolic acid  treatment,  and  some  observers 
report  good  results  from  the  local  use 
of  ice  or  freezing  mixtures  or  treatment 
in  a  cold  room.  For  palliative  treat- 
ment, chloral  and  the  bromides  appear 
to  have  been  most  extensively  used. 
Calabar  bean  has  been  much  employed, 
and  also  morphine,  which  should  be  used 
with  caution  on  account  of  its  inhibitory 
action  on  the  respiratory  centers.  There 
is  no  question  as  to  the  value  of  antitoxin 
as  a  prophylactic;  the  testimony  is  uni- 
formly in  its  favor.  It  should  be  used 
in  any  case  in  which  there  is  suspicion 
of  tetanus  infection.  In  a  well-developed 
case  of  the  disease  it  has  no  appreciable 
beneficial  effect,  neither  reducing  the 
mortality  nor  hastening  recovery.  J.  M. 
Anders  and  A.  C.  Morgan  (Journal  of 
the  American  Medical  Association,  July 
29,  1905). 

TRACHOMA  TREATED  WITH  RADIUM. 

The  results  of  a  series  of  experiments 
upon  four  patients  with  trachoma  who 
were  treated  with  radium  are  reported 
by  the  writer.  The  cases  selected  were 
very  marked,  and  the  entire  conjunctiva 
was  studded  with  typical  granulations. 
These  were  cases  that  under  ordinary 
method  of  treatment  required  operation. 
The  amount  of  radium  used,  which  was 
sealed  in  a  thin  glass  tube,  was  usual  lv 
1  milligram,  though  during  the  last 
seances  10  milligrams  were  used.  The 
exposure  of  each  eyelid  was  from  five  to 


422     TUBERCULAR  CERVICAL  LYMPH-NODES.       TUBERCULOSIS  AND  PREGNANCY. 


ten  minutes.  The  method  of  application 
consisted  of  a  slow  movement  of  the 
radium  tube  over  the  mucous  membrane, 
either  avoiding  actual  contact  with,  or 
very  lightly  touching  the  diseased  sur- 
face. No  other  treatment  was  used. 
The  results  obtained  were  remarkable. 
Of  seven  eyes  subjected  to  the  method, 
five  actually  were  permanently  cured, 
while  two  more  were  on  the  road  of 
complete  recovery  at  the  time  of  writing. 
The  granulation  disappeared  without  any 
pathological  changes  in  the  mucous  mem- 
brane, and  no  scars  remained.  The 
number  of  exposures  necessary  for  the 
complete  disappearance  of  the  granula- 
tion was  from  eight  to  fourteen.  While 
the  technique  of  the  application  of  ra- 
dium in  trachoma  is  still  to  be  perfected, 
the  author  is  convinced  that  radium  is 
an  excellent  means  of  treating  this  dis- 
ease, and  that  the  treatment  is  abso- 
lutely harmless  provided  the  amount  of 
radium  and  the  duration  of  the  exposure 
be  carefully  regulated.  J.  V.  Zelenkov- 
ski  (Eoussky  Vratch,  May  14,  1905). 

TUBERCULAR    CERVICAL   LYMPH-NODES, 
SURGICAL  TREATMENT  OF. 

Tuberculosis  of  the  cervical  lymph- 
nodes  is  apparently  due  to  infection  re- 
ceived from  the  fauces,  pharynx,  or 
nasal  mucous  membrane,  in  the  great 
majority  of  cases  (86  per  cent,  in  the 
present  series).  The  disease  shows  a 
tendency  to  extend  to  the  lungs  and 
other  internal  organs.  Statistics  indi- 
cate that  such  extension  occurs  in  one- 
quarter  to  one-half  of  the  cases  from 
whom  the  nodes  are  not  removed.  En- 
tirely apart  from  its  tendency  to  infect 
other  organs,  the  disease  is  very  tedious, 
causes  great  discomfort  and  disability, 
and  loaves  disfiguring  scars. 

The  thorough  removal  of  the  diseased 
nodes  by  operation  has  given  better  re- 


sults than  any  other  method  of  treat- 
ment which  the  writer  finds  recorded. 
The  records  of  operations  justify  the 
following  assurances:  (a)  In  favorable 
cases:  safety  of  operation  (many  op- 
erators reporting  more  than  100  cases 
without  mortality)  ;  a  scar  which  is 
hardly  to  be  seen;  probable  confinement 
to  bed  of  two  or  three  days;  the  wear- 
ing of  a  bandage  dressing  from  one  and 
one-half  to  three  weeks;  freedom  from 
recurrence  in  about  75  per  cent.,  and 
ultimate  recovery  in  about  90  per  cent, 
of  the  cases,  (b)  In  the  less  favorable 
cases :  safety  of  operation ;  less  disfig- 
urement from  scars  than  discharging 
sinuses  will  cause;  freedom  from  recur- 
rence in  50  to  55  per  cent.,  and  ultimate 
cure  in  70  to  75  per  cent,  of  the  cases. 

Transverse  incisions,  either  in  the 
neck-creases  or  parallel  to  them,  are  usu- 
ally to  be  used.  They  should  be  so  placed 
that  the  fibers  of  the  facial  nerve  will 
not  be  cut.  A  vertical  incision  back  of 
the  hair-line  is  occasionally  helpful.  Ex- 
tensive incisions  are  necessary  for  the 
far  advanced  cases.  Every  precaution 
should  be  taken  to  preserve  the  normal 
structures  of  the  neck. 

It  is  not  feasible  to  divide  the  cases 
into  groups,  some  suitable,  others  un- 
suitable for  operation.  Every  case  with 
tubercular  cervical  lymph-nodes  should 
be  operated  upon  unless  there  is  a  par- 
ticular reason  to  believe  that  the  opera- 
tion would  not  be  endured.  C.  N".  Dowd 
(Annals  of  Surgery,  July,  1905). 

TUBERCULOSIS  AND  PREGNANCY. 

Pregnancy  affects  all  the  important 
systems  of  the  body.  For  practical  pur- 
poses, gestation  may  be  looked  upon  as 
a  functional  exercise  of  the  female  gen- 
erative system,  leading  to  characteristic 
changes  in  various  other  systems,  similar 
to  exercise  of  the  muscular  system  caus- 


TUBERCULOSIS  AND  PREGNANCY. 


423 


ing  changes  in  other  parts  of  the  body; 
parturition  is  a  more  or  less  violent  ex- 
ercise, and  the  puerperium  may  be  re- 
garded as  (a)  a  period  of  recuperation 
from  the  shock  of  labor,  and  (b )  a  period 
of  involution  of  many  of  the  changes  in 
the  various  systems  evolved  during  ges- 
tation. 

Tuberculosis  is  usually  at  first  a  pure 
infection  by  the  tubercle  bacillus,  but 
frequently  the  patients  do  not  present 
themselves  to  the  physician  until  the 
disease  is  a  true  phthisis,  a  multiple  in- 
fection, in  which  a  pulmonary  sepsis  is 
superimposed  upon  a  tuberculosis.  The 
occurrence  of  secondary  infection  in- 
creases the  virulence  of  the  toxins  and 
in  every  way  makes  the  condition  of  the 
patient  worse.  Laryngeal  tuberculosis 
and  miliary  tuberculosis  are  exceedingly 
grave  forms  of  the  disease. 

Many  writers  have  reported  that  tu- 
berculosis is  especially  liable  to  occur 
during  pregnancy.  It  is  possible  that 
this  may  be  only  apparent,  the  disease 
being  more  frequently  aroused  from  a 
latent  state  by  pregnancy,  or  first  recog- 
nized at  this  time.  On  the  other  hand, 
the  seclusion  of  patients  at  the  time  of 
pregnancy  may  place  them  under  condi- 
tions that  predispose  to  tuberculosis, 
especially  through  close  association  with 
tuberculous  patients. 

The  practice  of  pregnant  women  going 
into  retirement  should  not  be  tolerated, 
if  such  seclusion  predisposes  to  infection 
through  unhygienic  surroundings  or  as- 
sociation with  tuberculous  patients.  The 
pregnant  woman  should  be  placed  under 
good  hygienic  surroundings,  protected 
as  far  as  possible  from  the  causes  that 
predispose  to  tuberculosis.  To  this  end 
it  is  advisable  to  recommend  suitable 
exercise  in  the  open  air  and  sunlight. 
Pregnant  women,  especially  if  tubercu- 
lous, should  be  protected  from  conditions 


that  predispose  to  secondary  infection; 
they  should  avoid  impure,  vitiated  at- 
mosphere, and  association  with  infected 
individuals,  and  those  affected  with  in- 
fluenza or  the  ordinary  "colds,"  since 
these  increase  the  virulence  of  the  dis- 
ease. 

The  gravity  of  tuberculosis  is  increased 
by  pregnancy,  especially  during  the  puer- 
perium. The  highest  maternal  mortality 
has  been  observed  by  the  writer  in  primi- 
paras.  A  tuberculous  lung  is  necessarily 
a  defective  organ.  Hemoptysis  does  not 
occur  with  especial  frequency  at  the  time 
of  parturition. 

Tuberculous  patients,  when  pregnant, 
should  come  under  treatment  early. 
They  should  receive  instructions  regard- 
ing hygiene,  the  care  of  the  emunctories, 
diet,  exercise,  and  protection  from  the 
predisposing  causes  of  tuberculosis. 
Pregnant  women  bear  the  tuberculin 
treatment  remarkably  well.  The  diet  of 
the  tuberculous,  when  pregnant,  should 
be  carefully  suited  to  the  requirements 
of  the  individual.  Suralimentation,  so 
valuable  in  tuberculosis,  may  be  detri- 
mental during  pregnancy  through  the 
strain  imposed  upon  the  kidneys. 

The  excessive  vomiting  of  preg- 
nancy requires  especial  attention  in  tu- 
berculosis. Interruption  of  pregnancy 
is  a  serious  matter,  and  usually  is  not 
beneficial  so  far  as  pulmonary  tubercu- 
losis is  concerned.  But  tuberculosis  is 
not  a  contraindication  to  this  operation 
when  required  for  other  reasons.  Tn 
laryngeal  and  miliary  tuberculosis,  the 
interruption  of  pregnancy  should  be 
practiced  early  or  not  at  all. 

Tuberculosis  seems  to  increase  the  sex- 
ual appetite  and  to  actually  predispose 
to  pregnancy.  Tn  the  indulgence  of  the 
sexual  appetite,,  tuberculous  patients 
should  be  instructed  to  always  stop  short 
of  the  point  of  fatigue.     Tn  the  genito- 


424 


TUBERCULOSIS  OF  CECUM. 


UREMIC  HEMIPLEGIA. 


urinary  tuberculosis  the  axiom  should  be 
observed  that  a  diseased  member  is  best 
treated  by  rest. 

Marriage  of  the  tuberculous  is  usually 
not  desirable;,  but  to  this  rule  there  are 
exceptions.  Tuberculous  women  should 
not  nurse  children.  A  child  may  be  in- 
fected by  association  with  a  tuberculous 
mother.  G.  E.  Malsbary  (American 
Journal  of  Obstetrics,  July,  1905). 

TUBERCULOSIS  OF  THE  CECUM. 

Tuberculous  disease  of  the  cgecum  is 
of  comparatively  common  occurrence, 
the  caecum  being  involved  in  85  per  cent, 
of  all  cases  of  intestinal  tuberculosis. 
Infection  may  be  either  primary  or  sec- 
ondary, the  latter  being  most  common  in 
children  and  young  adults,  the  former 
between  the  ages  of  20  and  45  years. 
There  are  two  main  types,  the  ulcerative 
and  the  hyperplastic.  If  it  occurs  dur- 
ing the  active  progress  of  pulmonary  dis- 
ease, it  usually  pursues  an  ulcerative  or 
destructive  course  with  varying  rapidity, 
but  if  secondary  to  a  healed  pulmonary 
lesion,  or  if  it  is  primary,  then  the  in- 
fection is  of  a  mild  type,  and  the  patho- 
logical changes  are  of  a  chronic  hyper- 
plastic nature.  The  author  reports  a 
case  of  the  latter  nature  occurring  in  a 
woman  aged  23  years,  in  which  opera- 
tion was  performed  successfully,  the  pa- 
tient leaving  the  hospital  on  the  thirty- 
fifth  day.  The  characteristic  clinical 
feature  of  these  cases  is  the  development 
of  a  tumor  which  is  hard  and  nodular, 
movable,  but  usually  only  toward  the 
middle  line,  not  in  an  outward  direction, 
not  moving  with  respiration,  and  giving 
a  hollow,  impaired  tympanitic  note  on 
percussion.  The  patients  are  frequently 
well  nourished,  but  there  is  usually  some 
disturbance  of  digestion,  attacks  of 
colicky  pain  occurring  at  irregular  in- 


tervals,   without    any    apparent    cause. 
E.  A.  Stoney  (Lancet,  July  29,  1905). 

URiEMIC    HEMIPLEGIA,    INTRACRANIAL 
PRESSURE  IN. 

The  writer  calls  attention  to  the  fact 
that  by  no  means  all  cases  that  show 
chronic  interstitial  nephritis  are  sub- 
ject to  uraemia,  and  to  the  still  more 
important  circumstance  that  neither 
sclerosis  of  the  kidney  nor,  in  fact, 
arteriosclerosis,  predisposes  to  uraemia 
until  hypertension  of  the  vascular  sys- 
tem is  superadded.  The  two  by  no 
means  always  go  hand  in  hand.  Many 
cases  of  high-grade  sclerosis  present  a 
comparatively  normal  blood-pressure. 
Certain  cases  of  hypertension  show  little 
or  no  sclerosis  and  yet  apoplexy  occurs. 
If  hypertension  is  added  to  sclerosis  of 
the  arteries  and  veins,  however,  with  the 
consequent  intracranial  tension  due  to 
this  and  to  local  toxic  irritation,  there 
is  present  at  once  the  ideal  conditions 
for  the  causation  of  the  uraemic  picture. 

The  writer  reaffirms  the  belief  that 
various  toxins  are  influential  in  produc- 
ing the  symptoms  in  various  instances 
of  uraemia.  Among  these,  probably  the 
most  important  is  one  originating  in  an 
abnormal  digestive  tract,  or  elsewhere, 
and  resembling  adrenalin  in  its  physio- 
logic action,  as  suggested  by  Thomson. 

Whether  as  a  result  of,  or  a  coincidence 
with,  toxic  irritation,  intracerebro-spinal 
overpressure,  due  to  an  accumulation  of 
fluid,  may  and  usually  does  cause  the 
majority  of  the  classical  symptoms  of 
uraemia,  and  is  often  the  dominant  in- 
fluence. Spinal  drainage  may,  and  in 
nrany  cases  does,  promptly  relieve  the 
symptoms  of  uraemia,  furnishing  clinical 
proof  of  the  foregoing  statement.  Oc- 
casionally when  intracranial  pressure 
has  boon  removed  llio  toxin  alone  may 
cause  the  picture  of  uraemia. 


URETHRORECTAL  FISTULA. 


425 


Uraemic  manifestations  (other  than 
coma),  when  due  to  intracranial  pres- 
sure, may  be  either  general  or  localized. 
Unilateral  convulsions,  convulsive  move- 
ments of  one  limb,  monoplegia,  hemi- 
plegia, motor  or  sensory  aphasia,  and 
similar  phenomena  are  of  rather  fre- 
quent occurrence.  The  toxic  influence, 
in  the  few  instances  in  which  it  has 
seemed  to  act  independently  of  intra- 
cranial pressure,  has  caused  only  general 
manifestations,  usually  of  an  irritative 
nature  (convulsions,  etc.),  seldom,  if 
ever,  paralytic  phenomena. 

Urasmic  hemiplegia  and  other  uremic 
paralyses  are  due  usually  to  direct  pres- 
sure on,  or  cedematous  infiltration  of, 
the  motor  centers  of  the  brain,  and  may 
usually  be  relieved  by  withdrawal  of  the 
cerebro-spinal  fluid.  There  is  a  striking 
suggestiveness  in  the  frequent  absence  of 
general  oedema,  though  there  be  an  ex- 
cess of  intracranial  fluid,  arising  from 
an  entirely  different  influence  and  cause. 
The  writer's  most  successful  cases  showed 
no  oedema  of  the  external  body,  but 
without  exception  a  high  degree  of  intra- 
vascular and  intracranial  tension. 

Lumbar  drainage  should  be  employed 
as  a  routine  measure,  together  with  all 
the  known  means  of  reducing  systemic 
pressure  or  hypertension.  Among  these, 
the  most  valuable  are  free  bleeding,  free 
purging,  free  diuresis,  and  the  adminis- 
tration of  large  doses  of  aconite. 

The  ultimate  cause  of  the  vascular 
hypertension  of  uraemia  has  not  yet  been 
discovered.  It  would  appear  by  no 
moans  impossible  that  the  intracranial 
fluid  pressure  is  partly  due  to  toxic  in- 
flammatory exudate;  that  tin's  causes 
hypertension  within  the  cranium  and 
favors  a  similar  hypertension  through- 
out the  genera]  circulal  ion,  or  vice  versa; 
and  that  the  symptom-complex  of  uraemia 
is  thus  usually  due  to  such  a  sequence  of 


causes.  Probably  uraemia  cannot  occur 
in  the  presence  of  low  intravascular  and 
intracerebro-spinal  tension. 

It  would  appear  from  the  failure  in 
repeated  instances  to  produce  any  dele- 
terious effect  on  healthy  small  animals 
by  injecting  successive  small  quantities 
of  the  cerebro-spinal  fluid  from  uraemic 
subjects,  that  the  toxic  principle  of 
uramiia  is  not  to  be  found  in  the  latter. 
The  experiments  of  Hughes  and  Carter 
in  1893  seemed  to  show  that  it  may  pos- 
sibly be  found  constantly  present  in 
small  quantities  in  the  normal  blood- 
serum. 

While  lumbar  puncture  is  not  infal- 
lible, nor  devoid  of  a  slight  risk  to  the 
patient,  the  procedure  should  be  em- 
ployed early  in  the  course  of  uraemia, 
and  repeatedly,  if  necessary,  to  accom- 
plish the  lowering  of  systemic  hyperten- 
sion. It  may  save  life  and  will  often 
dissipate  the  ursemfa  at  least  for  the  time 
being.  Transfusion  of  normal  or  other 
salt  solution  is  harmful  in  uraemia,  in 
that  it  causes,  both  by  its  mechanical 
and  chemical  influence,  an  increase  of 
intravascular  and  intracranial  tension, 
and  supplies  certain  of  the  conditions 
necessary  to  the  uraemic  seizure.  E.  1ST. 
Willson  (Journal  of  the  American  Med- 
ical Association,  July  1,  1905). 

URETHRO-RECTAL   FISTULA. 

Urethro-rectal  fistula,  though  com- 
paratively rare,  is  apt  to  be  overlooked. 
If  iliere  is  any  doubt,  the  permanganate 
test  should  be  used.  It  is  generally  of 
gonorrhoeal  origin,  generating  prostatic 
abscess.  It,  may  lie  of  traumatic  origin 
by  (lie  use  of  sounds  or  the  operation  of 
lithotomy.  The  symptoms  may  point 
to  cystitis,  urethritis,  and  proctitis,  in 
addition  to  inforoominunieabilit  v  of  the 
urethra  and  rectum.  This  is  a  type  of 
fistula    in    which   suture  must   be  used. 


426 


UTERINE  CARCINOMA. 


UTERINE  HEMORRHAGE. 


and  a  No.  3,  40-day  catgut.  Failure  to 
close  the  tract  should  not  cause  surprise 
or  discouragement.  Personal  care  of 
the  wound  is  of  paramount  importance. 
It  should  never  be  left  to  an  assistant, 
for  no  one  can  possibly  be  so  familiar 
with  the  wound  as  he  who  made  it.  A 
certain  number  of  cases  of  urethral 
origin  will  heal  spontaneously,  if  recent, 
and  if  the  stricture  is  removed.  W.  M. 
Beach  (American  Medicine,  July  29, 
1905). 

UTERINE     CARCINOMA,     EARLY    DETEC- 
TION OF. 

The  author  makes  the  emphatic  state- 
ment that  there  is  no  characteristic  first 
or  early  symptom  of  uterine  carcinoma 
either  of  the  cervix  or  of  the  body. 
From  a  list  of  questions  concerning  can- 
cer patients,  sent  to  many  surgeons,  the 
replies  showed  that  in  45  cases  the  first 
symptom  was  a  leucorrhcea,  which  in  it- 
self was  in  no  wise  characteristic.  In  21 
cases  the  first  symptom  was  bleeding, 
varying  from  a  slight  staining  to  profuse 
flowing.  In  12  cases  pain  was  the  first 
symptom  preceding  both  leucorrhoea  and 
bleeding.  Pain  as  an  initial  symptom 
appeared  slightly  more  often  in  cancer 
of  the  uterine  body,  but  not  with  suffi- 
cient emphasis  to  be  considered  charac- 
teristic or  pathognomonic.  Leucorrhcea 
had  existed  previous  to  the  onset  of  the 
illness  in  33  cases  and  had  not  so  existed 
in  an  exactly  equal  number.  In  9  cases 
no  satisfactory  answer  was  obtainable. 
This  pre-existing  leucorrhcea  had  under- 
gone a  noticeable  augmentation  before 
becoming  blood-stained  in  42  cases,  in- 
cluding both  classes  of  cases  with  leu- 
corrhcea, namely,  those  which  started 
with  leucorrhcea  and  those  having  a  pre- 
existing discharge.  The  bleeding  began 
in  from  six  weeks  to  one  year  beforo 
examination,  with  an  average .  duration 


of  six  months.  Pain  was  entirely  absent 
in  36  cases,  and  in  35  cases  in  which  it 
was  a  noticeable  factor  it  had  been  slight 
in  18  cases  for  periods  varying  from 
three  weeks  to  one  year,  and  severe  in 
17  cases  from  two  months  to  one  year. 
Thirty-six  cases  were  too  far  advanced  to 
admit  of  more  than  palliative  operation, 
and  radical  operation  was  advised  or  per- 
formed in  42  cases.  In  42  cases  the  can- 
cer was  in  the  cervix ;  in  30  cases  in  the 
body,  and  in  6  cases  not  stated.  As  is 
seen  by  the  statistics,  no  one  symptom 
can  be  regarded  as  characteristically  the 
first  symptom  of  uterine  cancer,  and  the 
author  therefore  emphasizes  the  neces- 
sity of  making  a  thorough  examination 
of  the  pelvis  both  bimanually  and  with 
the  speculum  in  every  patient  having 
pelvic  symptoms.  D.  H.  Craig  (New 
York  Medical  Journal  and  Philadelphia 
Medical  Journal,  July  8,  1905). 

UTERINE  HEMORRHAGE,  ARTERIOSCLE- 
ROSIS OP  THE  UTERUS  AS  A  CAUSAL 
FACTOR  IN. 

Metritis  as  a  primary  lesion  and  in- 
dependent of  infection  is  not  accorded 
the  consideration  which  the  frequency  of 
its  occurrence  and  its  clinical  signifi- 
cance would  warrant.  The  muscular 
fibers  of  the  uterine  wall  have  an  im- 
portant function  in  controlling  the  cali- 
ber of  the  blood-vessels,  and  hence  in 
regulating  the  blood-supply  to  the  uterus, 
as  evidenced  in  the  relaxed  condition  of 
the  uterine  wall  during  menstruation,  in 
post-abortive  and  postpartum  haemor- 
rhages, and  in  the  free  bleeding  which 
accompanies  curettage  when  the  uterus 
has  relaxed  under  the  irritating  influ- 
ence of  the  curette.  In  all  these  condi- 
tions the  haemorrhages  are  controlled  by 
the  contractions  of  the  uterus.  Any 
event  which  lowers  the  muscular  tone  of 
the  uterus  may  occasion-  an   abnormal 


UTERUS,  FIBROID  TUMORS  OF,  SURGICAL  TREATMENT. 


427 


loss  of  blood  into  the  endometrium  and 
uterine  cavity. 

Prominent  among  the  factors  which 
contribute  to  muscular  atony  in  the 
uterus,  are  the  wasting  diseases,  anaemias 
and  acute  febrile  diseases,  which  are  not 
infrequently  accompanied  and  followed 
by  uterine  haemorrhages  as  the  result  of 
weakened  support  to  the  vessel  walls 
from  myodegeneration.  Fibrosis  uteri 
is  a  far  more  common  cause  of  muscular 
insufficiency.  The  building  up  of  con- 
nective tissue  in  the  uterine  wall  at  the 
expense  of  the  muscular  elements  is  the 
result  of  long-continued  passive  conges- 
tion, which  in  turn  is  due  to  numerous 
general  and  local  lesions,  such  as  an  in- 
competent heart,  obstructions  in  the 
lungs,  liver,  kidney,  and  spleen,  abdom- 
inal swellings,  varicose  veins  of  the  pel- 
vis, and  uterine  displacements. 

The  walls  of  the  blood-vessels  share 
in  these  hyperplastic  changes,  in  that 
the  media  and  adventitious  coats  of  the 
vessels  are  thickened.  In  this  matter 
the  elasticity  of  the  vessel  walls  is  im- 
paired, and  if  the  lumen  of  the  vessels 
is  not  narrowed  by  contraction  of  the 
vessel  walls  and  thickening  of  the  in- 
tima,  there  will  be  added  reasons  for 
venous  engorgement  of  the  uterine  wall 
and  capillary  oozing  into  the  endome- 
trium. In  such  cases  the  prime  factor 
in  the  causation  of  uterine  haemorrhages 
is  the  muscular  incompetency;  the  thick- 
ened vessel  walls  and  the  remote  embar- 
rassments to  the  circulation  are  but  con- 
tributing factors.  This  condition  of  the 
vessel  walls  is  to  be  distinguished  from 
the  arterio-obliterans  of  the  normal  se- 
nile uterus,  in  which  the  vessels  are  par- 
tially or  wholly  obliterated  by  the  thick- 
ened intima  and  tire  contraction  of  the 
vessel  walls.  In  such  cases  haemor- 
rhages do  not  occur  for  the  reason  that 
the  blood-supply  is  greatly  diminished. 


In  none  of  the  recorded  cases  were 
haemorrhages  seen  to  come  from  rup- 
tured vessel  walls,  nor  were  aneurisms 
of  the  arteries  seen  in  the  uterine  wall. 
On  the  contrary,  the  escaped  blood  was 
farthest  removed  from  the  sclerosed  ves- 
sels and  were  evidently  capillary.  The 
author  therefore  considers  that  he  is  not 
justified  in  ascribing  the  haemorrhages 
directly  to  the  sclerosed  vessels. 

The  diagnosis  can  only  be  made  by 
first  excluding  all  other  possible  causes, 
such  as  polyps,  carcinoma,  and  fibroids. 

Hysterectomy  has  been  frequently  re- 
sorted to  after  repeated  curettements 
have  failed.  Palliative  methods,  i.e., 
rest,  ergot,  styptic  applications  to  the 
bleeding  surface,  and  finally  tamponing 
the  uterine  cavity,  may  be  resorted  to, 
but  have  repeatedly  failed.  Palmer 
Findley  (American  Journal  of  Obstet- 
rics, July,  1905). 

UTERUS,  FIBROID  TUMORS  OF,  SURGICAL 
TREATMENT. 
The  routine  treatment  for  fibroids  of 
the  uterus,  presenting  symptoms  in 
women  under  45  years  of  age,  should  be 
supra-vaginal  hysterectomy,  except  as 
hereinafter  stated.  The  exceptions  to 
this  rule  should  be  (a)  in  subperitoneal 
tumors  either  pedunculated  or  not,  in 
which  only  one  or  more  distinct  devel- 
opments exist  which  do  not  materially 
increase  the  size  of  the  uterus  proper  and 
the  area  of  its  endometrium,  when  myo- 
mectomies may  be  resorted  to;  (b)  in 
fibroids  which  present  excessive  haemor- 
rhagic  tendencies,  in  which  the  haemo- 
globin is  reduced  below  25  per  cent.,  or 
in  which  serious  vascular  cardiac  or  kid- 
ney complications  exist  which  greatly 
increase  the  risk  of  the  operation,  when 
a  preliminary  operation  of  vaginal  liga- 
tion of  the  uterine  arteries  should  be  re- 
sorted to;    (c)  in  cases  where  a  radical 


428 


X-KAY  TREATMENT  OF  CANCER. 


operation  will  not  be  accepted,  a  curette- 
ment  and  vaginal  ligation  of  the  uterine 
arteries  may  be  resorted  to,  or,  if  no 
operation  at  all  will  be  accepted,  general 
tonics,  ergotine  in  tonic  doses,  and  gal- 
vanism scientifically  applied  may  be  de- 
pended upon  to  relieve  the  patients  mate- 
rially, and  occasionally  tide  them  over 
the  menopause  to  a  complete  symptom- 
atic cure. 

The  treatment  for  large,  complicated 
tumors  without  regard  to  age,  or  large 
apparently  uncomplicated  tumors  in 
which  symptoms  of  haemorrhage  or  pres- 
sure exist,  should  be  supra-vaginal  hys- 
terectomy. 

Tumors  of  medium  size  apparently 
uncomplicated,  in  women  over  45  years 
of  age,  may  be  managed  by  one  of  the 
less  radical  forms  of  treatment  as:  (a) 
when  the  tumors  are  of  the  symmetrical 
development  type,  enlarging  uniformly 
the  uterus,  and  the  principal  symptom  is 
an  exaggerated  menstrual  flow,  the  cases 
may  almost  invariably  be  relieved  by 
galvanism  and  tided  over  the  menopause ; 
or  (b)  if  the  growth  is  of  the  irregular 
type  which  has  distorted  more  or  less  the 
uterine  cavity,  the  case  should  be  sub- 
mitted to  dilatation,  finger  exploration, 
curettement,  and,  if  considerable  flow- 
ing is  a  symptom,  vaginal  ligation  of 
the  uterine  arteries,  with  the  idea  of  ob- 
taining a  symptomatic  cure  over  the 
menopause. 

The  extremely  small  class  of  tumors 
coming  under  the  head  of  "inoperable" 
cases  must  be  managed  on  general  prin- 
ciples— rest  in  bed,  general  tonics,  treat- 
ment of  the  cardio-vascular  and  kidney 
complications  when  they  exist,  curetting 
and  irrigating  for  septic  endometritis, 
electricity  for  pain  and  haemorrhage, 
ligation  of  the  uterine  blood-supply  if 
practicable  for  intractable  hemorrhage, 
and  vaginal  incision  of  impacted  cysts  or 


YEAST  CELLS,  ACTION  OF. 

pus  accumulations.  F.  H.  Martin  (New 
York  Medical  Journal  and  Philadelphia 
Medical  Journal,  June  17,  1905). 

X-RAY   TREATMENT    OF   CANCER. 

The  results  of  the  x-ray  treatment  of 
malignant  tumors  up  to  the  present  time 
have  proven  that  the  x-ray  exerts  a  pow- 
erful influence  upon  cancer  cells  of  all 
varieties,  but  most  marked  in  cases  of 
cutaneous  cancer.  In  some  cases,  chiefly 
in  superficial  epithelioma,  the  entire  tu- 
mor may  disappear,  probably  by  reason 
of  fatty  degeneration  of  the  tumor  cells 
with  subsequent  absorption.  In  a  much 
smaller  number  of  cases  of  deep-seated 
tumors,  chiefly  cancer  of  the  breast  and 
glandular  sarcoma,  tumors  have  disap- 
peared under  prolonged  x-ray  treatment. 
In  nearly  every  one  of  these  cases,  how- 
ever, that  has  been  carefully  traced  to 
final  result,  there  has  been  a  local  or 
general  return  of  the  disease  within  a 
few  months  to  two  years.  In  view  of 
this  practically  constant  tendency  to 
early  recurrence,  furthermore,  in  the  ab- 
sence of  any  reported  cases  well  beyond 
three  years,  the  method  should  never  be 
used  except  in  inoperable  cases,  or  as  a 
prophylactic  after  operation,  as .  a  pos- 
sible, though  not  yet  proven,  means  of 
avoiding  recurrence. 

The  use  of  the  x-ray  as  a  pre-operative 
measure  in  other  than  cutaneous  cancer 
is  contraindicated,  (1)  because  the  agent 
has  not  yet  been  proven  to  be  curative; 
(2)  because  of  serious  risks  of  an  exten- 
sion of  the  disease  to  inaccessible  glands 
or  to  other  regions  by  metastases  during 
the  period  required  for  a  trial  of  the 
x-ray.  William  B.  Coley  (Annals  of 
Surgery,  August,  1905). 

YEAST  CELLS,  ACTION  OF. 

Living  yeast  does  not  possess  any 
directly  bactericidal  or  phagocytic  prop- 


INTERNATIONAL  MEDICAL  CONGRESS. 


429 


erties,  nor  does  it,  when  injected  subcu- 
taneously,  pass  unaltered  into  the  cir- 
culation, but  is  quickly  disintegrated 
and  absorbed.  When  injected  intraven- 
ously it  causes  intravascular  clotting  of 
the  blood,  and  is  therefore  an  unsafe 
substance  to  use  in  this  manner.  Sub- 
cutaneous injections  of  pure  cultures  of 
living  yeast  can  be  made  in  animals 
without  producing  any  ill  effects  except 
the  formation  of  a  slight  swelling  at  the 
point  of  puncture,  which  rapidly  disap- 
pears. Killed  yeast  produces  exactly  the 
same  effect  as  living. 

The  immediate  effects  of  subcutaneous 
injections  is  to  produce  a  leucopenia  rap- 
idly  followed   by   a   leucocytosis.      The 


effects  of  subcutaneous  injections  of 
yeast  on  animals  infected  with  strepto- 
coccus pyogenes,  staphylococcus  albus, 
and  tubercle,  is  in  some  cases  to  cause 
a  recovery  of  the  animals  and  in  others 
to  prolong  their  lives.  The  effects  pro- 
duced by  the  injections  of  yeast  are  prob- 
ably due  to  the  liberation  of  the  nucleo- 
albumin  contained  in  the  cell  which  acts 
as  a  powerful  stimulant  to  the  cejls  of 
the  body  generally,  and  causes  a  large 
increase  in  the  antiseptic  and  anti-bac- 
tericidal substances  normally  present  in 
the  blood  serum.  Walter  Maiden  (Sup- 
plement to  the  British  Medical  Journal. 
July  1, 1905). 


CHANGES  IN  THE  PHAKMACOPCEIA. 

In  the  new  United  States  Pharmacopoeia  the  following  changes  are  noted : 
The  strength  of  tincture  of  aconite  has  been  reduced  from  35  per  cent,  to  10  per 
cent.,  and  that  of  tincture  of  veratrum  from  40  per  cent,  to  10  per  cent.  The 
strength  of  tincture  of  strophanthns  has  been  increased  from  5  per  cent,  to  10  per 
cent.     These  changes  officially  go  into  effect  on  September  1,  1905. 


THE  INTERNATIONAL  MEDICAL  CONGRESS. 

The  International  Medical  Congress  is  an  occasion  always  of  large  importance. 
Here  are  brought  together  the  leading  members  of  the  profession  who  are  able  to 
attend.  They  select  and  discuss  topics  of  urgent  importance,  giving  to  the  reading 
medical  public  the  rec-alts  of  their  findings  and  conclusions.  It  is  of  importance  for 
all  progressive  medical  practitioners  to  attend  such  meetings  when  possible.  The 
local  limitations,  the  minor  controversies  inevitable  in  state  and  national  meetings 
find  no  place.  The  whole  realm  of  progressive  medicine  is  before  the  meetings 
un trammeled  by  sectional  considerations. 

The  meeting  in  Lisbon  is  not  likely  to  attract  so  many  as  a  more  central  place, 
yet  the  very  fact  of  there  being  fewer  distractions  than  would  be  met  in  Paris, 
London,  or  Vienna,  will  assure  fuller  attention  to  the  business  in  hand. 

We  publish  the  outline  of  seel  ions  with  the  subjects  for  discussion.  II  will  be  of 
educational  value  to  see  what  it  is  that  shall  engage  the  attention  of  these  distin- 


430  INTERNATIONAL  MEDICAL  CONGRESS. 

guished  speakers.    This  furnishes  a  key  to  what  is  engaging  the  interest  of  research 
workers  in  all  lands. — J.  M.  T. 

The  next  International  Medical  Congress  will  be  held  in  Lisbon,  April  19  to  26, 
1906.  It  is  expected  that  it  will  be  one  of  unusual  importance,  for  a  meeting  which 
will  be  held  in  what  has  always  been  considered  as  an  out  of  the  way  country. 
Already  the  titles  of  papers  from  some  of  the  most  distinguished  men  of  the  medical 
profession  have  been  received.  Some  of  the  topics  for  discussion  that  have  been 
selected  by  the  Executive  Commitee  are  the  following: — 

Section  of  Descriptive  and  Comparative  Anatomy,  Anthropology,  Embry- 
ology, and  Histology. 
Definition,  structure,  and  composition  of  protoplasm. 
Origin,  nature,  and  classification  of  pigments. 
Cellular  changes  in  normal  tissues. 
Evolution  and  involution  of  the  thymus  gland. 

Section  of  Physiology. 

The  role  of  leucocytes  in  nutrition. 

The  thyroid  secretion. 

Eenal  permeability. 

The  nutritive  value  of  alcohol. 

The  physiology  of  the  cytotoxins. 

The  blood  ferments. 

Section  of  General  Pathology,  Bacteriology,  and  Pathological  Anatomy. 
What  are  the  present  scientific  proofs  of  the  parasitic  nature  of  neoplasms,  espe- 
cially of  cancer? 
Preventive  inoculations  against  bacterial  diseases. 
Preventive  inoculations  against  protozoic  diseases. 

Preventive  inoculations  against  diseases  from  an  unknown  specific  agent. 
The  pancreas  and  fat  necrosis. 

Therapeutics  and  Pharmacology. 

Local  therapeutics  in  infectious  diseases. 

Separation,  from  a  physiologic  and  therapeutic  point  of  view,  of  the  different 

radiations  produced  in  Crooke's  tubes  and  of  those  which  are  sent  out  by 

radio-active  bodies. 
The  therapeutic  value  of  bactericidal  serums. 
The  relation  between  the  molecular  constitution  of  organic  bodies  and  their 

physiologic  and  therapeutic  action. 

Section  of  Medicine. 

The  pathogenesis  of  diabetes. 

The  pathogenesis  of  arterial  hypertension. 

The  treatment  of  cirrhosis  of  the  liver. 

Cerebro-spinal  meningitis. 

International  defense  against  tuberculosis. 

Meningeal  haemorrhages. 

Section  of  Pediatrics. 

Spastic  affections  of  infancy ;   classification  and  pathogenesis. 

Cerebro-spinal  meningitis;   etiology  and  treatment. 

The  social  struggle  against  rickets.  -  "/ 


INTERNATIONAL  MEDICAL  CONGRESS.  431 

Orthopedic  surgery  in  affections  of  nervous  origin,  spastic,  and  paralytic. 

Congenital  dislocation  of  the  hip. 

The  treatment  of  abdominal  tuberculosis  (peritoneal). 

Neurology,  Psychiatry,  and  Criminal  Anthropology. 

Penal  reform  from  the  anthropologic  and  psychiatric  point  of  view. 

Forms  and  pathogenesis  of  dementia  praecox. 

The  relations  of  progressive  muscular  atrophy  to  Charcot's  disease. 

Cerebral  localization  in  mental  disease. 

Education  and  crime. 

Stigmata  of  degeneration  and  crime. 

Section  of  Surgery. 

Septic  peritoneal  infections;    classification  and  treatment. 
Gastro-intestinal  and  intestino-intestinal  anastomoses. 
Eecent  additions  to  arterial  and  venous  surgery. 

Section  of  Medicine  and  Surgery  of  the  Urinary  Organs. 
Surgical  intervention  in  Bright's  disease. 
Surgical  treatment  of  prostato-vesical  tuberculosis. 
Progress  of  urology  in  the  diagnosis  of  renal  disease. 
Painful  cystides. 

Section  of  Ophthalmology. 

Blepharoplasty. 

Serotherapy  in  ophthalmology. 

Section  of  Laryngology,  Ehinology,  Otology,  and  Stomatology. 

Study  of  the  epileptogenous  action  of  foreign  bodies  in  the  ear  and  of  vegeta- 
tions in  the  naso-pharynx. 

The  different  forms  of  suppuration  of  the  maxillary  sinus. 

Injections  of  paraffin  in  rhinology. 

Differential  diagnosis  of  tubercular,  syphilitic,  and  cancerous  lesions  of  the 
larynx. 

Choice  of  anaesthesia  in  the  extraction  of  teeth. 

Treatment  of  alveolar  suppuration. 

Section  of  Obstetrics  and  Gynecology. 
Conservative  surgery  of  the  ovaries. 
Tuberculosis  of  the  adnexa. 
Symphisiotomy. 

Pregnancy  and  cancer  of  the  uterus. 
Therapy  of  puerperal  infections. 

Section  of  Hygiene  and  Epidemiology. 
The  intermediary  of  yellow  fever. 
The  cooperation  of  nations  to  prevent  the  importation  of  yellow  fever  and  the 

pest. 
Watering  the  streets  as  a  means  against  tuberculosis. 
Eecent  additions  to  the  etiology  and  epidemiology  of  epidemic  cerebro-spinal 

meningitis. 

Section  of  Military  Medicine. 

Portable  ration  of  the  soldier  during  campaign. 
The  purifying  of  the  country  water. 
Emergency  hospitals  on  the  battlefields. 


432 


INTERNATIONAL  MEDICAL  CONGRESS. 


Section  of  Legal  Medicine. 

Signs  of  death  from  drowning. 
Ecchymoses  in  legal  medicine. 
Epilepsy  in  legal  medicine. 
Organization  of  medico-legal  services. 

Section  of  Colonial  and  Naval  Medicine. 
Etiology  and  prophylaxis  of  beri-beri. 
Etiology  and  prophylaxis  of  dysentery  in  hot  countries. 
Mental  diseases  in  tropical  countries. 
Hospital  ships  and  their  function  in  time  of  war. 
Tuberculosis  in  the  navy  and  its  prophylaxis. 

Eamon  Guiteras,  M.D., 

Secretary  American  Committee  Fifteenth  International  Medical  Congress. 

75  West  Fifty-fifth  Street,  New  York  City. 


EDITORIAL    STAFF. 

Sajous's  Analytical  Cyclopaedia  of  Practical  Medicine. 


J.  GEOEGE  ADAMI,  M.D., 

MONTREAL,  P.  Q. 

LEWIS  H.  ADLER,  M.D., 

PHILADELPHIA. 

JAMES  M.  ANDERS,  M.D.,  LL.D. 

PHILADELPHIA. 

THOMAS  G.  ASHTON,  M.D., 

PHILADELPHIA. 

A.  D.  BLACKADER.  M.D., 

MONTREAL,  P.  Q. 
E.  D.  BONDURANT,  M.D., 

MOBILE,  ALA. 

DAVID  BOVAIRD,  M.D., 

NEW  YORK  CITT. 

WILLIAM  BROWNING,  M.D., 

BROOKLYN,  N.  T. 

WILLIAM  T.  BULL,  M.D., 

NEW  YORK  CITY. 
CHARLES  W.  BURR,  M.D., 

PHILADELPHIA. 

HENRY  T.  BYFORD,  M.D., 

CHICAGO,  ILL. 

HENRY  W.  CATTELL,  M.D., 

PHILADELPHIA. 

WILLIAM  B.  COLEY.  M.D., 

MEW  YORK  CITY. 

FLOYD  M.  CRANDALL,  M.D., 

NEW  YORK  CITY. 
ANDREW  F.  CURRIER,  M.D., 

NEW  YORK  CITY. 

ERNEST  W.  CUSHING,  M.D., 

BOSTON,  MASS. 

GWILYM  G.  DAVIS,  M.D., 

PHILADELPHIA. 

N.  S.  DAVIS,  M.D., 

CHICAGO,  ILL 

AUGUSTUS  A.  ESHNER,  M.D., 

PHILADELPHIA. 

8IMON  FLEXNER,  M.D., 

PHILADELPHIA. 

LEONARD  FREEMAN,  M.D., 

DENVER,  COL. 

8.  G.  GANT,  M.D., 
NEW  YORK  CITY. 

J.  McFADDEN  GASTON,  Sr.,  M.D., 

ATLANTA,  OA. 

J.  McFADDEN  GASTON,  Jr.,  M.D., 

ATLANTA,  GA. 

E.  B.  GLEASON,  M.D., 

PHILADELPHIA. 

EGBERT  H.  GRANDIN,  M.D., 

■■W  YOBK  CITY. 


ASSOCIATE.    EDITORS. 

J.  P.  CROZER  GRIFFITH,  M.D  , 

PHILADELPHIA. 

C.  M.  HAY,  M.D., 

PHILADELPHIA. 

FREDERICK  P.  HENRY,  M.D., 

PHILADELPHIA. 

L.  EMMETT  HOLT,  M.D., 

NEW  YORK  CITY. 

EDWARD  JACKSON,  M.D., 

DENVER,  COL. 

W.  W.  KEEN,  M.D., 

PHILADELPHIA. 

EDWARD  L.  KEYES,  JR.,  M.D., 

NEW  YORK  CITY. 

ELWOOD  R.  KIRBY,  M.D., 

PHILADELPHIA. 

L.  E.  La  FETRA.  M.D., 

NEW  YORK  CITY. 

ERNEST  LAPLACE,  M.D.,  LL.D., 

PHILADELPHIA. 

R.  LEPINE,  M.D., 

LYONS,  FRANCE. 

F.  LEVISON,  M.D., 

COPENHAGEN,  DENMARK. 

A.  LUTAUD,  M.D., 

PARIS,  FRANCE. 

G.  FRANK  LYDSTON,  M.D., 

CHICAGO,  ILL. 

F.  W.  MARLOW,  M.D., 

SYRACUSE,  N.  Y. 
SIMON  MARX.  M.D., 

NEW  YORK  CITY. 

ALEXANDER  McPHEDRAN,  M.D., 

TORONTO,  ONT. 

E.  E.  MONTGOMERY,  M.D., 

PHILADELPHIA. 

HOLGER  MYGIND,  M.D., 

COPENHAGEN,  DENMARK. 

W.  P.  NORTHRUP,  M.D.. 

NEW  YORK  CITY. 
RUPERT  NORTON,  M.D., 

WASHINGTON,  D.  0. 

H.  OBERSTEINER.  M.D., 

VIENNA,  AUSTRIA. 

CHARLES  A.  OLIVER,  M.D., 

PHILADELPHIA. 

WILLIAM  OSLER,  M.D., 

BALTIMORE,  MD. 

LEWIS  S.  PILCUER,  M.D., 

BROOKLYN.  N.  Y. 

WILLIAM  CAMPBELL  POSEY,  M.D., 
PHILADELPHIA. 


W.  B.  PRITCHARD,  M.D.. 

NEW  YORK  CITY. 
JAMES  J.  PUTNAM,  M.D., 

BOSTON. 

B.  ALEXANDER  RANDALL.  M.D., 

PHILADELPHIA. 

CLARENCE  C.  RICE,  M.D., 

NEW  YORK  CITY. 

ALFRED  RUBINO,  M.D., 

NAPLES,  ITALY. 

REGINALD  H.  SAYRE,  M.D., 

NEW  YORK  CITY. 

JACOB  E.  SCHADLE,  M.D., 

ST.  PAUL,  MINN. 

•  JOHN  B.  SHOBER,  M.D., 

PHILADELPHIA. 

J.  SOLIS-COHEN,  M.D., 

PHILADELPHIA. 

SOLOMON  SOLIS-COHEN,  M.D., 

PHILADELPHIA. 

H.  W.  STELWAGON,  MD, 

PHILADELPHIA. 

D.  D.  STEWART,  M.D., 

PHILADELPHIA. 

LEWIS  A.  STIMSON,  M.D., 
NEW  YORK  CITY. 

J.  EDWARD  STUBBERT,  M.D., 
LIBERTY,  N.  Y. 

A.  E.  TAYLOR,  M.D., 
SAN  FRANCISCO,  CAL. 

J.  MADISON  TAYLOR,  M.D., 
PHILADELPHIA. 

M.  B.  TINKER,  M.D., 

PHILADELPHIA. 

CHARLES  S.  TURN  BULL,  M.D., 

PHILADELPHIA. 

HERMAN  F.  VICKERY,  M.D., 

BOSTON,  MASS. 

F.  E.  WAXHAM,  M.D., 

DENVER,    COL. 

J.  WILLIAM  WHITE,  M.D., 
PHILADELPHIA. 

JAMES  C.  WILSON,  M.D., 
PHILADELPHIA. 

C.  SUMNER  WITHERSTINE.  M.D., 

PHILADELPHIA. 

ALFRED  C.  WOOD,  M.D., 

PHILADELPHIA. 

WALTER  WYMAN,  M.D., 
WASHINGTON,  D.  0. 


THE    MONTHLY   CYCLOPEDIA 

OF 

PRACTICAL   MEDICINE 


(Published  the  Last  of  Each  Month) 


Vol.  XVIII. 
Old  Series. 


PHILADELPHIA,  OCTOBER,  1905. 


Vol.  VIII,  No.  10. 
New  Series. 


TABLE  OF  CONTENTS. 


PAGE 

EDITORIALS 

A  VALUABLE  SIGN  IN  THE 
DIFFERENTIATION  OF  PSOAS 
ABSCESS  FROM  INGUINAL  OR 
FEMORAL  HERNIA.  J.  Tor- 
rance Rugh 433 

IMMUNITY    THROUGH     EXPOSURE. 

Edward  W.  Watson *35 

THE  PROBLEM  OF  THE    ENLARGED 

PROSTATE.     H.  II.  Christian....  438 

REMARKS  ON  THE  TREATMENT  OF 
MUSCULAR  RHEUMATISM 
AND  ALLIED  PAINFUL 
8TATE8.     J.  Madison  Taylor 440 

CYCLOPEDIA    OF   CURRENT 
LITERATURE 

ABDOMINAL     SYMPTOMS,     ACUTE. 

W.  W.  Cheney 444 

ACID  AUTOINTOXICATION  IN  IN- 
FANCY.    J.  L.  Morse 445 

ADRENALIN,     ACTION    OF.      T.    R. 

Elliott 445 

ANAEROBIC     CELLULITIS.        J.    C. 

Stewart 44C 

ANESTHESIA  PRECEDED  BY  IN- 
JECTIONS OP  STRYCHNINE. 
I.  Eyenhof. 446 

ANESTHETICS,  POI80NOUS  EF- 
FECTS OF.  A.  D.  Bevan  and  U. 
B.  Favill 446 

APPENDICITIS,     CAUSES  OF.     Bot- 

tomley 447 

APPENDIX,  RELATION  OF    PELVIC 

DI8EA8E  TO.     C.  W.  Barrett 447 

ARSENIC     POI80NING,     TEST    FOR. 

J.  Justus 44g 

ARTERI08CLER08IS,  HYPERTEN- 
SIVE 0RI8E8  IN.     J.  B.  Briggs,  44^ 

ASTHMA.     S.  Kohn 449 

ASTHMA.     PROGNOSIS    OF.     G.    n' 

Jack _ 449 

BRADYCARDIA.     George  Dock 450 

CEREBROSPINAL  MENINGITIS 
M  INNER  OF  INFECTION  IN. 
Westenhoffer 45O 

CHANCRE  AND  CHANCROID, TREAT- 
MENT OF.     D.  E.  Wheeler 450 

CH0LELITHIA8I8,  EXPERIMENTAL 
CONTRIBUTION  TO  TREAT- 
MENT OF.     William  Bain 451 

CHOLELITHIASIS:       TREATMENT. 

A.  Hecht "  451 

COPPER  AND  ZINC  POISONING      M 

H.  Sicard ,  452 

CORYZA  IN  NUR8LING8,  TREAT- 
MENT OP.     L.  Ballin 452 


DIABETES  MELLITU8,  IMPROVE- 
MENT IN  TREATMENT  OF.  E. 
P.  Joslin 453 

DIABETES  M  ELLITUS,  ORAL  MAN- 
IFESTATIONS OF.  Hermann 
Prinz 454 

DIAGNOSIS,     ERRORS     IN.      J.    R. 

Bradford 454 

DIGESTION    IN    THE    INSANE        D. 

M.  Cowie  and  F.  A.  Inch 455 

DIPHTHERIA.     Koussell  and  Job 456 

DISLOCATIONS  OF  THE  SHOULDER- 
JOINT,  REDUCTION  OF.  H. 
Huguier 456 

ECTOPIC  PREGNANCY.  S.  M.Brickmer  457 
ENTEROPTOSIS     AND     PENDULOUS 

ABDOMEN.     H.  Quincke 457 

EPILEPSY.     Brower -159 

GASES  OF  THE  BODY.    L.U.Watson,  459 

HEAD  INJURIES.     W.  S.  Wiatt 459 

HERNIA  FOLLOWING  ABDCMINiL 
SECTION,    THE     PREVENTION 

OF.     Payne 460 

HERNIA  OF  THE  PELVIC  FLOOK 
NEW  OPERATION  FOR.     G    W. 

Crille 460 

INFANTILE  INTE8TINAL  INFEC- 
TION, TREATMENT  OF.  11. 
Tissier 461 

INTESTINAL     EXCLUSIONS.        Pas- 

quale  Longo 462 

INTESTINAL  OBSTRUCTION.     F.  F. 

Lawrence 463 

INVAGINATION,  ACUTE,  IN  IN- 
FANTS: MEDICAL  TREAT- 
MENT OF.     Louis  Xetter 464 

IODINE,    ANTI-MICROBIC    ACTION 

OF.     G.  C.  Kinnainan 455 

IODINE  IN  SURGERY.    Nicholas  Semi,  465 

LACERATIONS      OF      THE      CERVIX 

UTERI.     A.   H.  Gardner |06 

LEUC00YTE8  IN  MALIGNANT 
GROWTHS,  BEHAVIOR  OF.  J. 
B.  Farmer  and  J.  E.  S.  Moore 466 

LEUKEMIA,     MIXED-CELL.      C.  II. 

Browning 4(;(j 

MIGRAINE       AND       CANNABIS 

INDICA.     G.    Carron  de  la  Car- 

riere 466 

NA8AL  CATARRH.  TREATMENT  OF 

CHRONIC.     L.  Kopliniki 467 

NEPHRITIS,  MEDICAL  TREATMENT 

OF.     A.  R.  Elliott 107 

OS8IFIOATION     OF      THE     LOWER 

JAW.     Edward  Fawcett 468 

OTITIS    MEDIA,     TREATMENT     OF. 

J.  G.  Huizinga njy 


PAGE 

PANOPHTHALMITIS,  SYMPATHE- 
TIC INFLAMMATION  FOL- 
LOWING.    William  Zentmayer...  469 

PERITONITIS,  ACUTE:  TREAT- 
MENT.   Lennander 470 

PERTUSSIS,  LEUCOCYTOSIS  IN.     C. 

G.  Grulee  and  D.  B.  Phemister....  471 

PULMONARY  TUBERCULOSIS,  EX- 
AMINATION OF  THE  BLOOD 
IN.     J.  T.  Ullom  and  F.  A.  Ciaig,  471 

RACHICOCAIN1ZATIPN.  NIWTICB- 

NIQUE  OF.     JI.  Le  Filliatre 471 

SALICYLATES,      ACTION      CF,      ON 

KIDNEYS.     Quenstedt 47-' 

SCOFOLAMINE-MORFHINE  AS  AN 
ADJUVANT  IN  THE  ADMIN- 
ISTRATION OF  GENERAL  AN- 
ESTHESIA.     Seelig 472 

SPINAL  CORD,  LOCALIZATION  OF 
THE  MOTOR  FUNCTION  IN 
THE.     Lapinsky 472 

SPLEEN,  INDICATIONS  FOB  El- 
MOVAL  OP  THE  PATHOLOGIC. 
B.  B.  Davis 47 

STOMACH,    ULCER      AND     CANCER 

OF  THE.     Christopher  Graham...  474 

SWEATING  FEET,   TREATMENT  OF. 

Fischer 474 

SYPHILIS.   PROGNOSIS  OF.      K.    W. 

Taylor 474 

TABES,   PRINCIPLES  OF  PHYSICAL 

RE-EDUCATION      IN.         H.    S. 

Frenkel 475 

THYROID    GLAND.  IRON  PIGMENT 

IN  THE.     G.  E.  Gulland  and  A. 

Goodall 476 

TUBERCULOSIS,     PULMONARY.     H. 

P.  Loomis „ 476 

TUBERCULOUS  PERITONITIS,  RE- 
CURRENT, AFTER  INCOM- 
PLETE OPERATION.  J.  B.  Sho- 
ber 476 

TYPHOID  FEVER,  BLOOD-PRESSURE 

IN.     G.  Garriereand  C.  Dancourt,  477 

URETERAL  STONES,  DIAGNOSIS  OF. 

Harris 477 

URETHRITIS,    LOCAL    TREATMENT 

OF.     Paul  Lebreton 477 

URINARY  TRACT,  EARLY  DIAG- 
NOSIS OF  SURGICAL  DIS- 
EASES OF  THE.  Benjamin  Ten- 
ney 478 

VULVA,     EPITHELIOMA      OP     THE. 

Howard  Dittrick 478 

BOOKS  AND  MONOGRAPHS  RE- 
CEIVED     479 

8TAFF  LIST 480 


Editorials. 

DEPARTMENT   IN    CHARGE   OF 

J.  MADISON  TAYLOR,  A.M.,  M.D. 

A  VALUABLE  SIGN  IN  THE  DIFFERENTIATION  OF  PSOAS  ABSCESS 
FROM  INGUINAL  OR  FEMORAL  HERNIA. 

A  psoas  abscess  is  much  more  frequently  mistaken  for  a  hernia,  than  a  hernia 
for  a  psoas  abscess.    In  fact,  I  know  of  no  record  or  instance  of  the  latter  condition, 

(433) 


434  DIFFERENTIATION  OF  PSOAS  ABSCESS  FROM  HERNIA. 

but  am  very  familiar  with  instances  of  the  former.  The  confusion  of  the  two 
conditions  is  rather  common  with  the  general  practitioners  who  have  not  had  the 
privilege  of  observing  the  great  numbers  of  cases  that  present  themselves  to  the 
worker  in  the  large  surgical  or  orthopaedic  clinic.  That  it  is  not  confined  to  them 
is  shown  by  the  fact  of  two  well-known  instances  where  professors  of  surgery  in 
two  leading  colleges  announced  at  separate  times  the  performance  of  an  operation 
for  the  radical  cure  of  hernia  (one  femoral  and  one  inguinal),  arid  in  the  course 
of  the  operation,  on  opening  the  "sac,"  released  a  large  quantity  of  pus  which,  on 
investigation,  was  shown  to  be  the  contents  of  a  psoas  abscess.  Further  investigation 
in  both  cases  also  revealed  a  kyphos  in  the  lower  spine  which  had  not  been  previously 
observed.  These  mistakes  are  naturally  ascribed  to  incomplete  examination  of  the 
patients;  yet  the  ability  and  thoroughness  of  the  two  operators  is  unquestioned 
and  the  final  explanation  is  that  too  much  reliance  was  placed  upon  the  classical 
symptoms  of  the  supposed  hernia.  In  all  works  on  surgery  the  classical  signs  of 
hernia  are  detailed  to  serve  as  a  guide  to  differentiate  it  from  resembling  condi- 
tions, but  almost  all  of  these  symptoms  may  be  found  in  the  psoas  abscess,  so  that 
without  a  careful  search  for  the  spinal  kyphos  or  muscular  rigidity  or  for  the  psoas 
muscle  itself,  there  is  a  possibility  of  such  a  mistake,  and  it  is  not  a  remote  one. 

For  several  years,  in  the  orthopaedic  department  of  the  Jefferson  Medical 
College,  I  have  taught  the  students  that  in  addition  to,  or  irrespective  of,  the  signs 
mentioned  in  works  on  surgery,  the  presence  of  a  tumor  in  the  iliac  fossa  continuous 
with  the  external  tumor  was  sufficient  to  eliminate  the  presence  of  a  hernia.  In 
hernia,  the  tumor  exists  only  outside  the  abdominal  wall,  while  in  the  psoas  abscess 
there  is  a  tumor  in  the  iliac  fossa  and  in  the  line  of  the  psoas  muscle. 

In  hernia,  the  contraction  of  the  psoas  muscle  can  be  felt  as  the  patient  flexes 
the  thigh  on  the  abdomen,  while  in  the  psoas  abscess  the  psoas  muscle  is  destroyed, 
hence  cannot  be  felt  to  contract.  Fluctuation  between  the  external  and  internal 
tumors  can  be  easily  demonstrated  in  the  psoas  abscess,  but  it  does  not  exist  in  a 
hernia.  In  many  cases,  also,  fluctuation  may  be  obtained  between  the  external 
tumor  and  the  back,  opposite  the  origin  of  the  psoas  muscle. 

There  are  numerous  symptoms  which  are  rather  distinctive  of  the  psoas  abscess, 
and  which,  when  present,  direct  the  attention  away  from  hernia.  Chief  among 
these  are  flexion  and  external  rotation  of  the  thigh,  causing  a  decided  limp  in 
walking;  rigidity  of  the  lower  spine  and  of  the  spinal  muscles;  kyphos  of  the 
lower  spine,  more  or  less  angular,  etc. ;  but  when  these  are  absent,  as  they  may  be 
in  any  given  case,  the  differentiation  hinges  upon  the  presence  or  absence  of  the 
■  uli- a -abdominal  tumor  continuous  with  the  external  one. 

In  a  case  recently  seen,  a  child  4  years  old  had  a  lumbar,  caries  for  which  a 
brace  had  been  applied.  In  spite  of  careful  supervision  a  psoas  abscess  developed 
in  the  left  side,  and  about  the  same  time  an  inguinal  hernia  was  discovered  on  the 


[MMUNITY  THROUGH  EXPOSURE.  435 

right.  Thus  it  was  possible  to  demonstrate  in  the  same  subjecl  the  value  of  the 
sign  just  mentioned  as  clearly  differentiating  the  two  conditions.  The  abscess  dis- 
appeared as  more  efficient  support  was  afforded  the  spine  and  the  hernia  was 
easily  held  reduced  by  a  truss.    The  recovery  of  the  child  seems  assured. 

In  the  fourth  and  last  edition  of  "Modern  Surgery,"  by  Dr.  J.  Chalmers  Da 
Costa,  and  in  a  paper  by  Dr.  H.  Augustus  Wilson,  published  in  American  Medicine, 
July  8.  1905,  this  sign  is  mentioned  and  credit  given  lor  the  originality  of  the 
observation. 

J.    TORRAXCE    RUGH.* 


[MMUNITY  THEOUGII  EXPOSURE. 


We  can  generally  look  at  a  subject  from  several  sides,  but  often  forget  to  do 
so,  for  we  arc  all.  more  or  less,  partisan.  Immunity  is  one  of  such  subjects,  but. 
nowadays  every  one  looks  at  it  from  the  viewpoint  of  immediate  action  and  imme- 
diate returns.     There  are  other  ways,  however. 

Explanations  of  this  acquirement  of  immunity  from  disease  are  various,  and  all 
more  or  less  unsatisfactory.  Some  are  puerile  and  some  so  involved  that  the  mind 
refuses  to  .understand  them.  We  all  know,  at  least  superficially,  the  argument  of 
each,  and  the  bacteriologic  explanation  for  the  immunity  conferred  by  the  many 
serums  that  do  not  immune.,  as  well  as  the  diphtheria  antitoxin  which  sometimes 
does;  but  we  confess  that  it  has  never  seemed  clear  to  us,  brought  up  within  the 
old  theologic  lines  (though  like  all  the  world,  somewhat  emancipated),  still  think- 
ing more  or  less  in  the  old  thought  grooves,  of  an  Overruling  Power  and  a  logical 
plan  of  creation,  that,  if  there  be  any  plan  about  man  and  his  doings  and  destiny, 
or  any  recognizable,  intelligent  power  over  him  and  his  world,  it  is  doubtful  if  such 
power  and  plan  ever  intended  that  he  should  light  disease  and  prolong  his  life  in  the 
clumsy  way  of  the  serum  cures.  The  way  is  too  round-about,  too  involved  and 
uncertain,  and  too  costly  to  life  and  happiness  other  than  human.  Of  course,  it 
is  better,  from  the  view  of  very  old.  decrepit  theology,  that  many  animals  should 
suffer  and  perish  rather  than  that  man  should  suffer  a  pang  or  lose  an  hour  of  life. 
But  man  no  longer  occupies  the  proud  position  he  once  held;  he  is  scientific,-!  1 1  \ 
considered  now,  as  onl\  one  of  ••the  beasts  thai  perish."  The  bacteriologic  way  is  to 
eliminate  diseas  i  .-it  once,  and  with  the  laboratory  making  its  serums,  there  is  also 
the  "health  law" — the  power  to  supervise,  immure,  remove,  and  stamp  out  disease, 
i.e.,  when  it  consent.-  to  be  stamped  out.  But  this  is  not  Nature's  way,  which  is 
ever  acting  and  with  the  Bame  end  in  view  as  the  way  of  the  laboratory,  the  bac- 
teriologist, and  the  official. 

*  Demonstrator  of  Orthopedic  Surgery  in  the  Jefferson  Medical  College. 


436  IMMUNITY  THROUGH  EXPOSURE. 

There  is  also  the  way  called  "the  survival  of  the  fittest/'  and  for  it  we  sub- 
stitute the  survival  of  the  unfit.  There  is  also  the  way  we  might  call  "immunity 
through  exposure/'  and  we  substitute  for  it  immunity  by  seclusion,  quarantine,  and 
segregation — but  for  immunity  through  exposure  there  is  still  something  to  be 
said. 

When  the  diseases  we  know  and  have  known  in  civilization  are  suddenly  im- 
ported into  a  community  which  has  been  hitherto  isolated  and  ignorant  of  their 
existence,  as  when  Europe  carried  measles  into  New  Zealand  and  syphilis  into  the 
Sandwich  Islands,  and  to  many  other  places  where  it  was  before  unknown,  we  find 
these  diseases,  which  had  gradually  acquired  with  us  a  comparatively  mild  char- 
acter, suddenly  becoming  deadly  pestilences — in  other  words,  we  enjoy  a  partial 
immunity  which  virgin  populations  do  not.  This  immunity  is  not  due  in  any 
particular  case  to  the  fact  that  the  individual  exposed  has  previously  had  the  dis- 
ease, but  either  through  inheritance  of  immunity,  or  from  having  been  exposed 
during  our  lives,  from  time  to  time,  to  minute  doses  of  contagion  (microbic  or 
otherwise),  and  to  having,  in  consequence,  found  in  ourselves  a  resistance  (an  anti- 
toxin) in  small  quantity,  which  both  acts  as  a  partial  preventive  and  as  an  antidote 
to  the  poison  when  encountered  in  larger  quantity.  In  this  way,  year  after  year, 
century  after  century,  the  race,  while  losing  by  death  the  extremely  non-resistant 
type,  which  can  form  no  resistant  body,  and  (naturally)  cutting  it  off  by  death 
from  the  chance  of  propagating  its  kind,  acquires  generally  more  and  more  resist- 
ance^— the  disease  is  said  to  have  become  milder. 

Take  tuberculosis,  as  an  example.  Granting  that  the  bacillus  of  tubercle 
(Koch)  is  its  cause,  the  bacteriologist  tells  us  that  we  are  all  of  us  everywhere 
exposed  to  it;  that  we  frequently  have  short  and  small  attacks,  which  we  may 
consider  "colds,"  and  which  disappear ;  that  post-mortem  evidence  proved  that  most 
of  us  have  had  a  minor  tuberculosis  some  time  in  a  lifetime.  We  agree  that  these 
transient  cases  leave  behind  in  the  triumphal  economy  of  nature  a  gradually  increas- 
ing immunity,  a  power  of  resistance,  whereas,  if,  from  birth  to  death,  a  whole  gen- 
eration had  no  opportunity  to  inhale,  or  come  in  contact  with  these  bacilli ;  if  the 
dust  was  never  laden  with  them ;  if  there  were  no  old  infected  houses  and  stuffs  to 
retain  them ;  no  fellow-beings  to  expectorate  them — then,  if  after  one  or  two  genera- 
tions such  a  race  were  suddenly  confronted  with  imported  tuberculosis,  what  result 
could  we  expect  but  a  vastly  increased  sensitiveness  on  the  part  of  the  community, 
and  a  vastly  augmented  and  accelerated  mortality.  If  we  knew  of  a  race — continu- 
ous in  its  history,  without  foreign  intermixture,  peculiarly  exposed,  through  its  cir- 
cumstances and  surroundings,  to  all  transmissible  diseases,  we  should  expect  to  find 
them  acquiring  immunity  through  these  two  great  forces — immunity  through  sur- 
vival of  the  resistant  type  and  elimination  of  the  feebler,  and  immunity  through 
exposure.  Such  a  race  is  the  Hebrew,  and  all  observers  credit  them  with  just  this 
condition  of  things. 


IMMUNITY  THROUGH  EXPOSURE.  437 

But  this  method  is  much  too  slow  for  us;  we  look  only  at  the  present;  we 
bear  less  disease  to-day,  even  if  it  should  become  more  virulent  to-morrow.  So  the 
stamping  out  method  appeals  to  us — if  only  it  would  stamp  out.  This  way  is  the 
way  of  the  bacteriologist  and  the  health  officer,  by  which  some  one  individual,  gen- 
erally an  animal,  is  called  on  to  endure  great  and  overwhelming  experimental  ex- 
posure, and  then  we  are  to  profit  by  its  peril.  If  only  there  was  full  success  to 
counterbalance  its  cruelty — with  cruelty  to  animals  alone — but  cruelty  is  .to  the 
sick,  for  this  method  makes  sickness  a  crime,  and  educates  the  community  into 
such  a  horror  of  disease  that  they  lose  courage  and  kindness  and  mercy  and  love, 
even  for  their  own  nearest,  in  the  presence  of  epidemic  disease. 

And  all  this,  too,  could  be  condoned  if  altogether  successful;  but  is  it?  Why, 
for  instance,  did  the  epidemic  of  smallpox  in  Philadelphia  in  the  early  '70's  die 
out  practically  in  a  year,  and  the  subsequent  epidemic  in  '81  and  '88  fail  to  persist 
in  succeeding  years,  when  bacteriologic  and  health  law  strenuosity  were  unknown, 
while  with  all  the  power  of  such  laws  and  all  the  skill  of  to-day,  and  far  more 
money  to  spend,  the  recent  epidemic  ran  its  course  unchecked  for  three  years, 
during  which  quarantine  and  removal  to  hospitals  were  carried  out  with  dominant 
hand  ?  If  the  bacteriologist  had  a  perfect  weapon,  and  perfect  skill  in  its  use,  and 
if  before  his  valiant  thrusts  disease  fled  shrieking  away,  then  the  question  would 
be  solved- — the  new  way  would  be  the  best.  But  with  serums  that  fail  to  immune 
or  cure,  with  disease  as  deadly  as  ever,  we  cannot  help  thinking,  sometimes,  that 
the  world  will  gain  more  in  the  long  run.  by  the  old,  non-sensational  way  which 
is  ever  acting  for  us,  unless  we  wilfully  stay  its  hand. 

Immunity  by  exposure  is  based  on  a  great,  underlying  law,  which  extends  to 
things  moral  as  well  as  to  things  microbic — to  the  action  of  the  elements  that  war 
against  us  as  well  as  to  the  bacteria  that  so  silently  bear  death  influences.  Do  we 
shun  cold  and  fear  draughts  and  exposure,  how  are  we  best  inured  but  by  the 
repeated  short  shocks  of  cold  bathing  that  rouse  up  resistance?  And  in  another 
question  of  great  moment,  this  method  seems  pre-eminently  successful.  There  are. 
for  example,  two  possible  ways  of  making  a  nation  temperate — one  by  force  (pro- 
hibition) ;  (he  other  by  exposure.  And  supposing  each  to  have  in  different  com- 
munities full  sway  and  way,  which  would  in  the  end  produce  the  best  permanent 
results?  If  we,  to  imagine  such  a  situation,  could  keep  all  alcoholic  drinks  from 
a  whole  people  till  even  their  theoretic  knowledge  of  them  were  Lost,  and  beer, 
wine,  and  spirits  were  to  them  unmeaning  and  unknown  words,  and  then  sud- 
denly spring  upon  such  a  | pic  alcohol  in  every  form — offered  freely— what  would 

be  the  probable  result?  Most  likely  utter  demoralization  and  universal  drunken- 
ness; while  to-day,  were  every  corner  to  offer  to  the  passer-by,  five  whisky,  if  it 
stood  labeled  and  wailing,  with  the  convivial  glass  in  evidence— eight  in  fen  yes, 
ninety-nine  in  one  hundred — would  pass  it  by  unharmed.    Such  is  the  success  of  the 


438  THE  PROBLEM  OF  THE  ENLARGED  PROSTATE. 

plow,  natural  method  of  immunity  by  exposure,  which  has  changed  the  British 
"aristocracy,  the  lineal  descendants  of  those  who,  two  generations  ago,  were  the 
most  intemperate,  into  the  most  temperate,  sober  and  useful  aristocracy  in  the 
world.  The  very  children  of  total  abstainers  are  often  the  first  to  yield,  and  the 
children  of  the  drunkard,  while  some  of  them  inheriting  weakness,  also  comprise 
among  their  number  the  very  apostles  of  "temperance." 

Left  to  itself  without  intemperance,  the  survival  of  the  fittest  would  alone, 
in  time,  eliminate  disease,  or,  more  truly,  death  from  disease,  for  the  susceptible 
and  weak  contracting  disease  readily  and  dying,  the  survivors  would  propagate  a 
more  resistant  race.  In  this  way  an  eminent  yellow  fever  expert  (Dr.  Guiteras) 
was  accustomed  to  explain  the  apparent  immunity  of  natives  in  yellow  fever  dis- 
tricts. It  might  be  said  that  some  diseases  are  not  respecters  of  persons,  slaying 
alike  the  weak  and  the  strong;  but  this  is  doubtful.  Hamburg,  in  its  great  cholera 
epidemic,  illustrates  this,  where  the  cholera  deaths  caused  so  little  real  change  in 
the  rate  of  mortality  that  the  percentage  of  deaths  from  all  causes  for  the  two 
years  before  the  epidemic  was  very  little  less  than  for  the  succeeding  two  years, 
which  included  the  cholera  year,  showing,  apparently,  that  cholera,  which  is  sup- 
posed to  slay  indiscriminately  those  who  have  received  its  contagion,  in  reality 
killed  only  those  who  were  doomed  to  die  in  the  next  few  years,  viz.,  the  susceptible 
and  non-resistant.  So,  while  no  one  could  urge  an  entire  abandonment  of  modern 
methods,  it  is  perhaps  as  well,  once  in  a  while,  to  pause  and  try  to  realize  that, 
apart  from  them,  there  is  ever  working  a  force  that  makes  for  health,  and,  though 
slow,  can,  through  hard  fought  battles  and  many  slain,  bring  us  victory — and  that 
its  law  is  what  we  have  called  immunity  by  exposure. 

Edward  W.  Watson, 

Philadelphia. 


THE  PROBLEM  OF  THE  ENLARGED  PROSTATE. 

It  is  perfectly  safe  to  say  that  the  question  as  to  what  is  the  most  successful 
method  of  treatment  for  prostatic  hypertrophy  is  one  that  has  received  more  atten- 
tion at  the  hands  of  genito-urinary  surgeons  during  the  last  few  years,  than  any 
other  involving  the  genito-urinary  tract.  It  is  also  equally  safe  to  say  that  where 
so  many  varied  operative  measures  have  been  suggested  that  the  ideal  operation  has 
not  as  yet  been  devised.  At  the  time  that  castration  was  suggested,  all  operative 
measures  directed  to  the  gland  itself  had  practically  fallen  into  disfavor.  The 
result  was  that  the  comparatively  simple  operation  of  castration  was  welcomed 
with  delight,  as  offering  a  safe  and  efficient  method  of  treating  this  condition. 
The  subsequent  history  of  the  operation  is  well  remembered.  Testicles  all  over  the 
world  were  sacrificed  in  the  hope  of  reducing  the  size  of  the  prostate.     It  must 


THE  PROBLEM  OF  THE  ENLARGED  PROSTATE.  439 

be  confessed  that  some  of  the  earlier  reported  cases  showed  remarkably  good  effects; 
but  the  terminal  results  were  not  so  good  and  as  it  developed  that  the  operation, 
simple  as  it  seemed,  was  at  times  followed  by  death,  it  has  been  practically  aban- 
doned. 

In  more  recent  years  the  methods  of  Bottini  occupied  the  attention  of  the 
profession  and  operators  began  falling  over  each  other  in  their  eagerness  to  report 
successful  cases  thus  treated.  The  writer  must  plead  guilty  of  having  reported 
quite  a  few  himself.  The  operation  is  still  in  favor  in  Europe,  but  most  surgeons 
here  employ  it  in  limited  cases  only.  It  has  a  place  in  very  old  men  where  more 
formidable  operative  measures  could  not  be  done.  The  early  age  of  many  of  the 
cases  reported  as  cured  would  lead  one  to  suspect  that  they  were  cases  of  chronic 
prostatitis  and  not  senile  hypertrophy. 

At  the  present  time  prostatectomy  occupies  the  "center  of  the  stage;"  and 
he  is  indeed  a  modest  genito-urinary  surgeon  who  has  not  devised  a  modification  of 
some  one  else's  modification  of  this  operation.  The  method  of  performing  this  oper- 
ation, whether  by  the  supra-pubic  or  the  perineal  route,  is  the  question  being  most 
discussed  at  present.  From  my  own  experience  with  both  methods  I  am  at  present 
inclined  to  favor  the  supra-pubic  route  as  offering  the  best  opportunity  for  total 
removal  of  the  gland.  In  cases  where  the  growth  is  markedly  downward  into  the 
rectum  with  a  normal  urethral  length,  perineal  prostatectomy  is  the  operation  of 
choice.  In  spite  of  the  fact  that  one  well-known  surgeon  has  publicly  stated  that 
he  had  relegated  perineal  prostatectomy  to  the  field  of  minor  surgery,  the  operation 
by  either  route  remains  a  formidable  undertaking  and  one  that  should  be  thought- 
fully considered  before  being  employed.  Whiteside1  recently  reports  end  results 
in  238  cases;  of  these  30  per  cent,  only  could  be  considered  absolutely  good  results. 
"Not  very  cheerful  reading  this  to  the  man  with  an  enlarged  prostate  who  is  con- 
templating operation. 

The  statistics  just  quoted  are  the  only  ones  that  I  know  of  giving  end  results: 
i.e.,  the  condition  present  at  least  one  year  after  operation. 

The  investigator  desiring  to  ascertain  from  a  study  of  reported  cases  just 
what  permanent  benefit  the  operation  of  prostatectomy  has  been  to  the  patient 
will  find  it  no  easy  matter  to  arrive  ai  a  satisfactory  conclusion;  as  most  operators 
are  content  to  merely  report  the  number  of  cases  operated  upon  and  the  mortality 
following  the  operation. 

And  right  here  il  might  be  pertinent  to  ask  the  question,  What  has  become 
of  the  conservative  treatmenl  of  the  hypertrophied  prostate?  Has  the  time  come 
when  the  catheter  is  to  be  discarded  in  .-ill  ruses  and  the  patienl  advised  to  submit 
at  once  to  operative  measures?  I  know  thai  this  is  the  opinion  of  quite  a  number 
of  prominent  surgeons;    but  I   fail  as  yet  to  see  the  need  of  such  radical  teaching 

o" 
'American  Journal  of  Urology. 


440  MUSCULAR  RHEUMATISM  AND  ALLIED  PAINFUL  STATES. 

Operation  is  undoubtedly  indicated  in  advanced  cases  where  there  is  marked 
atony  of  the  bladder  with  complete  retention  and  chronic  cystitis,  and  where  the 
introduction  of  the  catheter  is  difficult,  or  painful,  or  causes  hasmorrhage. 

In  another  class  of  cases  where  there  is  some  enlargement  of  the  gland  with 
three  to  four  ounces  of  residual  urine  and  the  bladder  uninfected,  I  think  it  is  only 
right  to  the  patient  to  give  the  catheter  a  fair  trial,  especially  as  the  mortality 
from  operative  procedures  is  still  fairly  high— 8  to  10  per  cent. — and  in  view  of 
the  factvthat  so  many  men  live  out  comfortable  and  useful  lives  on  partial  catheter 
life. 

The  great  danger  to  be  guarded  against  in  these  cases  is  infection  of  the  blad- 
der by  means  of  a  dirty  catheter  and  by  traumatism  induced  by  rough  handling 
of  the  instrument  on  the  part  of  the  patient. 

To  avoid  this  the  following  three  points  should  be  carefully  looked  into: — 

1.  The  selection  of  the  proper  catheter.  This  should  be  either  a  soft  rubber 
or  single  elbow  Mercier  catheter,  preferably  of  the  French  make,  olive-tipped. 

2.  The  sterilization  and  preservation  of  ilte  catheter.  This  is  best  accom- 
plished by  boiling  for  ten  minutes  after  using  and  keeping  the  catheters  wrapped 
in  sterile  gauze  in  a  receptacle. 

3.  Careful  instruction  on  the  part  of  the  medical  attendant  as  to  the  manner 
in  which  the  patient  should  introduce  the  instrument  so  as  to  avoid  traumatism. 

The  surgeon  should  impress  upon  the  patient  the  importance  of  these  points 
and  should  be  constant  in  his.  warnings  to  him  not  to  relax  his  vigilance  as  regards 
the  care  of  the  instrument  and  the  technique  of  the  operation. 

H.  M.  Christian.* 


REMAEKS  ON  THE  TEEATMENT  OF  MUSCULAE  RHEUMATISM  AND 
ALLIED  PAINFUL  STATES. 

From  the  brief  and  partial  review  of  the  underlying  factors  conditioning 
muscular  rheumatism  and  the  large  group  of  sensory  disorders  which  arise  from 
a  common  source,  referable  to  the  acidoses  (given  in  the  preceding  article),  it  will 
be  seen  that  their  treatment,  to  be  successful,  must  include  the  repair  of  several 
phases  of  constitutional  depression  along  with  that  of  a  series  of  complex  local 
derangements.  The  relief  of  the  painful  states  is  a  secondary  matter,  and  involves 
a  wide  range  of  rational  measures. 

The  systemic  perversions  and  perturbations  include  autotoxamiias,  due  to 
digestive  disorders,  various  in  feel  ions  traumata,  fatigue,  and^uboxidation  states, 


Clinical  Professor  GenitoUrinary  Diseases,  Medico-Chirurgical  College  of  Philadelphia. 


MUSCULAR  RHEUMATISM  AND  ALLIED  PAINFUL  STATES.  441 

katabolism  of  a  large  and  puzzling  variety,  with  usually  exposure  to  cold.  These 
factors  are  active  and  retroactive,  always  demanding  close  scrutiny  with  points  of 
contact  to  any  of  the  whole  gamut  of  morbific  possibilities. 

Much  can  be  done  by  fixing  in  the  mind  certain  definite  principles  and  working 
through  such  of  these  as  the  problem  requires,  selecting,  adapting,  and  applying 
wisely.  The  need  of  the  organism  is  for  more  ox}'gen;  not  only  much  more  must 
be  taken  inj  but  the  great  oxygen  distributers  should  be  enhanced  in  all  practicable 
directions.  This  is  to  be  accomplished  by  using  those  agents  which  fortify  and 
expedite  the  adrenal  system  by  some  drugs,  but  chiefly  by  supplying  the  depleted 
blood  with  its  normal  constituents  which  are  here  both  vitiated  and  lost,  especially 
the  plasmatic  salines.  Not  until  the  plasma  is  restored  to  its  norm  can  the  remoter 
cells  secure  enough  of  the  vitalizing  principle  (oxygen)  which  is  its  function  to 
distribute. 

Next  we  may  refer  to  the  vitiated  condition  of  the  eliminating  organs,  espe- 
cially of  the  liver,  kidneys,  and  skin. 

This  is  done,  in  great  part,  by  relieving  the  system  of  the  burden  of  disposing 
of  too  much  food,  too  varied  a  diet,  or  of  certain  offending  articles,  of  which  it 
seems  probable  that  excess  of  nitrogenous  foods  is  the  worst  error. 

The  extreme  simplification  of  ingested  foods  is  of  vastly  greater  efficacy  than 
the  most  perfect  selection  of  such  items  as  are  chemically  permissible.  It  is  by 
this  means,  reducing  the  diet  to  the  simplest  variety,  that  we  secure,  not  only  relief 
from  the  cardinal  fault  of  excessive  eating,  but  make  the  most  reasonable  demands 
upon  those  overworked  organs  on  which  the  burden  of  elaboration  falls..  At  the 
same  time  the  possibility  must  be  borne  in  mind  of  impaired  nutrition  passing  into 
exhaustions.  Food  in  plenty  may  be  taken  which  has  failed  to  meet  existing  needs, 
whereas  the  cells  cry  in  vain  for  what  they  sorely  lack. 

At  all  times,  when  the  status  of  the  patient  permits,  normal  active  exercises 
should  be  freely  taken,  and  for  the  cogent  but  complex  reasons  pointed  out  by  me 
elsewhere. 

If  full  activities  are  not  yet  to  be  encouraged,  it  is  important  to  supply  substi- 
tutes, and  massage  and  systematized  movements,  active  and  passive,  will  at  once 
occur  to  (lie  mind.  Let  me  say  here  that  much  as  I  value  these  measures,  it  is  my 
firm  conviction  that  they  should  be  employed  with  the  same  judgment,  equal  knowl- 
edge of  the  physiologic  problems  involved,  and,  above  all,  the  same  variants  in 
character,  quality,  direction,  force,  and  amounl  as  is  (supposed  to  be)  given  1" 
the  administration  of  drugs. 

Let  ns  review  the  measures  which  suggest  themselves  for  the  relief  of  a  well- 
marked  condition  of  muscular  rheumatism.  Not  all  will  be  needed  in  such  in- 
stance; only  those  which  arc  specifically  indicated.  From  these  may  be  chosen 
such  as  the  case  requires;    also  in   minor  derangements  modilications  will  suffice. 


442  MUSCULAR  RHEUMATISM  AND  ALLIED  PAINFUL  STATES. 

Pain,  when  prominent,  demands  instant  relief.  The  custom  is  to  supply 
some  drug  which  obtunds,  the  most  common  being  opiates,  now  out  of  fashion. 
Dover's  powder  often  acts  magically,  but  is  open  to  many  objections.  Salicylates 
are  still  much  in  vogue,  but  have  not  made  any  material  impression  upon  the 
prevalence,  progress,  or  complications  of  rheumatism.  They  are  all  cardiac  depres- 
sants, gastric  irritants,  and  produce  so  many  evil  by-effects  that  they  deserve  to 
be  abandoned.  A  few  well-directed  doses  often  act  satisfactorily,  but  salicylic  acid 
in  any  form  should  never  be  continued  beyond  three  or  four  days. 

The  coal-tar  analgesics  are  often  gratifying  in  intense  neuralgic  pains,  but 
are  untrustworthy,  dangerous,  sometimes  fatal;  only  to  be  employed  for  emer- 
gencies and  with  great  caution.  The  sodium  and  potassium  salts — normally  present 
in  the  plasma — are  of  much  value.  Benzoate  of  soda  will  often  mitigate  fierce 
pains,  in  doses  of  5  to  10  grains  every  three  to  four  hours,  even  often  er  for  a  short 
time. 

The  bicarbonate  is  almost  as  useful.  Much  evidence  is  being  adduced  to  show 
that  this  preparation  is  almost  a  necessary  part  of  treatment  in  a  number  of  acute 
and  chronic  conditions,  among  which  are  pneumonia,  coryza,  diabetes,  emphasiz- 
ing Sajous's  strong  recommendation  that  the  essence  of  relief  in  some  maladies 
lies  in  supplying  the  lost  plasmatic  salines.  Hence  the  value  of  spas.  In  this  con- 
nection it  is  well  to  note  the  as  yet  undefined  efficacy  of  lithium,  strontium,  and 
bromine  salts  which,  though  foreign  to  the  organism,  are  yet  of  a  limited  usefulness. 
Bicarbonate  of  potassium  is  invaluable  as  a  urinary  stimulant,  especially  when 
to  it  is  added  fresh  lemon  juice,  making  a  fresh  citrate  of  potassium;  40  grains 
before  breakfast  and  at  bedtime  is  often  most  comforting.  Sodium  phosphate  has 
a  double  value,  acting  mildly  upon  the  liver  and  bowels,  and  also  supplying  two 
substances  much  needed  in  acid  states. 

A  hot  bath  or  locally  hot  water  answers  well;  dry  heat  with  pressure  much 
better.  A  hot  flatiron  applied  over  flannel  or  a  thick  bath-towel,  using  slow  move- 
ments with  distributed  pressure,  will  lessen  local  pains  and  deep-seated  tenderness. 
To  continue  the  effect  of  the  local  heat  thin  rubber  tissue  laid  on  will  adhere  and 
gradually  dilate  the  surface  vessels,  acting  the  part  of  a  poultice.  It  is  cleanly, 
free  from  bulkiness,  permitting  the  wearing  of  customary  clothing,  and  encourag- 
ing activities.  It  is  cheap  and  easily  renewed.  Every  physician  would  do  well  to 
carry  some  with  him  in  his  emergency  kit. 

Hot-air  treatment,  up  to  240°  F.  or  more,  by  means  of  certain  modern  devices, 
cabinets  or  super-heated  air  chambers,  is  preeminent  in  certain  cases.  It,  however, 
involves  either  the  transportation  of  the  bulky  apparatus  to  the  patient  or  the 
patient  to  the  place  of  treatment,  and  demands  expert  handling.  Dry  heat  is 
amazingly  comforting;  witness  the  universal  use  of  the  hot-wafcr  bag,  the  thermo- 
lite  bag,  etc.  Salt  or  sand  in  a  bag  holds  the  boat  rather  better  than  water,  and 
has  the  merit  of  being  adaptable  to  the  inequalities  of  surface — often  a  boon. 


MUSCULAR  RHEUMATISM  AND  ALLIED  PAINFUL  STATES.  443 

A  simple  way  whereby  myself  and  many  grateful  patients  have  achieved  vast 
relief  is  to  go  to  the  boiler  of  the  range  and,  removing  the  outer  garments,  adjust 
oneself  to  this  large  heated  surface  as  much  or  little  as  is  needed — back,  shoulders, 
neck,  face,  or  limb,  using  as  much  pressure  and  for  as  long  as  is  comfortable.  Cold 
sometimes  is  better  than  heat,  and  serves  a  useful  purpose  as  an  alternate. 

In  many  acutely  painful  states,  and  in  a  much  greater  number  of  chronic  ones, 
the  most  practicable  and  effective  agent,  both  for  analgesia  and  repair,  is  manipula- 
tion, finger  or  hand  pressure,  coupled  with  passive  stretchings,  rotations,  and  tor- 
sions. The  rationale  of  these  measures  is  not  generally  well  known,  hence  would 
justify  outlining  if  space  permited.  Suffice  to  say  it  includes  emptying  of  lymph 
channels,  limiting  the  number  of  sensory  impulses  passing  through  fibrils  of  nerves, 
improving  normality  of  speed  of  nervous  discharge,  of  central  nutrition,  relieving 
tension,  infiltration  in  muscle  and  other  tissues,  and  reflexly  influencing  tone  of 
blood-vessels,  hence,  local  congestions,  etc. 

It  is  a  subject  on  which  my  enthusiasms  have  excited  comment,  because  work 
of  this  nature,  when  employed  at  all,  is  usually  relegated  to  one  not  medically  edu- 
cated. It  is  supposed  to  require  too  much  muscular  effort  for  the  physician  to  use 
himself — which  is  not  the  case,  because  many  of  the  procedures  require  but  a  few 
minutes  and  little  effort,  except  to  decide  just  what  to  do. 

It  is  unfortunate  that  physicians  take  so  little  pains  to  acquire  skill  in  per- 
sonally applying  this  valuable  measure.  Massage,  as  ordinarily  practiced,  is  of 
excellent  utility,  but  limited  scope,  time-consuming  to  the  patient,  clumsy,  and, 
too  often  by  reason  of  deficient  specific  knowledge  in  the  operator,  inefficient  in 
sensory  difficulties.  Some  of  the  more  intelligent  and  skillful  exponents  of  the 
art  are,  however,  so  competent  that  to  them  is  due  the  credit  of  relief,  often  of 
cures.  The  masseur  may  have  been  sought  by  the  patient  who,  when  benefited, 
blames  the  physician  for  not  having  earlier  employed  so  excellent  a  remedy.  He 
could,  himself,  have  achieved  equal  or  better  results  by  less  laborious  but  better 
directed  manipulations.  It  might  interest  readers  to  learn  why  and  how  the 
author  came  to  feel  so  strongly  on  the  matter.  Accident  induced  me,  while  acting 
as  assistant  to  Weir  Mitchell  in  1882,  to  myself  learn  the  practice  of  massage  from 
a  Swede,  and  since  then  have  omitted  no  opportunity  to  study  details  from  the 
best  practitioners.  Lecturing  on  the  principles  of  systematic  movements  encour- 
aged me  to  study  the  subject  carefully,  and  now  it  is  one  of  the  most  powerful 
auxiliary  measures  at  my  command. 

In  the  whole  array  of  painful  states  under  consideration  there  air  few  in- 
stances when  judiciously  applied  pressure,  continuous,  distributed,  or  alternated. 
has  not  some  useful  place.  This  will  become  clear  to  any  deft-handed  physician 
who  will  study  the  principles  of  massage  as  taught  by  the  lii-si  masters.  These  have 
been  cheerfully  appropriated  by  certain   non-medical   practitioners   who   are  wise 


444 


ABDOMINAL  SYMPTOMS,  ACUTE. 


enough  to  recognize  the  enormous  efficacy  of  manipulations  which  they  regard  as 
sufficient  for  all  needs.  Clearly,  this  fact  above  all  ought  to  compel  full  attention 
from  the  profession  of  scientific  medicine. 

In  so  brief  a  communication  it  is  not  possible  to  discuss  the  value  of  the  ultra- 
violet rays,  high-frequency  currents,  and  other  forms  of  electric  manipulations. 
Suffice  to  say,  that  while  these  have  accomplished  much  and  promise  more,  we  are 
bere  attempting  only  to  describe  those  agencies  which  can  be  commanded  by  the 
average  practitioner. 

So  great  has  been  my  satisfaction  in  the  rational  measures  outlined,  it  has 
seldom  proved  necessary  for  me  to  seek  for  help  outside  those  described. 

J.  Madison  Taylor.* 


C^clopeedia  of  Current  literature. 


ABDOMINAL  SYMPTOMS,  ACUTE. 

The  author  discusses  the  significance 
of  acute  abdominal  symptoms  as  fol- 
lows: Pain. — In  perforations  of  the 
stomach  and  intestines  the  pain  is  usu- 
ally extremely  severe,  constant,  and 
burning,  and,  localized  at  first,  it  soon 
spreads  over  the  abdomen.  In  rupture 
of  cysts  the  pain  is  diffuse  from  the 
start,  and  not  so  severe.  In  rupture  of 
the  appendix  the  pain  is  usually  asso- 
ciated with  colicky  pains  in  the  um- 
bilical region.  Gall-stone  pain  is  epi- 
gastric, passes  through  to  the  back  and 
shoulder,  and  is  not  spasmodic.  Renal 
or  ureteral  pain  is  of  the  same  charac- 
ter, but  shoots  down  to  the  scrotum  and 
thigh.  Tenderness. — Tins  is  marked 
from  the  first  in  cases  of  inflammation 
and  rupture,  and  is  greater  on  percus- 
sion than  on  pressure.  Tbe  revert 
the  rase  in  strangulation.  The  seat  of 
disease  is  generally  indicated  by  an 
area  of  marked  tenderness.  In  the  pas- 
sage of  renal  or  biliary  calculi,  pressure 
seems  to  relieve  the  pain.     Aodoiviiml 


Rigidity. — This  is  a  very  marked  symp- 
tom in  peritonism,  and  is  most  marked 
over  the  seat  of  disease.  In  the  early 
stage  it  is  general  over  the  abdomen. 
If  it  persists  it  means  either  rupture 
or  general  peritonitis.  In  bad  cases  it 
may  disappear  and  give  place  to  disten- 
tion. Vomiting. — This  occurs  early  in 
many  cases  and  is  not  a  sign  of  much 
diagnostic  value.  It  is  its  persistence 
which  is  of  the  greatest  importance,  as 
pointing  to  some  mechanical  .obstruc- 
tion. The  character  of  the  vomited  ma- 
terials may  be  a  guide.  Collapse. — This 
indicates  rupture,  internal  strangula- 
tion, or  haemorrhage.  Its  degree  de- 
pends greatly  upon  the  severity  of  the 
case,  more  especially  upon  the  sudden- 
ness and  amount  of  the  extravasation. 
A  slight  leak  will  not  have  the  same 
effect  as  a  sudden  and  free  discharge 
into  a  previously  healthy  peritoneal 
cavity.  Collapse  in  inflammatory  affec- 
tions is  of  grave  significance,  pointing 
to  perforation  or  gangrene.  It  is  a 
strong  indication  for  operation.     Rigor. 


•Formerly   Neurologist    <<>  the   Howard   Hospital,  etc. 


ACID  AUTOINTOXICATION  IN  INFANCY. 


ADRENALIN,  ACTION  OF      445 


— This  generally  indicates  some  in- 
flammatory condition.  Pulse.  —  In- 
crease in  the  pulse-rate  is  common;  it 
usually  rises  comparatively  slowly  in 
inflammatory  conditions.  A  rate  of 
120  or  over  indicates  a  serious  state  of 
a  Hairs.  Temperature. — Early  elevation 
of  temperature  separates  inflammations 
from  strangulations,  hernia?,  etc.  Gas. 
— This  is  always  a  sign  of  rupture  of 
the  alimentary  canal.  W.  W.  Cheync 
(British  Medical  Journal,  June  17, 
1905). 

ACID  AUTOINTOXICATION  IN  INFANCY. 
The  acetone  bodies  are  not  found  in 
the  urine  of  comparatively  healthy  in- 
fants and  children  by  the  ordinary  clin- 
ical tests.  They  appear  in  their  urine 
under  approximately  the  same  conditions 
as  in  adults.  Certain  disturbances  of 
digestion  associated  with  the  presence  of 
the  acetone  bodies  in  early  life  have 
peculiar  symptomatologies.  It  is  prob- 
able that  the  peculiar  symptoms  are  due, 
in  part  at  least,  to  acid  intoxication.  It 
is  also  probable  that  the  acid  intoxica- 
tion is  not  primary  but  secondary.  The 
connection  of  the  symptom-complex  seen 
in  many  cases  of  recurrent  vomiting  with 
acid  intoxication  is  probably  even  closer 
than  in  the  digestive  disturbances  just 
mentioned.  In  these  cases,  also,  the  acid 
intoxication  is  presumably  always  sec- 
ondary In  some  other  abnormal  condi- 
tion, which  may  or  not  be  digestive  in 
origin.  In  any  event,  the  etiology  is  ob- 
scure. In  spite  of  the  fact  that  Hie 
amount  of  the  acetone  bodies  found  in 
these  conditions  is  relatively  much 
smaller  than  those  found  in  diabetes, 
the  demonstration  of  their  presence  in 
connection  with  symptoms  of  gastro- 
intestinal disturbance  and  the  symptom- 
complex  of  recurrent  vomiting,  and 
probably  also  with   other  conditions,   is 


of  importance  both  in  diagnosis  and  in 
treatment.  J.  L.  Morse  (Archives  of 
Pediatrics,  August,  1905). 

ADRENALIN,  ACTION  OF. 

Apart  from  the  general  poisonous 
properties  that  are  suggested  by  its 
chemical  structure,  adrenalin  has  one 
peculiar  power,  according  to  the  writer. 
Independent  body  cells,  nerve-cells  and 
their  processes,  skeletal  muscles  and 
visceral  muscles  in  union  only  with 
sacral  and  cranial  visceral  nerves  are 
influenced  by  it,  as  they  are  by  any 
featureless  poison.  Its  single  charac- 
teristic is  the  aptness  to  stimulate  plain 
muscle  and  gland  cells  that  are  or  have 
been  in  functional  union  with  sympa- 
thetic nerve  fibers.  In  all  vertebrato 
the  reaction  of  any  plain  muscle  to  ad- 
renalin is  of  a  similar  character  to  that 
following  excitation  of  the  sympathetic 
(thoracico-lumbar)  visceral  nerves  sup- 
plying that  muscle.  The  change  may 
be  either  a  contraction  or  a  relaxation. 
In  default  of  sympathetic  innervation 
plain  muscle  is  indifferent  to  adrenalin. 
Extent  of  reaction  varies  directly  with 
the  frequency  of  normal  physiological 
impulses  to  rapid  change  of  tension  re- 
ceived by  the  muscle  in  life  through  the 
sympathetic  nerves.  A  positive  reaction 
to  adrenalin  is  a  trustworthy  proof  of 
the  existence  and  nature  of  sympathetic 
nerves  in  any  organ.  Plain  muscle. 
when  denervated,  shows  increase  of  the 
capacity  for  irritation  by  adrenalin  than 
it  had  previously  possessed.  Sympa- 
thetic nerve  cells  with  their  libers,  and 
the  contractile  muscle  fibers,  are  not 
irritated  by  adrenalin.  The  stimulation 
takes  place  at  the  junction  of  muscle 
and  fiber.  The  irritable  substance  at 
the  myoneural  junction  depends  for 
continuance  of  life  on  the  nucleoplasm 
of  the  muscle  cell,  not  of  the  nerve  cell. 


446       ANAEROBIC  CELLULITIS. 


ANAESTHETICS,  POISONOUS  EFFECTS. 


Such  peculiar  irritability  makes  the 
profound  biochemical  distinction  be- 
tween all  post  ganglionic  nerves  of  the 
thoracico-visceral  class,  whether  motor 
or  inhibitor,  on  the  one  side,  and  all 
other  efferent  nerves  with  their  respec- 
tive junctions  on  the  other.  T.  R. 
Elliott  (Journal  of  Physiology,  July 
13,  1905). 

ANAEROBIC   CELLULITIS. 

Gas  bacillus  infection,  while  not  a 
common  disease,  demands  the  attention 
of  all  surgeons  because,  while  regularly 
fatal  when  untreated,  its  early  diagnosis 
is  easy  and  its  successful  treatment  re- 
quires only  the  prompt  and  thorough  ap- 
plication of  well-established  surgical 
principles.  Either  removal  of  entire 
disease  by  amputation  or  thorough  ex- 
posure of  its  site  to  air  and  drainage 
seem  the  essentials  to  be  attained.  Free 
incisions,  the  continuous  bath,  or  irri- 
gation and  wet  dressings,  have  afforded 
the  best  results,  and  theoretically  hydro- 
gen peroxide  is  indicated.  J.  C.  Stew- 
art (Journal  of  the  American  Medical 
Association,  August  19,  1905). 

ANAESTHESIA  PRECEDED  BY  INJECTIONS 
OF  STRYCHNINE. 
In  189  G  the  author  suggested  the 
preparatory  injection  of  strychnine  in 
persons  about  to  be  chloroformed,  as  he 
had  seen  that  after  such  injections  the 
patient  bore  larger  doses  of  the  anass- 
thetic.  This  beneficial  effect  of  strych- 
nine is  attributed  to  the  action  of  this 
drug  on  the  vasomotor  system.  The 
method  which  was  adopted  by  the  writer 
\v;is  to  inject  several  doses  of  strychnine 
sulphate,  l/80  grain  each,  into  the  pa- 
tient during  the  few  days  preceding  the 
operation.  The  dose  depends  upon  the 
condition  of  the  patient's  pulse,  the 
length  and  severity  of  the  proposed  op- 


eration, and  as  to  whether  the  patient  is 
suffering  with  arteriosclerosis,  valvular 
disease,  myocarditis,  etc.,  or  is  in  the 
habit  of  using  intoxicants  or  tobacco  to 
excess.  The  number  of  strychnine  injec- 
tions given  before  the  operation  varies, 
therefore,  from  one  to  twenty,  and  just 
before  the  narcosis  14  grain  of  morphine 
is  given.  Under  these  conditions  chloro- 
form is  borne  with  remarkably  few  acci- 
dents. I.  Evenhof  (Roussky  Vratch, 
June  18,  1905;  New  York  Medical  Jour- 
nal and  Philadelphia  Medical  Journal, 
August  12,  1905). 

ANESTHETICS,    POISONOUS    EFFECTS    OF. 

Chloroform  (and  ether  to  a  very  lim- 
ited degree)  can  produce  a  destructive 
effect  on  the  muscle  cells  of  the  heart 
and  other  muscles,  resulting  in  fatty 
degeneration  and  necrosis  very  similar 
to  the  effects  produced  in  phosphorus 
poisoning.  The  constant  and  most  im- 
portant injury  done  is  that  to  the  liver. 
The  injury  to  the  liver  cells  is  in  direct 
proportion  to  the  amount  of  anaesthetic 
employed  and  the  length  of  anaesthesia. 
As  a  result  of  this  fatty  degeneration 
and  necrosis  of  the  liver  cells,  toxins  are 
produced  either  from  the  liver  ceils 
themselves  or  as  a  result  of  the  failure 
of  these  cells  to  eliminate  substances 
which,  under  normal  conditions,  they 
eliminate,  but  which  under  these  ab- 
normal conditions  they  fail  to  do,  and 
these  substances,  therefore,  may  accu- 
mulate and  produce  toxic  effects.  These 
toxins  produce  a  definite  symptom  com- 
plex which  makes  its  appearance  from 
ten  to  one  hundred  and  fifty  hours 
after  the  anaesthesia.  This  symptom 
complex  consists  of  vomiting,  restless- 
ness, delirium,  convulsions,  coma, 
Cheyne-Stokes'  respiration,  cyanosis, 
icterus  in  varying  degree,  and  usually 
terminates  in  death. 


APPENDICITIS,  CAUSES. 


APPENDIX  AND  PELVIC  DISEASE. 


447 


It  is  probable  that  milder  degrees  of 
this  poisoning  are  recovered  from,  and 
that  the  transient  icterus  noticed  after 
chloroform  anaesthesia  without  other 
evident  cause  is  due  to  such  poisoning, 
and  many  cases  which  exhibit  restless- 
ness, fright,  mild  delirium,  drowsiness, 
etc.,  after  anaesthesia  may  be  due  to  the 
same  cause.  That  chloroform  is  capable 
of  producing  these  serious  late  poison- 
ous effects  is  a  strong  argument  against 
its  employment,  and  an  argument  in 
favor  of  the  more  general  use  of  ether. 

The  recognition  of  this  danger  of 
hepatic  toxaemia  is  a  strong  argument 
against  the  employment  of  chloroform 
for  long  anaesthesia,  as  it  can  be  shown 
that  a  two-hour  chloroform  anaesthesia 
is  almost  invariably  fatal  to  rabbits  and 
guinea  pigs,  from  fatty  degeneration  and 
necrosis  of  the  liver  cells;  and  a  two- 
hour  chloroform  anaesthesia  in  man  is 
an  exceedingly  dangerous  thing. 

These  facts  in  regard  to  the  late  poi- 
sonous effects  of  anaesthetics  and  the 
fact  that  the  dangers  increase  with  the 
amount  of  the  drug  employed,  and  with 
the  length  of  the  anaesthesia,  form  a 
strong  argument  in  favor  of  rapid  op- 
erating and  in  favor  of  limiting  in 
every  way  possible  the  length  of  the 
anaesthesia  and  the  dose  of  the  anaes- 
thetic. A.  D.  Bevan  and  H.  B.  Fa \  ill 
(Journal  of  the  American  Medical  As- 
sociation, September  9,  1905). 

APPENDICITIS,    CAUSES    OF. 

Tn  the  Beverer  forms  of  the  disease 
associated  with  abscess  or  peritonitis  the 
micro-organisms  can  be  readily  deter- 
mined. In  the  pus  within  or  outside 
the  appendix  many  varieties  of  bacteria 
arc  found,  the  bacillus  coli  communis 
most  frequently.  Ordinarily  harmless. 
it  may  become  virulent,  especially  where 
associated     with    streptococcus.      Other 


organisms  found  in  this  disease  are 
the  staphylococcus  pyogenes  aureus  and 
citreus  pneumococcus,  bacillus  pyo- 
cyaneus,  proteus,  various  anaerobic  and 
putrefactive  bacilli,  and  those  of  influ- 
enza, diphtheria,  glanders,  and  tetanus. 
Actinomycosis  may  be  a  cause,  and  tu- 
berculous and  typhoid  ulcers  may  be 
associated  with  it.  The  mucous  mem- 
brane of  the  appendix  contains  Lieber- 
kiihn's  follicles  and  Peyer's  patches, 
also  much  lymphoid  tissue.  The  func- 
tion of  the  latter  is  to  destroy  invading 
microbes,  but  it  may  be  destroyed  by 
them  with  resulting  appendicitis.  The 
bacterial  activity  is  at  its  maximum  in 
the  caecum,  and  as  the  contents  of  the 
latter  are  fully  digested  and  semi-fluid, 
they  form  a  good  medium  for  micro- 
bial growth.  In  many  cases  of  the  dis- 
ease concretions,  ulcers,  and  narrowing 
of  the  lumen  act  as  contributing  causes. 
True  foreign  bodies  are  rarely  a  cause. 
It  is  encouraged  by  constipation,  the  use 
of  purgatives,  indigestion,  bad  teeth, 
and  the  uric  acid  diatheses.  It  is  three 
or  four  times  more  frequent  in  men 
than  in  women.  It  is  very  common 
among  children,  40  per  cent,  of  all 
eases  occurring  between  the  tenth  and 
twentieth  years.  This  may  be  due  in 
part  to  the  larger  amount  of  lymphoid 
tissue  in  the  appendix  during  the  earlier 
vciis  of  life.  Children  are  also  prone 
to  catarrh  of  the  bowels,  which  may  re- 
sult in  infection  of  the  appendix.  Sev- 
eral members  of  a  family  may  suffer 
from  the  disease,  thus  showing  a  par- 
ticular  family  tendency  in  this  direc- 
tion. Bottomley  (Practitioner,  June, 
L905). 

APPENDIX,    RELATION    OF    PELVIC    DIS- 
EASE  TO. 

Appendicitis    favors   the   development 

of  salpingitis,  ami  salpingitis  ami  other 


448        ARSENIC  POISONING,  TEST  FOR. 


ARTERIOSCLEROSIS,  CRISES  IN. 


pathological  pelvic  conditions  favor  the 
development  of  appendicitis.  Menstrua- 
tion may  favor  the  development  of  either 
one.  The  diagnosis  of  appendicitis  in 
the  female  meets  with  greater  obstacles 
than  the  male,  and  for  this  reason  it  is 
undoubtedly  more  often  overlooked  than 
in  the  male.  This  is  probably  one  of 
the  reasons,  although  not  the  only 
reason,  that  statistics  show  more  cases 
of  appendicitis  in  the  male  than  in 
the  female.  Every  gynaecological  case 
should  have  the  appendiceal  region 
thoroughly  examined  before  operation. 
It  should  be  a  part  of  every  gynaecolog- 
ical celiotomy  to  examine  the  appendix. 
A  pathological  appendix  should  be  re- 
moved at  such  celiotomy,  when  the  pa- 
tient's life  is  not  endangered  thereby. 
Every  healthy  appendix  should  be  left, 
for  in  its  removal  the  patient's  life  may 
be  needlessly  endangered.  C.  W.  Bar- 
rett (American  Journal  of  Surgery, 
September,  1905). 

ARSENIC  POISONING,  TEST  FOR. 

The  possibility  of  detecting  arsenic  in 
the  tissues  with  the  microscope  has  been 
studied  by  the  writer,  as  well  as  the 
technique  best  adapted  for  the  purpose. 
By  transforming  the  arsenic  in  the  tis- 
sues into  arsenic  trisulphide,  a  striking 
reaction  can  be  obtained  with  it  even 
in  a  very  thin  layer ;  the  color  is  charac- 
teristic, and  the  localization  of  the  sub- 
stance in  the  tissues  shows  the  distribu- 
tion of  the  arsenic  and  throws  light  on 
its  functions.  Arsenic  is  transformed 
into  the  trisulphide  by  passing  sulphur- 
eted  hydrogen  through  its  solution. 
The  characteristic  odor  is  lost  at  once, 
and  the  fluid  turns  yellow.  A  yellow 
precipitate  is  thrown  down  by  long 
standing  or  by  addition  of  a  concentrated 
solution  of  TK'l.  NaCl,  or  Aid,.  This 
yellow  precipitate  is  arsenic  trisulphide, 


and  the  greenish  yellow  crystals  are  read- 
ily recognized  under  the  microscope.  In 
examining  tissues  for  arsenic,  they  are 
first  fixed  in  4  per  cent,  formalin  for  a 
day  or  so,  then  rinsed,  cut  into  very  thin 
sections,  and  placed  in  a  fresh,  neutral 
solution  of  sulphureted  hydrogen  for 
three  or  four  days  at  a  temperature  of 
from  60°  to  80°  C. ;  they  are  then  rinsed 
with  alcohol  and  embedded  in  celloidin. 
The  sections  are  then  placed  for  from 
ten  to  twenty  minutes  in  a  5  to  10  per 
cent,  solution  of  hydrochloric  acid  to 
dissolve  out  the  iron  sulphide,  and  then 
rinsed  several  times,  after  which  they  are 
stained,  cleared  up  in  carbol  xylol  and 
mounted  in  balsam.  On  applying  this 
test  for  arsenic  in  experimental  research 
it  was  found  that  arsenic  injected  subcu- 
taneously  combined  first  with  the  plasma 
of  the  red  corpuscles.  This  technique 
readily  revealed  its  presence  here  and  in 
the  various  organs,  in  the  epithelium  of 
kidneys  and  intestines,  and  especially  in 
the  muscle  and  liver  cells,  sweat  glands, 
stratum  corneum,  and  hairs.  J.  Justus 
(Dermatologische  Zeitschrift,  vol.  xii, 
No.  5,  1905;  Journal  of  the  American 
Medical  Association,  July  8,  1905). 

ARTERIOSCLEROSIS,      HYPERTENSIVE 
CRISES   IN. 

Albuminuria  (and  cylindruria)  in 
the  subjects  of  generalized  arteriosclero- 
sis, where  no  other  cause  is  at  work,  is 
always  accompanied  by  a  state  of  high 
blood-pressure.  Intermittent  attacks  of 
hypertension  of  the  pulse  and  concomi- 
tant albuminuria,  separated  by  longer 
or  shorter  intervals  of  normal  blood- 
pressure  during  which  the  urine  is  nor- 
mal, may  be  the  only  clinical  expres- 
sions of  a  generalized  arteriosclerosis. 

Therapeutic  relief. -of  hypertension  in 
this  general  class  of  cases,  if  not  carried 
too  far,  will  tend  to  relieve  the  patho- 


ASTHMA. 


ASTHMA,  PROGNOSIS  OF. 


449 


logical  condition  of  the  urine.  In  a 
certain  number  of  cases  we  may  reason- 
ably hope  by  this  means  to  postpone  the 
onset  of  chronic  renal  changes.  J.  B. 
Briggs  (American  Journal  of  Medical 
Sciences,  August,  1905). 

ASTHMA. 

The  writer  states  that  asthma  has 
no  distinctive  pathology,  and  the  le- 
sions that  actually  cause  it  have  not  as 
yet  been  discovered,  but  the  essential 
cause  of  the  disease  is  probably  some 
organic  lesion  of  the  nerve  centers  of 
the  medulla,  though  this  has  not  yet 
been  demonstrated.  Although  the  views 
of  causation,  especially  as  regards  the 
nose,  are  very  divergent,  the  fact  which 
stands  out  distinctly,  in  all  that  has 
been  written,  is  that  peripheral  or  cen- 
tral irritations  in  certain  individuals  of 
a  neurotic  temperament  produce  a  char- 
acteristic, distressing,  periodic  dyspnoea 
which  is  sui  generis;  it  is  unlike  the 
dyspnoea  of  destructive  lung  disease;  it 
is  entirely  different  from  cardiac  or 
ursemic  dyspnoea;  it  is  well  defined 
and  unmistakable  in  the  suddenness  of 
onset  of  the  paroxysm,  the  seeming 
gravity  of  respiratory  insufficiency  that 
makes  those  about  the  patient  fear  that 
death  is  imminent,  and  in  the  more  or 
less  rapid  return  to  a  normal  condition. 
It  is  the  consensus  of  opinion  that  this 
uniformity  entitles  asthma  to  be  con- 
sidered as  a  disease  and  not  as  a  symp- 
tom. The  writer  has  been  able  to  find 
the  record  of  only  three  autopsies  on 
asthmatics,  and  in  none  of  these  was 
anything  characteristic  discovered.  Thus 
far  no  change  in  the  nerve  centers  has 
been  discovered  to  which  the  disease  can 
be  positively  attributed ;  we  are  conse- 
quently driven  to  the  hypothesis  that 
there  must  be  a  molecular  change  in  the 
nerve  centers  or  a  periodic  disturbance 


in  their  vascular  supply,  and  that,  as 
stated,  the  asthmatic  attack,  like  that  of 
urticaria,  migraine,  or  epilepsy,  is  the 
culmination  of  a  series  of  irritations 
transmitted  to  the  nerve  centers,  which 
finally  result  in  the  explosion  which, 
in  this  case,  is  the  asthmatic  paroxysm. 
Of  the  list  of  drugs  recommended, 
the  writer  has  had  the  most  success  with 
potassium  iodide.  He  doubts  the  uni- 
versal utility  of  operative  work  in  the 
nose,  and  says  that  there  must  be  inter- 
nal treatment  directed  to  the  underlying- 
cause  in  the  brain,  respiratory,  and  vaso- 
motor centers.  Every  asthmatic  should 
have  his  nose  examined  and  treated,  if 
necessary,  but  it  must  be  borne  in  mind 
that  the  asthmatic  is  such  not  because 
of  some  abnormality  in  his  nose,  bron- 
chi, or  in  some  other  organ,  but  because 
at  bottom  there  is  a  derangement  of  his 
entire  nervous  system  and  an  irritable 
condition  of  his  nerve  centers  with  ex- 
plosions in  the  domain  of  the  vagus 
nerve.  S.  Kohn  (Medical  Record,  Au- 
gust 26,  1905). 

ASTHMA,  PROGNOSIS  OF. 

The  successful  management  of  asthma 
is  an  art  to  be  acquired  only  by  years 
of  patient  study  and  clinical  observa- 
tion. The  prognosis  in  uncomplicated 
cases  of  the  condition  is  positively  good. 
Nature  may  require  two  or  three  years 
to  bring  about  a  cure,  and  during  that 
time  the  patient  should  be  under  con- 
stant supervision  of  a  physician.  Rules 
essential  to  successful  management  of 
a  case  are:  Physiologic  measures  are, 
when  possible,  to  be  substituted  for 
drugs;  blood  showing  an  excess  of  lym- 
phocytes indicates  1  lie  withholding  of 
lymphogenous  foods,  as  milk  and  raw 
oysters;  blood  giving  a  pronounced  io- 
dophilia  indicates  the  withholding  of 
starches;    a  lack  of  fibrine  elements  in 


450 


BRADYCARDIA. 


CHANCRE  AND  CHANCROID,  TREATMENT  OF. 


the  blood  indicates  the  giving  of  gela- 
tine; a  toxic  cadaveric  stool  indicates 
withholding  proteids  or  meats;  urine 
containing  indioan,  intestinal  toxaemia, 
indicates  restricted  diet.  G.  N.  Jack 
(Buffalo  Medical  Journal,  August, 
1905). 

BRADYCARDIA. 

The  writer  holds  that  a  diagnosis  of 
bradycardia  cannot  be  based  solely  on 
the  pulse-rate.  To  establish  an  abso- 
lute diagnosis  it  is  essential  to  note,  in 
addition  to  the  pulse-rate,  the  character 
of  the  heart  sounds  and  to  take  tracings 
of  the  arterial  and  venous  pulses,  as  well 
as  of  the  apex  beat.  In  the  two  cases 
reported  tracings  of  the  arterial  pulse 
alone  were  taken.  The  first  patient  ex- 
hibited, in  a  general  way,  the  symptoms 
of  Stokes-Adams  disease.  The  syphyg- 
mogram  of  this  patient  shows  a  pulse- 
rate  of  twenty-six  and  one-half  beats  a 
minute.  There  was  great  regularity  in 
the  duration  of  each  pulsation  as  well 
as  in  the  height  of  the  stroke.  The  sec- 
ond patient  had  a  pulse-rate  of  fifteen 
to  thirty  a  minute.  There  was  consid- 
erable arhythmia,  and  there  were  no 
Stokes-Adams  symptoms.  Both  pa- 
tients eventually  died.  The  author  is  of 
the  opinion  that  in  both  cases  the  brady- 
cardia was  due  to  lowered  automatic  ex- 
citability. George  Dock  (Medical  News. 
August  19,  1905). 

CEREBRO-SPINAL  MENINGITIS,  MANNER 
OF   INFECTION  IN. 

A  valuable  pathological  study,  based 
on  a  series  of  30  autopsies,  has  been 
made  by  the  writer.  The  results  of  his 
investigations  seem  to  show  that  the 
point  of  entrance  for  the  infectious 
germs  is  the  posterior  nasopharynx,  and 
particularly  the  pharyngeal  tonsil.  The 
meningitis  is  at  first  invariably  a  basilar 


process  and  centers  in  the  region  of  the 
hypophysis.  It  takes  place  in  a  lympho- 
genous manner.  The  involvement  of  the 
cranial  cavity  is  analogous  to  the  inflam- 
mation of  the  mucous  membrane  of  the 
accessory  sinuses  connected  with  the 
nasopharyngeal  space.  A  meningitis  of 
this  type  never,  or  at  least  very  rarely, 
occurs  by  the  extension  of  an  inflamma- 
tory process  from  the  ethmoid  cells.  The 
writer  claims  that  both  adults  and  chil- 
dren who  happen  to  be  attacked  by  this 
disease  show  distinct  evidences  of  the  so- 
called  lymphatic  diathesis.  The  disease 
is  due  to  the  inhalation  of  the  infectious 
organism  and  its  prophylaxis  is  essen- 
tially hygienic.  The  meningococcus 
Weichselbaum-Jager  is  found  in  the  ma- 
jority of  cases,  although  it  is  by  no  means 
decided  that  it  is  solely  and  alone  the 
cause  of  the  disease.  The  fact  that  many 
other  cocci  are  found  with  this  coccus, 
either  alone  or  in  a  mixture,  makes  it- 
probable  that  all  of  these  bacteria  play 
only  a  secondary  role  in  the  etiology  of 
the  disease  and  that  the  real  etiological 
factor  has  not  yet  been  discovered.  This 
seems  to  be  analogous  with  the  strepto- 
coccus infection  in  scarlatina.  Westen- 
hoffer  (Berliner  klinische  Wochenschrif t, 
June  12,  1905;  Medical  Newsj  August 
19,  1905). 

CHANCRE  AND  CHANCROID,  TREATMENT 
OF. 

The  venereal  ulcer  of  the  penis  is  best 
treated  by  simple  mechanical  cleanli- 
ness, the  frequency  with  which  it  must 
be  washed  to  secure  cleanliness  varying 
with  the  intensity  of  the  infection  and 
the  amount  of  discharge.  Mercurial 
solutions  are  slightly  preferable  to  oth- 
ers, probably,  because  they  form  with 
the  discharges  an  insoluble  albuminate 
of  mercury.  Iodoform  seems  to  have 
only  slight  specific  action,  and  on  ac- 


CHOLELITHIASIS,  TREATMENT  OE. 


CHOLELITHIASIS. 


451 


count  of  its  disagreeable  and  compro- 
mising odor  should  be  reserved  for  the 
most  severe  forms  of  infection.  De- 
formities of  the  foreskin  forming  me- 
chanical obstruction  to  the  circulation 
or  to  cleanliness  should  be  relieved  at 
once,  but  operations  for  cosmetic  effect 
should  not  be  performed  in  the  presence 
of  infected  ulcers.  D.  E.  Wheeler 
(American  Medicine,  August  19,  1905). 

CHOLELITHIASIS,    EXPERIMENTAL    CON- 
TRIBUTION TO   TREATMENT   OF. 

Gall-stones  introduced  into  a  normal 
gall-bladder  become  dissolved  within  a 
comparatively  short  space  of  time,  in 
about  eight  or  nine  weeks.  When  a  mild 
degree  of  cholecystitis  is  set  up  gall- 
stones inserted  into  the  gall-bladder  do 
not  disappear,  although  there  is  always 
a  reduction  in  weight.  Ichthoform, 
cholelysin,  olive-oil,  and  calomel  do  not 
appear  to  have  any  effect  in  resolving 
calculi  introduced  into  a  gall-bladder, 
the  mucous  membrane  of  which  is  in- 
flamed. During  a  course  of  the  Harro- 
gate old  sulphur  water  gall-stones  be- 
come disintegrated  in  cases  of  cholecys- 
titis experimentally  induced.  In  the 
treatment  of  artificially-produced  chole- 
lithiasis a  mixture  of  urotropin  and 
iridin  has  a  pronounced  effect  in  causing 
dissolution  of  the  calculi.  In  regard  to 
the  action  of  barium  chloride  further 
experiments  are  necessary  to  determine 
its  role  in  experimentally-produced  chole- 
lithiasis. William  Bain  (British  Med- 
ical Journal,  August  5,  1905). 

CHOLELITHIASIS:      TREATMENT. 

Inasmuch  as  mix  vomica  preparations 
increase  peristalsis  slightly,  and  calo- 
mel in  non-laxative  doses  increases  se- 
cretory flow,  the  author  advises  them  in 
combination  to  prevent  the  formation 
of  gall-stones.    With  sufficient  peristalsis 


and  biliary  flow  "residual  bile"  is  al- 
most impossible,  and  without  residual 
bile,  gall-stone  formation  and  infection 
is  almost  unknown,  and  without  infected 
bile,  cholecystitis  and  gall-stone  colic 
are  very  rare.  If  stones  are  present,  it 
is  possible  to  sweep  them  out  by  em- 
ploying these  drugs.  The  action  of  nux 
vomica  as  a  stomachic  also  aids  the  pre- 
vention of  gall-stones  by  increasing  the 
appetite  and  thus  exciting  the  forma- 
tion of  a  larger  amount  of  bile.  The 
treatment  of  cholelithiasis  must  first 
concern  itself  with  the  removal  of  the 
impediment  to  the  flow  of  bile,  and 
where  this  can  be  done  medicinally,  it 
must  be  by  regulating  the  mode  of  liv- 
ing, diet,  and  intestinal  peristalsis;  and 
by  the  prevention  of  infection,  without 
which  there  is  no  gall-stone  colic.  In 
the  interval  between  colics  the  follow- 
ing preparation  is  advised  by  the 
writer : — 

1^  Mild  chloride  of  mercury, 

Extract  of   nux   vomica,   of   each, 

gr.  vj-viiss. 
Aromatic  powder, 
Extract  of   rhubarb,   of   each,   gr. 
xxiiss. 
This  is  to  be  made  into  thirty  pills. 
and    from    two    to    three    given    daily. 
Neither    diarrhoea   nor   intestirnal   colic 
is  produced  by  this,  but  gastric  oppres- 
sion,   sensation  of  fulness,  and  disten- 
tion,   constipation,    diarrhoea,    jaundice, 
and   loss   of   appetite,   also   asthma,   art1 
made  to  disappear.     Gall-stone  colic  re- 
quires morphine,  and  a  pill  made  up  of 

1$   Podophyllin,   gr.    iij. 

Mild  chloride  of  mercury,  gr.  vj. 

Extract  of  nux  vomica. 

Extract  of  belladonna,  of  each.  gr. 

ivss. 

This  is  to  he  made  into  twenty  pills, 

and  a  pill  token  every  two  hours  until 


452 


COPPER  AND  ZINC  POISONING. 


COPYZA  IN  NURSLINGS. 


the  patient  is  better,  when  one  or  two 
pills  are  taken  daily.  If  diarrhoea  re- 
sults, the  first  pill  should  again  be  re- 
turned to.  A.  Hecht  (Therapeutische 
Monatshefte,  Bd.  xviii,  172,  Nu.  4, 
1905;  American  Medicine,  August  12, 
1905). 

COPPER  AND  ZINC  POISONING. 

Copper  smelting  is  a  dangerous  occu- 
pation, because  of  the  tremendous 
amount  of  dust  which  rises  from  the 
fire  when  feeding  the  furnace,  and  men 
canDot  work  long  in  this  position;  they 
contract  both  the  lighter  and  more  se- 
vere pulmonary  diseases;  where  the 
ore  runs  a  high  percentage  of  lead  and 
arsenic,  cases  of  severe  poisoning  occur 
and  paralyses  are  not  uncommon. 

As  zinc  occurs  with  sulphur,  lead,  and 
arsenic  as  impurities,  the  effects  of  zinc 
roasting  is  about  similar  to  that  of  cop- 
per, with  the  addition  of  the  so-called 
ague  seizure  and  its  accompanying 
symptoms. 

The  chills  occurring  in  brass  workers 
are  due  to  zinc  for  the  following  rea- 
sons: Oxide  of  copper  is  not  volatile, 
while  zinc  oxide  is  very  readily  volatile; 
chills  do  not  occur  among  melters  of 
pure  copper ;  in  the  roasting  of  zinc  ore 
Hie  men  suffer  from  similar  symptoms; 
chills  do  not  occur  while  making  bronze, 
which  contains  much  copper  and  but 
little  zinc;  workers  in  zinc  oxide  suffer 
from  a  like  complaint. 

The  respiratory  influence  of  brass- 
making  in  the  course  of  time  is  bad, 
luil  depends  largely  upon  the  means  of 
ventilation ;  Ithe  respiratory  effect  of 
polishing  is  not  bad,  providing  the 
workers  are  protected  by  Hie  proper  suc- 
tion apparatus;  under  poor  conditions 
both  oeeupations  can  lead  to  serious  re- 
sults. Working  over  the  sulphuric  acid 
bath  is  the  most  dangerous  part  of  the 


trade.  Sand  blasting  is  detrimental  to 
health,  corresponding  to  the  dangers  of 
stone-cutting. 

The  gastro-intestinal  effects  are  seen 
more  particularly  in  filers  and  polishers, 
who  transfer  dust  and  filings  to  their 
mouths.  Copper  here  plays  a  great  fac- 
tor, as  do  lead  and  arsenic  in  metal  of 
poor  quality.  Nervous  results,  due  to 
copper  and  zinc,  the  author  has  not  been 
able  to  prove  satisfactory;  those  re- 
ported by  the  English  authorities  as  due 
to  copper  are  open  to  question.  Schloc- 
kow  reports  cases  among  zinc  workers 
with  sclerosis  of  the  anterior  and  lateral 
columns  of  the  cord.  These  the  writer 
has  been  unable  to  verify  among  work- 
ers in  zinc  ore  that  contains  but  a  small 
amount  of  lead  and  arsenic.  Muscular 
and  joint  pains  complained  of  by  metal 
founders  can  be  ascribed  to  the  changes 
of  temperature  to  which  they  are  sub- 
jected. Heat  prostrations  occur  in  hot 
weather.  Alcohol  must  be  borne  in 
mind  when  the  bad  effects  of  metallic 
working  are  looked  for.  M.  H.  Sicard 
(Medical  Record,  August  5,  1905). 

CORYZA     IN     NURSLINGS,     TREATMENT 
OF. 

Acute  coryza  of  nurslings  is  not  by 
any  means  a  harmless  affection;  the 
occlusion  of  the  nasal  passages  and  the 
accumulation  of  the  secretion,  by  ob- 
structing nasal  breathing,  have  a  num- 
ber of  sequela?.  Nutrition  is  seriously 
interfered  with,  and  lung  diseases  are 
predisposed  to.  The  method  of  treat- 
ment used  by  the  writer  is  as  follows: 
Adrenalin  preparations  are  used  in  pref- 
erence to  cocaine,  because  of  the  slighter 
toxicity.  Small  cotton  tampons  are 
saturated  with  adrenalin  solution,  1  to 
1000,  and  introduced  into  the  nasal  ori- 
fices alternately  ancT  kept  there  for  two 
to   three    minutes;    the   mucous    mem- 


DIABETES  MELLITUS,  IMPROVEMENT  IN  TREATMENT  OF. 


453 


branes  become  anaemic  and  the  swelling- 
decreases.  This  has  to  be  repeated  three 
io  four  times  daily,  as  the  adrenalin 
action  persists  only  about  four  hours. 
A  cure  is  usually  produced  in  a  few 
days.  The  fluid  secretion  diminishes  . 
quickly,  and  the  crust  formation  must 
be  treated  with  white  vaselin.  In  weak 
infants,  in  whom  the  acute  infection 
often  passes  into  a  persistent  rhinitis, 
characterized  by  bloody  muco-purulent 
secretion,  in  addition  to  the  adrenalin. 
y<2,  to  1  per  cent,  solution  of  silver  ni- 
trate is  employed,  permitting  one  drop 
to  enter  each  nasal  orifice  daily.  The 
treatment  must  be  continued  beyond 
the  time  necessary  to  produce  a  cure. 
Of  75  children  with  coryza,  48  were 
treated  according  to  this  description;  G 
developed  bronchitis,  1  very  weak  in- 
fant died  of  broncho-pneumonia;  of 
the  other  27,  12  developed  bronchitis,  1 
died  of  pneumonia.  The  nutrition  of 
the  latter  group  suffered  much  more 
than  that  of  the  former.  Syphilitic 
coryza  was  also  favorably  influenced, 
and  there  have  been  no  more  deaths 
from  lung  complications  in  this  disease 
since  this  treatment  has  been  applied. 
L.  Ballin  (Therapie  der  Gegenwart,  Bd. 
vii.  Nu.  2,  1905;  American  Journal 
Medical    Sciences,   September,   1905). 

DIABETES  MELLITUS,   IMPROVEMENT  IN 
TREATMENT   OF. 

The  improvement  in  the  treatment  of 
diabetes  in  the  last  ten  years  is  un- 
doubted, and  is  in  great  measure  due 
to  the  substitution  of  facts  for  guess- 
work in  diagnosis.  One  of  the  greatest 
advances  is  that  in  quantitali\e  analysis 
of  the  urine.  Of  almost  equal  impor- 
tance is  the  examination  of  the  tweniv- 
four-hour  quantity  of  urine  instead  of 
a  single  specimen.  The  knowledge  of 
the  amount  of  carbohydrates  in  the  diet 
4 


of  diabetic  patients  was  practically  un- 
known ten  years  ago.  At  that  time  the 
only  attempt  to  determine  the  amount 
of  carbohydrates  in  the  diet  of  these  pa- 
tients was  directed  to  the  exposure  of 
the  starch  in  gluten  flour.  The  author 
states  that  it  is  a  great  gain  to  medicine 
that  to-day  it  is  known  that  bread  and 
cereals  contain  GO  per  cent,  carbohy- 
drates; potatoes  and  bananas,  20  per 
cent.;  grape  fruit  and  oranges,  from 
4.5  to  10  per  cent.,  and  milk,  from  3 
to  5  per  cent.  The  physician  by  the 
more  accurate  knowledge  of  the  severity 
of  the  disease,  becomes  less  easily  dis- 
couraged in  its  treatment.  One  cannot 
expect  to  arrest  the  case  of  diabetes  in 
which  the  tolerance  is  less  than  nil  any 
more  than  one  can  arrest  a  tuberculous 
process  which  has  reached  the  cavity 
stage.  The  urine  must  be  rendered  free 
from  sugar,  and  to  do  this  especial  at- 
tention must  be  paid  to  the  diet.  This 
may  be  obtained  by  the  withdrawal  of 
the  carbohydrates.  It  may  be  necessary 
also  to  limit  the  quantity  of  albumin 
ingested.  If  this  does  not  suffice,  the 
patient  must  be  put  on  a  strict  vege- 
table day,  and  occasionally  a  starvation 
day  will  be  necessary.  When  once  the 
urine  has  been  freed  from  sugar  the  pa- 
tient should  be  kept  on  the  same  diet 
by  which  this  has  been  attained  for  sev- 
eral days;  then  cream  may  be  added  to 
the  diet,  and  later,  milk.  The  writer 
says  that  a  diabetic  diet  is  really  a  diet 
in  which  the  carbohydrates  are  replaced 
by  fat.  It  is  necessary  for  the  diabetic 
individual  to  eal  from  two  to  five  times 
as  much  Ea1  as  usual.  Comparatively 
Little  of  this  fat  can  be  taken  as  meat, 
and  this  aeces8itates  the  use  of  much 
cream,  butter,  ami  oil.  The  diabetic's 
chance  for  life  depends  on  his  ability  to 
eat  fat,  and  consequently  great  care  must 
be  exercised  not  to  prejudice  him  against 


454     DIABETES  MELLITUS,  MANIFESTATIONS. 


DIAGNOSIS,  ERRORS  IN. 


its  digestibility.  It  is  well  to  remember 
that  fat  is  very  well  digested,  as  a  rule, 
if  taken  in  the  form  of  milk-fat  or  oil. 
Not  over  5  per  cent,  remains  unassimi- 
lated,  and  this  rule  holds  good  for  dia- 
betics except  in  one  of  those  most  rare 
cases  of  marked  pancreatic  disease. 
Drugs  do  not  permanently  increase  the 
tolerance  for  carbohydrates.  Circum- 
stances may  arise  in  the  course  of  dia- 
betes just  as  in  any  chronic  disorder 
when  they  are  indicated,  but  there  are 
as  yet  no  specific  remedies.  The  treat- 
ment of  coma,  the  author  states,  is 
chiefly  preventive.  E.  P.  Joslin  (Bos- 
ton Medical  and  Surgical  Journal,  July 
6,  1905). 

DIABETES  MELLITUS,  ORAL  MANIFESTA- 
TIONS   OF. 

Diabetes  mellitus  is  included  by  the 
author  as  one  of  the  diseases  producing 
a  distinct  form  of  pyorrhoea  alveolaris. 
which,  according  to  some  physicians,  is 
classed  as  a  prodromal  sign  of  the  pri- 
mary disease.  Not  any  one  organism  is 
recognized  by  the  writer  as  the  cause  of 
the  pyorrhoea,  but  he  considers  that  its 
general  depressant  effect  on  nutrition  is 
sufficient  to  make  way  for  the  infection. 
While  sugar  has  not  been  found  in  the 
saliva,  the  acid  action  that  is  produced 
is  followed  by  an  increased  sensitiveness 
about  the  necks  of  the  teeth.  The  cir- 
cular ligament  becomes  swollen  and  re- 
laxed, thus  affording  a  ready  gateway 
for  the  micro-organisms.  Pus  pockets 
and  necrosis  naturally  follow,  and,  ac- 
cording to  Arkoevy,  a  distinct  separa- 
tion of  the  two  upper  centrals  occurs. 
The  upper  arch  becomes  weakened  in 
consequence,  and  more  or  less  prog- 
nathism occurs.  The  rapid  formation 
of  soft,  light-colored  tartar  is  another 
diagnostic  symptom.  As  far  as  local 
therapeutics     is     possible,     the     usual 


routine  treatment  should  be  followed, 
but  little  can  be  expected  during  the 
continuance  of  the  primary  disease. 
Hermann  Prinz  (Journal  of  the  Amer- 
ican Medical  Association,  August  12, 
1905). 

DIAGNOSIS,   ERRORS   IN. 

In  discussing  errors  of  diagnosis,  the 
writer  considers  first  those  arising  from 
the  mistakes  in  the  interpretation  of 
symptoms.  Fatal  cases  of  angina  pec- 
toris associated  with  extensive  fatty  de- 
generation of  the  heart  are  often  over- 
looked and  the  pain  attributed  to  myal- 
gia. The  occurrence  of.  vomiting  is 
often  of  great  importance ;  cases  of  cere- 
bral haemorrhage  ushered  in  by  vomit- 
ing are  often  looked  on  as  mere  dys- 
pepsia. A  symptom  that  is  often  over- 
looked is  the  occurrence  of  retention  of 
urine  or  local  or  general  peritonitis 
which  is  running  a  latent  course.  A  far 
more  important  cause  of  error  in  diag- 
nosis is  the  very  frequent  presence  of 
serious  organic  disease  without  the  oc- 
currence of  symptoms  of  sufficient  in- 
tensity to  attract  notice.  General  sup- 
purative peritonitis,  dependent  even  on 
perforation,  may  be  present  without  the 
cardinal  symptoms — pain  and  vomiting. 
Cerebral  tumor,  abscess  of  the  brain, 
and  cerebral  aneurism  may  all  reach  a 
high  degree  of  development  without  the 
presence  of  any  noticeable  symptoms. 
Pleural  effusion  is  especially  apt  to  run 
a  latent  course — one  whole  side  of  the 
chest  may  be  full  without  symptoms. 
Gastric  ulcer,  cirrhosis  of  the  liver,  tu- 
berculous peritonitis,  and  renal  disease 
are  also  instances  of  serious  organic  dis- 
ease liable  to  run  a  symptomless  course. 
The  most  important  source  of  error 
with  regard  to  the  interpretation  of 
symptoms  arises  from  the  attribution  of 
acute  symptoms  to  the  onset  of  acute 


DIGESTION  IN  THE  INSANE. 


455 


diseases,  whereas  in  a  very  large  number 
of  instances  acute  symptoms  arise  in  the 
course  of  chronic  disease.  For  instance, 
sudden  acute  intestinal  obstruction  oc- 
curring in  those  apparently  healthy,  is 
sometimes  dependent  on  obstruction 
produced  by  chronic  tuberculous  perito- 
nitis. Sudden  paraplegia,  simulating  an 
acute  transverse  myelitis,  may  occur  in 
such  chronic  and  progressive  diseases  as 
malignant  disease  of  the  spine  or  an- 
eurism. Mistakes  in  diagnosis  arise  not 
only  from  want  of  examination,  but 
also  from  the  want  of  repeated  examina- 
tion. This  latter  is  necessary  because 
in  organic  disease  the  signs  are  some- 
times transitory,  or  at  any  rate,  not  per- 
sistent. The  physical  signs  of  dissemi- 
nated sclerosis — the  ankle  clonus,  the 
diplopia,  and  even  the  hemiplegia  are 
often  variable  and  transient  in  their 
occurrence. 

The  erroneous  interpretation  of  phys- 
ical signs  is  another  very  common 
source  of  error;  this  applies  especially 
to  the  chest.  Mimicry  of  organic  by 
functional  disease  often  leads  to  mis- 
takes, as  in  functional  and  hysterical 
palsies  on  the  one  hand,  and  in  dissemi- 
nated sclerosis  on  the  other.  In  an- 
other group  of  cases  inflammatory  mis- 
chief  in  the  chest  simulates  acute  ab- 
dominal affections,  such  as  peritonitis. 
Another  potent  cause  of  error  in  diag- 
nosis arises  from  the  fact  that  many 
common  diseases  are  apt  to  exist  in 
anomalous  form.  Some  errors  are  de- 
pendent on  treatment;  the  too  ready 
ai  I  ministration  of  morphine  often  hides 
the  signs  of  abdominal  disease;  menin- 
gitis may  be  erroneously  diagnosticated 
in  phthisis  where  the  trouble  is  due  to 
atropine  given  to  relieve  cough.  Alco- 
hol may  be  pushed  to  such  an  extent  as 
to  produce  coma,  which  may  be  re- 
garded as  dependent  on  the  underlying 


disease.     J.  K.  Bradford   (British  Med- 
ical Journal,  June  10,  1905). 

DIGESTION  IN  THE  INSANE. 

In  states  of  mental  depression  (mel- 
ancholia) hyperacidity  is  the  rule,  occur- 
ring in  71.4  per  cent,  of  von  Noorden's 
14  cases,  81.8  per  cent,  of  the  author's 
22  cases,  or  in  77.7  per  cent,  of  all  cases 
(36  in  number).  Males  and  females 
are  equally  affected.  This  hyperacidity 
is  due  to  a  true  hyperchlorhydria.  Hy- 
per-total acidity  also  occurred  in  the 
present  series  of  cases,  and  in  this  re- 
spect they  correspond  exactly  with  those 
reported  by  von  Noorden.  The  hyper- 
chlorhydria is  of  moderate  degree,  is 
fairly  constant,  and  is  associated  with 
increased  peptic  power  and  rapid  evacu- 
ation. The  increased  secretion  is  due 
to  the  neurosis  or  psychosis  and  not  to 
proliferative  changes  in  the  glands,  as 
is  evidenced  by  the  presence  of  increased 
secretion  associated  with  degenerative 
changes  in  the  glandular  elements,  and 
of  the  entire  mucosa. 

The  evacuation  of  the  stomach  is  usu- 
ally normal  or  somewhat  hastened  after 
the  Ewald  test  breakfast,  while  after  the 
large  stimulus  of  the  Biegel  meal  and 
ordinary  asylum  meal,  it  is  more  fre- 
quently hastened.  In  the  cases  showing 
hyperchlorhydria  the  peptic  value  is 
never  below  normal  and  is  frequently 
increased. 

Many  of  the  insane  suffer  from  vari- 
ous forms  of  gastro-intestinai  disease. 
These  conditions  are  very  frequently 
overlooked,  probably  because  complaints 
and  delusions  of  the  digestive  tract  are 
so  common  in  these  patients.  Personal 
experience  and  the  results  of  this  inves- 
tigation prompt  the  authors  to  urge  the 
absolute  necessity  for  systematic  routine 
examinations  of  all  the  secretions  and 
functions  of  the  body,  including  what 


456        DIPHTHERIA. 


DISLOCATIONS  OF  SHOULDER-JOINT,  REDUCTION. 


is  often  a  very  difficult  task,  the  ex- 
amination of  the  stomach  contents.  The 
signs  of  disease  in  the  insane  are  almost 
wholly  objective,  and  here,  more  than 
in  normal  mental  states,  it  is  essential 
that  every  modern  method  of  value 
should  be  exhausted  in  order  to  arrive 
at  a  complete  diagnosis  of  the  case. 
Cancer  and  ulcer  of  the  stomach  may 
thus  often  be  recognized  in  its  incip- 
iency.  Chronic  gastritis  in  its  several 
forms,  as  well  as  the  painful  neuroses, 
will  also  often  be  encountered.  If 
proper  treatment  be  instituted,  it  is  not 
at  all  improbable  that  the  mental  symp- 
toms in  these  cases  will  proportionately 
decrease.  D.  M.  Cowie  and  F.  A.  Inch 
(American  Journal  of  Medical  Sciences, 
September,  1905). 

DIPHTHERIA. 

The  authors  have  reached  the  follow- 
ing conclusions  in  regard  to  the  prophy- 
laxis of  diphtheria:  Every  individual 
who  is  attacked  with  diphtheria  should 
be  isolated,  as  well  as  every  individual 
who  may  be  suffering  with  any  disease 
which  has  for  its  cause  the  bacillus  of 
Loffier.  Every  convalescent  should  be 
isolated  who  shows  diphtheritic  phe- 
nomena, and  in  whom  the  specific  ba- 
cillus is  found  in  consecutive  bacterio- 
logical examinations,  made  at  an  inter- 
val of  at  least  eight  days.  If  this  bacil- 
lus still  persists  after  forty  days  of  con- 
valescence, the  patient  may  be  allowed 
to  go  out,  but  the  physician  in  charge 
must  be  instructed  to  keep  a  watchful 
eye  upon  the  surroundings.  There 
should  be  collective  isolation  of  all  con- 
taminated localities  with  daily  medical 
attendance,  when  it  is  possible,  for  fif- 
teen days  after  the  appearance  of  the 
last  pathological  phenomenon  which  can 
be  attributed  to  the  Loftier  bacillus. 
The   antidiphtheritic    serum    should    be 


injected  as  a  preventive  measure,  in 
those  who  are  in  suspicious  surround- 
ings, whenever  there  are  pronounced 
evidences  of  infection  in  the  commu- 
nity, provided  the  number  of  those  who 
may  possibly  be  infected  does  not  ren- 
der such  a  measure  impracticable.  All 
objects  and  localities  which  could  pos- 
sibly be  infected  by  a  person  attacked 
with  diphtheria,  within  a  radius  of  a 
meter  of  the  individual,  should  be  dis- 
infected. Eoussel  and  Job  (Revue  de 
Medecine,  July,  1905;  New  York  Med- 
ical Journal  and  Philadelphia  Medical 
Journal,  August  12?  1905). 

DISLOCATIONS  OF  THE  SHOULDER-JOINT, 
REDUCTION   OF. 

The  following  method  is  recom- 
mended by  the  author,  which  he  states 
has  been  successful  in  one  case  in  which 
Kocher's  method  has  been  tried  twice 
without  success.  If  the  dislocation  is  of 
the  right  shoulder  the  surgeon  places 
himself  on  the  right  side  of  the  patient, 
flexes  the  patient's  forearm  on  the  arm, 
so  as  to  form  a  right  angle,  gently,  with 
an  abducting  movement,  lifts  the  arm 
into  a  vertical  position  until  the  elbow 
is  over  the  shoulder,  the  forearm  hori- 
zontal, the  hand  above  the  head,  and 
maintains  it  in  this  position  by  holding 
the  wrist  with  the  right  hand.  The  sur- 
geon then  places  his  left  forearm  in  the 
bend  of  the  patient's  elbow,  seizes  the 
lower  part  of  his  own  right  arm  with 
his  left  hand  and  then  makes  gentle  trac- 
tion as  if  he  would  lift  the  patient,  whose 
weight  makes  a  counter-extension.  The 
scapula  Jbaseulates,  the  glenoid  cavity  is 
turned  upward  and  forms  the  base  of  a 
cone  formed  by  all  the  muscles  of  the 
arm.  After  waiting  about  half  a  minute, 
without  ceasing  traction,  the  surgeon  ro- 
tates the  arm  back  and  forth  about  its 
axis,  to  liberate  the  head  of  the  humerus. 


ECTOPIC  PREGNANCY. 


ENTEROPTOS1S  AND  PENDULOUS  ABDOMEN 


457 


During  this  manipulation  the  head  of 
the  humerus  is  usually  felt  to  slip  into 
the  glenoid  cavity.  He  then  places  his 
left  knee  in  the  axilla,  seizes  the  arm  at 
the  level  of  the  elbow  without  ceasing  to 
pull  it  upward,  lowers  it  horizontally  in 
abduction,  supports  the  head  of  the  hu- 
merus by  the  fingers  of  the  left  hand 
in  the  axilla  and  carries  the  elbow  close 
to  the  body.  H.  Huguier  (Presse  Me- 
dicate, July  12,  1905;  New  York  Med- 
ical Journal  and  Philadelphia  Medical 
Journal,  August  12,  1905). 

ECTOPIC   PREGNANCY. 

Sterility  does  not  necessarily  precede 
the  development  of  ectopic  pregnancy. 
If  it  does  exist,  its  cause  is  often  the 
same  as  the  cause  of  the  abnormal  preg- 
nancy. 

The  main  characteristic  of  the  bleed- 
ing in  ectopic  gestation  is  its  great  irreg- 
ularity, there  being  no  type.  As  a  gen- 
eral rule  it  is  not  profuse.  It  may  be 
constant  or  intermittent,  and  its  char- 
acter or  profuseness  has  no  relation  to 
the  typo  of  the  lesion.  A  chilly  feeling 
often  accompanies  the  bleeding,  and 
vomiting  and  nausea  may  accompany  the 
first  flow.  The  uterine  flow  has  appa- 
rently no  connection  with  the  death  of 
the  foetus. 

The  pain  in  tubal  pregnancy  is  usu- 
ally localized  over  the  site  of  the  lesion. 
It  lias  no  definite  character;  it  may  be 
cramp-like  over  the  affected  tuhe,  ii 
may  similate  labor  pains,  it  may  be 
sharp  and  sudden,  or  it  may  be  of  a 
bearing-down  nature.  The  pain  dur- 
ing a  tubal  abortion  and  that  concomi- 
tant with  the  presence  of  a  hematosal- 
pinx, is  usually  cramp-like. 

The  usual  symptoms  of  pregnancy 
may  bo  present.  They  are  frequently 
absent,  but  their  absence  does  not  mili- 
tate against  the  possibility  or  probability 


of  an  ectopic  pregnancy.  Tenderness 
on  palpation  of  the  mass  adjacent  to  the 
uterus  is  of  great  diagnostic  value  when 
taken  in  connection  with  the  history  and 
the  other  pelvic  findings.  A  rise  of 
temperature  between  99°  and  100°  F., 
in  the  absence  of  signs  of  infection,  is 
worthy  of  consideration  in  the  diag- 
nosis. 

The  causative  factors  of  tubal  preg- 
nancy are  probably  numerous.  Not  one 
element  but  many  may  bring  about  the 
connection  in  different  instances.  It  is 
likely  that  atavistic  tendencies,  congen- 
ital or  acquired  anomalies,  pelvic  inflam- 
mations, ovarian  and  tubal  disease,  all 
play  a  role  in  individual  cases ;  but  none 
of  these  factors  alone  is  sufficient  to  ex- 
plain all  cases. 

As  yet  there  is  no  definite  data  by 
which  all  the  varieties  of  ectopic  gesta- 
tion can  be  diagnosticaUy  differentiated 
between.  Occasionally  this  may  lie  done, 
but  it  is  impossible  always  to  distin- 
guish between  an  unruptured  tube  and 
a  tubal  mole.  A  hematocele  and  a 
freshly  ruptured  tube  can  almost  always 
be  differentiated  from  the  other  usual 
lesions.  The  value  of  Worth's  dictum, 
to  regard  every  unruptured  tube  in  the 
light  of  a  malignant  neoplasm,  has  not 
diminished  with  the  years.  S.  M. 
Brlckmer  (Medical  News,  August  12, 
1905). 

ENTEROPTOSIS    AND    PENDULOUS    ABDO- 
MEN. 

Three  causes  for  the  displacement  of 
the  abdominal  viscera  are  recognized  by 
I  lie  author:  1.  Relaxation  or  stretch- 
ing of  the  abdominal  wall.  2.  Change 
in  the  form  of  the  cavity.  3.  Stretching 
of  one  or  more  of  the  suspending  liga- 
ments. One  test  of  the  condition  of  the 
abdominal  muscles  is  the  change  of  po- 
sition   of    the    umbilicus    on    couching 


458 


ENTEROPTOSIS  AND  PENDULOUS  ABDOMEN. 


when  standing  and  when  lying  down. 
With  a  moderate  degree  of  pendulous 
abdomen  the  umbilicus  rises  1  centime- 
ter or  more  on  coughing  in  the  standing 
position,  but  not  when  reclining.  This 
is  a  reliable  index  of  the  amount  of  the 
relaxation.  The  upper  half  of  the  rec- 
tus being  relaxed,  the  umbilicus  sinks. 
On  coughing  in  the  upright  position, 
the  upper  half  of  the  muscle  contracts 
and  raises  the  umbilicus.  The  intensity 
of  the  symptoms  does  not  correspond  to 
the  degree  of  ptosis  present.  Very  high 
degrees  may  exist  without  any  symp- 
toms; on  the  other  hand,  slight  down- 
ward displacement  may  entail  striking- 
symptoms.  Often  the  ptosis  is  so  slight 
that  it  is  not  recognized.  This  is  fre- 
quently important,  because  otherwise  in- 
effectual treatment  becomes  successful 
when  the  abdominal  wall  is  supported 
and  strengthened.  In  many  cases  these 
measures  alone  are  sufficient.  To  illus- 
trate his  statements,  the  author  reports 
a  number  of  cases,  emphasizing  the  fact 
that  in  all  disturbances  dependent  on 
enteroptosis  an  important  point  to  bear 
in  mind  is  that  they  appear  pronounced 
in  an  upright  position,  and  on  lying 
down  become  much  diminished  or  van- 
ish entirely.  Often  immediate  relief 
will  be  obtained  by  supporting  the  ab- 
domen below  the  umbilicus  with  the 
hand.  Besides  the  ordinary  symptoms, 
backache,  sideache,  and  dyspepsia  may 
be  noted.  The  backache  may  lie  a  radia- 
tion of  the  epigastric  pain.  It  then 
corresponds  to  the  lower  thoracic  ver- 
tebra?. In  case  of  a  large,  fatty  abdo- 
men it  may  be  due  to  fatigue  of  the 
sacrolumbal  muscle,  since  the  displace- 
ment of  the  center  of  gravity  toward  the 
front  necessitates  correction  by  constant 
backward  bending  of  the  spine.  The 
pain  in  the  side  may  likewise  be  partly 
muscular,  partly  due  to  traction  from 


the  splenic  flexure  of  the  colon.  The 
disturbances  in  breathing  with  pendu- 
lous abdomen  may  be  easily  overlooked, 
because  the  effect  of  pressure  by  the  in- 
trathoracic fat  and  the  upward  pressure 
of  the  diaphragm  by  the  intra-abdom- 
inal fat  attract  more  attention.  Not 
only  is  the  expiratory  power  lessened  by 
loss  of  tone  in  the  abdominal  muscles, 
but  the  bottom  of  the  thorax  is  dragged 
down  with  the  sinking  of  the  viscera, 
and  the  elastic  pressure  exerted  by  the 
bowels  on  the  under  surface  of  the  dia- 
phragm is  still  further  reduced.  The 
pressure  may  even  be  negative,  as  shown 
by  the  occasional  sinking  in  of  the  epi- 
gastrium. The  relations  between  the 
diaphragm  and  the  ribs  are  disturbed 
in  many  ways,  and  this  is  liable  to  in- 
duce disturbances  in  breathing  from 
muscular  fatigue.  Ordinarily,  this 
manifests  itself  by  shortness  of  breath 
on  exertion  or  even  on  standing  up,  less 
frequently,  by  attacks  of  dyspnoea,  dis- 
tress, and  cardiac  oppression.  Some- 
times a  paroxysm  of  weakness  and  dizzi- 
ness accompanies  these  sensations,  and 
disturbances  of  the  vascular  tone  from 
stretching  of  the  splanchnic  nerve  may 
also  play  a  part.  The  conceptions  of 
enteroptosis  and  pendulous '  abdomen 
are  not  exactly  identical,  since  with  nor- 
mal abdominal  Avails  a  single  viscus  may 
sink,  while,  on  the  other  hand,  mechan- 
ical pendulous  abdomen,  without  the 
sinking  of  any  viscus,  may  be  occasioned 
merely  by  deposits  -of  fat.  Most  cases 
of  enteroptosis  are  accompanied  by  a 
more  or  less  pendulous  abdomen,  and 
this  is  important  for  treatment.  The 
insufficient  abdominal  muscles  may  be 
strengthened  and  the  stretched  abdom- 
inal walls  supported  with  a  bandage. 
Thus,  by  pushing  back  the  small  intes- 
tine the  position  ot  the  higher  abdom- 
inal viscera  may  be  indirectly  improved. 


EPILEPSY. 


HEAD  INJURIES. 


459 


The  abdominal  support  should  be  sup- 
plemented by  doing  away  with  every 
constricting  band,  the  support  for  draw- 
ers and  skirts  being  partly  or  entirely 
transferred  to  the  shoulders.  H. 
Quincke  (Therapie  der  Gegenwart,  Bd. 
xlvi,  Nu.  1 ;  Journal  of  the  American 
Medical  Associaion,  July  22,  1905). 

EPILEPSY. 

In  formulating  a  line  of  treatment,  it 
must  be  borne  in  mind  that  in  the 
pathogenesis  of  epilepsy  there  is  auto- 
intoxication, increased  irritability  of  the 
nervous  system,  deficiency  of  vasomotor 
tonus  and  circulatory  capacity,  and, 
lastly,  cerebral  sclerosis,  and  the  plan 
of  treatment  must  consider  in  due  pro- 
portion these  four  factors,  even  though 
it  is  possible  that  the  first  factor  is  the 
foundation  of  the  other  three.  Another 
thing  must  be  emphasized,  and  it  is  that 
treatment  must  be  continued  for  at  least 
five  years.  Many  treatments  have  come 
into  undeserved  disrepute,  simply  be- 
cause patients  have  not  been  kept  under 
observation  for  a  sufficient  length  of 
time.  A  patient  should  not  be  consid- 
ered cured  unless  he  has  been  free  from 
convulsions  for  at  least  five  years. 
Brower  (Boston  Medical  and  Surgical 
Journal,  August  3,   1905). 

GASES   OF   THE   BODY. 

The  writer  states  that  some  of  the 
gases,  like  oxygen,  nitrogen,  and  carbon 
dioxide,  are  essential  to  existence,  but 
others  are  waste  products,  and  appendi- 
citis, intestinal  obstruction,  ovarian  dis- 
ease, and  heart  troubles  may  be  simu- 
lated by  their  presence  in  the  intestinal 
tract.  Nitrogen,  oxygen,  carbon  diox- 
ide, sulphureted  and  carbureted  hydro- 
gen, and  marsh  gas  are  the  principal 
gases  of  the  body.  Carbon  dioxide  is 
the   greatest    in    volume    and    the    most 


widely  diffused.  It  has  usually  been 
designated  as  a  poisonous  gas,  but  mod- 
ern physiologic  chemistry  takes  a  differ- 
ent view  of  it,  and  it  can  be  considered 
poisonous  only  when  it  is  an  obstruction 
of  respiration.  Large  amounts  may  be 
found  in  the  stomach  and  bowels  in 
health,  and  still  more  in  neurotic  con- 
ditions, but  its  coefficient  of  absorption 
is  high  and  but  little  inconvenience  re- 
sults. The  accumulation  of  gas  in  the 
bowels  may  give  rise  to  diagnostic  diffi- 
culties, and  the  author  cites  several  such 
cases.  Lactic,  acetic,  and  butyric  acid 
fermentation,  and  the  decomposition  of 
fats,  proteid  matter,  and  cellulose  are  all 
concerned  in  the  formation  of  intestinal 
gases.  When  loops  of  gut  are  strangu- 
lated, first,  water,  and,  later,  gas  forms 
in  them,  giving  rise  to  meteorism.  Phan- 
tom tumors  are  of  this  order.  Headache, 
vertigo,  and  nausea  are  often  the  result 
of  the  presence  of  sulphureted  hydrogen 
in  the  bowel.  The  formation  of  intes- 
tinal gases  must  be  controlled  by  proper 
management  of  the  diet.  L.  H.  Watson 
(Medical  Eecord,  August  5,  1905). 

HEAD  INJURIES. 

All  cases  of  head  injury,  no  matter 
how  slight,  are  liable  to  be  followed  by 
intracranial  haemorrhage,  as  much  as 
thirty-six  days  having  been  known  to 
elapse  between  the  time  of  injury  and  the 
formation  of  a  clot  large  enough  to  pro- 
duce marked  symptoms  of  compression. 
Any  case  of  severe  concussion  is  liable 
to  be  accompanied  by  laceration  of  brain 
substance  and  cerebral  haemorrhage.  Im- 
mediate surgical  intervention,  if  there 
is  compression,  is  the  only  means  in 
most  instances  of  getting  a  clear  con- 
ception of  the  conditions  present  and 
of  remedying  them.  Since  lesion-  of 
the  central  nervous  system  produce 
death   by   respiratory,    rather   than   car- 


460 


HERNIA  FOLLOWING  ABDOMINAL  SECTION.    HERNIA  OF  PELVIC  FLOOR. 


diac,  paralysis,  an  anaesthetic  is  to  be 
given  cautiously  in  any  case  of  brain 
compression.  Most  cases  of  compres- 
sion can  be  operated  on  after  dissecting 
the  scalp  flap  without  anaesthesia,  since 
the  skull,  dura,  and  brain  are  insensible 
to  pain.  Eigid  asepsis  is  essential  to 
success  and  the  prevention  of  unpleasant 
sequelae  in  the  surgical  treatment  of  any 
case  of  head  injury.  W.  S.  Wiatt  (In- 
ternational Journal  of  Surgery,  Septem- 
ber,  1905). 

HERNIA    FOLLOWING    ABDOMINAL    SEC- 
TION,   THE    PREVENTION    OF. 

The  writer  affirms  that  the  following 
rules  will  give  the  largest  percentage  of 
successes  in  clean  cases:  The  incision 
should  always  be  made  along  the  line 
of  the  muscle,  rather  than  in  the  ten- 
dinous lines,  and  the  muscles  should 
never  be  cut,  but  the  fibers  should  be 
separated  with  the  handle  of  the  knife. 
The  wound  should  be  sutured  in  layers, 
similar  tissues  being  carefully  approxi- 
mated, and  special  attention  being  paid 
to  closure  of  the  aponeurosis,  which  is 
the  source  of  the  greatest  strength  to 
the  abdominal  wall.  The  baemostasis 
should  be  as  perfect  as  possible,  and 
there  should  be  no  dead  spaces  in  the 
wound.  However  careful  one  may  be, 
there  is  no  absolute  asepsis,  and  a  blood 
clot  in  a  dead  space  is  a  favorable  cul- 
ture medium.  Suppuration  in  the 
wound  means  permanent  weakening  of 
the  abdominal  wall.  Payne  (Interna- 
tional Journal  of  Surgery,  August, 
1005). 

HERNIA    OF    THE    PELVIC    FLOOR,    NEW 
OPERATION   FOR. 

After  two  attempts  to  correct  a  com- 
plete hernia  of  the  pelvic  floor,  the 
writer  finally  succeeded  by  performing 
an  operation  which  is  described  as  fol- 


lows: With  the  patient  in  the  Tren- 
delenburg posture,  a  median  incision 
of  good  length  was  made;  approxi- 
mately one-fourth  of  the  entire  abdom- 
inal contents  were  withdrawn  from  the 
hernial  sac,  the  pelvic  floor  steadied, 
and  the  hernia  reduced.  The  bladder 
was  found  well  down  in  this  cavity  and 
totally  prolapsed.  An  antero-posterior 
incision  was  made  across  the  middle  of 
the  floor  of  the  pelvis,  dividing  the  va- 
gina into  two  lateral  halves.  The  vag- 
inal mucous  membrane  of  the  part  to 
be  brought  through  the  abdominal  in- 
cision was  removed.  The  bladder  was 
separated  from  the  vagina  for  some  dis- 
tance downward.  It  was  then  found 
that  the  vagina  and  the  floor  of  the 
pelvis  had  been  so  stretched  that  they 
could  easily  be  brought  out  through  the 
abdominal  wound  beyond  the  surface  of 
the  skin.  After  making  an  incision 
through  the  abdominal  fascia  4  centime- 
ters from  the  median  line  on  each  side, 
the  fibers  of  the  recti  were  separated 
and  the  peritoneum  perforated.  Each 
half  of  the  split  vagina  with  the  at- 
tached utero-sacral  and  utero-pelvic  lig- 
aments and  all  the  other  structures  of 
the  floor  of  the  pelvis,  together  with  the 
round  and  broad  ligaments,  were  drawn 
out  through  these  openings  on  each  side 
of  the  median  incision.  While  the 
parts  were  well  up  in  place  so  that  the 
top  of  the  incised  vagina  presented 
closely  against  the  under  surface  of  the 
peritoneum,  the  latter  was  sutured  in 
this  position  with  plain  catgut.  The 
original  peritoneal  incision,  the  muscle, 
and  the  external  fascia  were  then  closed, 
the  latter'  by  '  continuous  sutures  of 
chromicized  gut,  after  which  the  freed 
ends  of  the  vagina  and  pelvic  floor, 
which  had  been  drawn  up  through  the 
lateral  openings  in*  the  peritoneum, 
recti,   and    fascia,    were   united    in   the 


INFANTILE  INTESTINAL  INFECTION,  TREATMENT  OF. 


461 


middle  line  by  means  of  cbromicized 
gut.  The  skin  was  then  closed.  The 
patient  made  a  good  recovery  from  the 
operation  and  was  discharged  in  three 
and  one-half  weeks.  For  some  time 
after  the  operation  the  patient  felt  a 
sensation  of  dragging  on  the  wound  and 
experienced  some  pain.  This  passed 
away  after  several  months.  She  has 
been  doing  her  usual  work,  and  at  the 
present  time,  more  than  three  years 
after  the  operation,  there  has  been  no 
recurrence  of  the  hernia.  The  author 
states  that  the  indication  for  this  op- 
eration exists  only  in  the  eases  of  com- 
plete hernia  (procidentia) .  In  the 
minor  degrees  of  prolapse  it  would  be 
quite  impossible  to  carry  out  this  tech- 
nique for  want  of  sufficient  length  of 
ligaments  and  of  vagina  to  reach  to  the 
external  fascia.  G.  W.  Crile  (Cleveland 
Medical  Journal,  July,  1905). 

INFANTILE       INTESTINAL       INFECTION, 
TREATMENT    OF. 

The  writer  describes  in  detail  a  num- 
ber of  cases  of  a  certain  variety  of  in- 
testinal infection  in  infants  for  which 
he  seems  to  have  evolved  a  successful 
method  of  treatment.  The  microscope 
revealed  the  constant  presence  in  the 
stools  of  a  strictly  anaerobic  bacterium,  a 
mixed  proteolytic  ferment,  the  bacillus 
perfringens,  which  has  a  powerful  fer- 
mentative action.  None  of  the  other 
bacteria  isolated  from  the  stools  had  a 
mixed  proteolytic  action;  they  were  all 
peptolytic  ferments.  He  endeavored  to 
arrest  the  proliferation  of  this  bacillus 
perfringens  in  the  intestine  by  utilizing 
the  antagonistic  action  of  other  bac- 
teria. Mixed  ferments,  by  producing 
acids,  check  the  simple  ferments,  and 
the  mixed  ferments  arrest  their  own 
proliferation  when  the  acid  production 
reaches  a  certain   height.     The   author 


cites  as  an  instance  that  the  putrefaction 
»>f  meat  can  be  arrested  and  all  micro- 
bian  action  paralyzed  by  adding  a  small 
amount  of  glucose  to  the  medium.    Con- 
sequently, he  reasoned  that  the  digestive 
disturbances  caused  by  the  proliferation 
of   this  proteolytic  bacterium   could   be 
arrested  without  injury  to  the   mucosa 
by  favoring  the  cultivation  of  the  pow- 
erful  mixed   ferments,   substituting  for 
the   harmful   microbian    vegetation    an- 
other, more  innocent  one.     This  can  be 
done  by  modifying  the  chemical  consti- 
tution of  the  medium  and  by  inducing 
the    reappearance    of    the    normal    bac- 
terial flora.     The  chemical  composition 
of  the  medium  can  be  modified  by  hav- 
ing nothing  pass  into  the  intestines  but 
carbohydrates,   with  the  smallest  possi- 
ble   proportion    of    proteid    substances. 
Sugars,      starches,      and     fats     should 
abound,    and    the    albuminoids    should 
be  entirely  suppressed  or  substituted  by 
merely  enough  proteids  to  sustain  life. 
The   simplest   way   to    insure   that   the 
flora  consists  exclusively  of  mixed  pro- 
teolytic ferments  is  to  have  the  patient 
ingest    pure   cultures   of   these    species, 
merely  refraining  from  giving  one  that 
induces    the    formation    of    gas,    indol, 
phenol,  or  an  irritating  acid.     The  one 
to  be  preferred  must  grow  in  a  medium 
without     oxygen,     and     must    generate 
more   acid    than   the   harmful    variety. 
Among  the  species   which   fulfill   these 
conditions  the   bacillus  bifidus  and   the 
bacillus   acidiparalactici   take   the   lead. 
The  latter  was  selected  for  the  purpose, 
as  it  is  an  anaerobe  very  easy  of  culti- 
vaion.      It    proliferates    readily    in    the 
human  intestine,  and   favors  the  reap- 
pearance of  the  bacillus  bifidus.     This 
method  of  treatment  consequently  aims 
to  transform  the  flora  of  the  intestine 
and  abandons  (lie  vain  attempl   to  real- 
ize  antisepsis    in    the    intestines.      The 


462 


INTESTINAL  EXCLUSIONS. 


first  step  is  to  modify  the  food.  If  the 
bottle  is  used,  pure  cows'  milk  is  stopped 
for  a  time,  and  glucose,  saccharose,  lac- 
tose, starch,  or  other  carbohydrates  are 
given  instead.  At  the  end  of  a  few 
days  a  small  amount  of  maternalized  or 
jieptonized  milk  is  added  to  the  diet. 
When  the  infant  is  on  a  mixed  diet, 
cows'  milk  is  suppressed  and  its  place 
filled  by  carbohydrates.  When  the 
child  is  exclusively  breast  fed,  the 
mother  must  aim  to  modify  her  milk 
by  living  on  vegetables  and  by  increas- 
ing the  amounts  of  fats  and  sugars 
taken.  Before  each  meal  the  child 
should  be  given  a  tablespoonful  of  a 
10  per  cent,  solution  of  lactose.  By 
these  means  the  chemical  composition 
of  the  medium  is  modified.  The  second 
indication  is  met  by  giving  the  infant 
one  or  two  teaspoonfuls  a  day  of  a 
pure  culture  of  bacillus  acidiparalactici, 
which  has  been  kept  in  the  incubator  for 
five  or  six  days  at  a  temperature  of  37° 
C.  (98.5°  F.).  Gradually  all  the  symp- 
toms subside,  and  the  reappearance  of 
the  normal  intestinal  flora  indicates  the 
complete  cure. 

This  variety  of  intestinal  infection 
can  be  differentiated  by  its  protracted 
course  of  one  or  two  months,  by  the 
appearance  of  the  stools  which  are  a 
greenish-yellow  fluid,  holding  fine  gray- 
ish-green lumps  in  suspension,  and 
foamy  from  the  gas  emitted  with  them. 
The  stools  turn  olive-green  on  exposure 
to  the  air.  The  children  act  sick,  lose 
appetite,  and  the  usual  measures,  cal- 
omel, etc.,  have  no  influence  on  the  con- 
dition. The  younger  the  child  the 
Beverer  the  symptoms,  as  a  rule.  Bac- 
teriologic  examination  of  the  stools  en- 
ables an  early  diagnosis.  The  micro- 
Bcope  si iows  that  the  bacillus  bifidus  is 
absent,  while  half  a  dozen  or  more  ab- 
normal   species  can   be   detected.      They 


are  all  of  the  peptolytic  ferment  type, 
except  the  bacillus  perfringens. 

This  treatment  has  been  tried  also  by 
other  physicians,  and  all  confirm  its 
absolute  harmlessness  and  complete  suc- 
cess. Prompt  bacteriologic  differentia- 
tion is  important,  as  inappropriate  treat- 
ment may  prolong  and  aggravate  the 
affection.  A  change  from  breast  milk 
to  cows'  milk  is  liable  to  transform  a 
generally  benign  affection  into  a  fatal 
illness.  In  one  of  the  author's  cases 
the  parents  insisted  on  giving  calomel. 
Immediately  afterward  the  symptoms 
that  had  been  nearly  conquered  reap- 
peared in  their  former  intensity,  and 
the  bacillus  bifidus,  which  had  made  its 
appearance  again  in  the  stools,  vanished 
anew.  The  mother  of  a  healthy  nurs- 
ling gave  the  breast  to  one  of  the  sick 
children,  with  the  result  that  in  a  week 
her  own  child  developed  the  same  symp- 
toms. H.  Tissier  (Annales  de  lTnstitut. 
Pasteur,  vol.  xix,  No.  5;  Journal  of 
the  American  Medical  Association,  July 
22,  1905). 

INTESTINAL    EXCLUSIONS. 

The  writer  presents  the  results  of  a 
series  of  experiments  upon  animals  on 
the  various  methods  of  excluding  por- 
tions of  intestine  from  the  tract,  with 
a  view  of  finding  the  best  means  of 
dealing  with  diseased  intestinal  seg- 
ments. When  the  radical  cure  of  an 
intestinal  tumor  is  out  of  the  question, 
the  patient  should  -not  be'  ruthlessly 
abandoned  to  his  fate,  for  his  life  may 
be  prolonged  and  his  sufferings  relieved 
by  an  operation.  This  may  be  an  arti- 
ficial anus,  or  an  intestinal  anastomosis, 
or  an  -intestinal  exclusion.  The  pallia- 
tive operation  of  artificial  anus  results 
in  a  most  uncomfortable  condition;  for 
in  spite  of  the  many  devices  now  at 
hand,  proper  retention  of  faecal  matter 


INTESTINAL  OBSTRUCTION. 


463 


and  gases  cannot  be  secured.  Anastomo- 
sis alone  does  not  offer  security  against 
the  entrance  of  faeces  into  the  diseased 
portion  of  gut.  Intestinal  exclusion, 
however,  overcomes  the  disadvantages  of 
both  these  methods.  Closed  exclusion  is 
to  be  rejected  in  favor  of  the  open 
method,  according  to  almost  universal 
agreement  among  modern  surgeons. 
Open  excision  with  a  fistula  in  the  ab- 
dominal wall  does  not  offer  any  danger 
and  presents  but  few  inconveniences. 
Still  better  is  a  method  worked  out  by 
the  writer  in  two  of  his  experiments :  It 
consists  of  the  exclusion  of  a  loop  of 
intestine  by  the  open  method  and  the 
implantation  of  the  excluded  gut  into 
a  portion  of  normal  gut.  After  median 
laparotomy,  a  loop  of  small  intestine 
is  isolated  by  circular  cuts  8  centime- 
ters apart;  the  terminal  openings  are 
united  by  anastomosis  with  double  rows 
of  sutures.  The  upper  end  of  the  iso- 
lated gut  is  now  closed  and  a  longitu- 
dinal incision  about  5  centimeters  in 
length  is  made  in  the  efferent  gut,  un- 
derneath the  anastomosis.  Into  this  the 
isolated  gut  is  implanted  by  the  lateral 
method  with  its  lower  end.  In  this 
manner  the  secretion  of  the  isolated  <rat 
is  poured  into  the  efferent  intestine  be- 
low the  anastomosis.  The  author  re- 
gards this  method  of  intestinal  exclu- 
sion as  superior  to  all  other  palliative 
operations  on  the  intestine.  Pasquale 
Longo  (Eiforma  Medica,  July  22,  1905 ; 
New  York  Medical  Journal  and  Phila- 
delphia Medical  Journal,  September  9 
1905). 

INTESTINAL    OBSTRUCTION. 

The  symptoms  and  signs  of  ob- 
struction should  enable  the  physician  io 
diagnosticate  the  condition  even  before 
fjecal  vomiting,  but  positively  when  this 
occurs.     These  signs  and  symptoms  are 


vomiting,  abdominal  pain,  localized  ten- 
derness, in  some  cases  tumefaction;  dis- 
tention, which  occurs  in  ascending  di- 
rection, following  coils  of  intestine; 
sharp  line  of  demarcation  between 
tympanitic  and  dull  areas;  rectal  tenes- 
mus and  mucous  or  bloody  stools  in  iu- 
tussusception ;  absence  of  rigidity  of 
right  rectus  muscle;  inability  to  secure 
movement  of  bowels;  all  symptoms  ag- 
gravated by  cathartics  or  enemata — in 
fact,  by  anything  which  increases  or  ex- 
cites peristalsis.  In  very  thin  abdom- 
inal walls  the  peristaltic  movement  may 
be  followed  to  the  point  of  obstruction. 

The  diagnosis  of  obstruction  being 
made,  operation  should  be  performed  at 
once.  Intussusception  operation  is  safer 
than  is  any  attempt  to  reduce  by  injec- 
tion of  fluid  or  air,  hence  no  attempt  at 
either  should  be  made.  In  obstruction 
due  to  adhesions,  every  precaution  must 
be  taken  to  avoid  overlooking  some  point 
of  adhesion  distant  from  the  apparent 
main  point.  jSTo  operation  can  be  con- 
sidered complete  which  leaves  the  in- 
testines distended,  hence  in  volvulus  of 
sigmoid  or  in  any  other  form  in  which 
there  may  be  found  serious  difficulty  of 
maintaining  the  correction  of  the  ob- 
struction, it  may  be  wise  to  perform  a 
colostomy  or  an  enterostomy. 

In  cases  in  which  the  patient  is  in 
a  state  of  collapse  when  operation  is  un- 
dertaken, it  may  be  a  life-saving  meas- 
ure to  perform  a  colostomy  or  an  enter- 
ostomy at  once,  and  later,  when  patient 
shall  have  recovered  sufficiently,  the  ab- 
domen may  be  reopened,  the  cause  of 
obstruction  removed,  and  the  artificial 
anus  closed.  Operation  for  relief  of 
intestinal  obstruction  performed  early 
is  of  small  mortality;  performed  late 
it  has  a  very  high  mortality,  hence  the 
rule  should  be  to  operate  early.  The 
smallest      possible     incision     should     be 


464  INVAGINATION,  ACUTE,  IN  INFANTS;  MEDICAL  TREATMENT  OF. 


used,  for  the  reason  that  the  distended 
bowel  will  cause  less  trouble,  the  shock 
will  be  less,  the  dangers  of  intestinal 
paralysis  will  be  reduced,  and  the  time 
of  operation  minimized.  However,  no 
cramping  by  too  small  an  incision 
should  be  entertained.  Cathartics  and 
enemas  should  not  be  used  in  any  case 
after  diagnosis  of  obstruction  is  clear 
or  even  probable. 

In  obstruction  from  a  Meckel's  diver- 
ticulum it  should  be  remembered  that 
the  precaution  to  use  ligature  before 
division  is  necessary  unless,  as  is  some- 
times the  case,  it  presents  as  a  simple 
fibrous  cord.  Even  then  it  is  safer  to 
use  both  the  distal  and  proximal  liga- 
ture. 

In  young  children  a  small  incision 
will  give  free  access  to  much  greater 
area  than  the  same  length  of  incision 
in  older  persons.  Hence  a  much  greater 
amount  of  work  can  be  done  in  a  child's 
abdomen  through  a  two  or  three-inch 
incision  than  is  possible  in  the  adult. 

The  question  of  enterostomy  or  colos- 
tomy in  acute  intestinal  obstruction  can 
only  be  decided  upon  the  individual 
case.  The  first  object  in  operation 
should  be  in  this,  as  in  all  other  acute 
conditions,  to  save  life.  If  the  patient 
be  in  profound  collapse  or  profound  in- 
testinal intoxication,  the  first  duty  of 
the  surgeon  is  to  relieve  the  obstruction 
in  the  quickest  manner  possible.  Here 
colostomy  or  enterostomy  unquestion- 
ably are  the  safest  life-saving  measures. 
The  patient  will  not  survive  a  prolonged 
or  careful  search  for  the  cause  of  ob- 
struction. 

Between  colostomy  and  enterostomy 
there  must  be  a  choice,  based  only  upon 
the  location  of  the  obstruction.  Ob- 
viously, an  obstruction  due  to  an  ileo- 
colic intussusception  or  an  ileo-colic 
volvulus   will   not  be   relieved   by  a  left 


lumbar  or  inguinal  colostomy;  in  truth 
a  colostomy  will  not  relieve  at  all.  Re- 
lief can  only  be  obtained  by  such  meas- 
ures as  will  give  vent  to  the  intestinal 
contents,  and  here  an  enterostomy  is 
the  only  thing.  On  the  other  hand,  an 
obstruction  in  the  sigmoid  will  be  com- 
pletely relieved  by  a  left  lumbar  colos- 
tomy. If  the  obstruction  be  due  to 
cancer,  this  is  the  best  possible  service 
that  can  be  rendered.  F.  F.  Lawrence 
(Cincinnati  Lancet-Clinic,  August  12, 
1905). 

INVAGINATION,     ACUTE,     IN     INFANTS; 
MEDICAL   TREATMENT    OF. 

The  writer  calls  attention  to  two  stages 
according  to  symptoms,  the  first  resem- 
bling gastro-enteritis,  and  the  second  the 
classic  symptoms  of  this  condition.  The 
importance  of  melena  as  a  symptom  of 
this  condition  is  insisted  upon. 

Treatment  should  first  consist  in  the 
use  of  rectal  injections,  given  by  passing 
a  soft  catheter  high  into  the  rectum  and 
allowing  saline  solution  at  the  tempera- 
ture of  the  body  to  pass  slowly  into  the 
bowel.  The  reservoir  should  not  be 
placed  more  than  three  feet  above  the 
patient.  The  solution  should  be  retained 
for  twenty  minutes,  during  which  time 
light  massage  may  be  practiced  over  the 
abdominal  wall.  If  reduction  is  accom- 
plished, opiates  may  be  administered  to 
prevent  recurrences  and  only  a  light  diet 
allowed.  If  reduction,  is  not  effected  at 
the  first  trial,  a  second  attempt  should 
be  made  after  a  short  time.  Great  care 
must  be  exercised  that  the  injection  is 
given  slowly,  as  too  great  pressure  sud- 
denly applied  may  cause  rupture  of  the 
intestinal  walls.  If  reduction  is  impos- 
sible, operation  is  indicated.  The  au- 
thor states  that  if  this  treatment  be  in- 
stil uted  during  the  first  six  hours  of  the 


IODINE,  ANTI-MICROBIC  ACTION. 


LACERATIONS,  CERVIX  UTERI.      465 


attack,  80  per  cent,  of  the  cases  will  re- 
cover. If  given  later,  the  results  are  not 
so  favorable.  Louis  Netter  (Journal  des 
Praticiens,  vol.  xix,  No.  3,  1905 ;  Amer- 
ican Medicine,  July  29,  1905). 

IODINE,    ANTI-MICROBIC    ACTION    OF. 

In  a  solution  of  iodine,  varying  from 
a  0.2  per  cent,  to  a  1  per  cent.,  we  have 
a  germicidal  agent  of  very  marked  po- 
tency. Its  germicidal  power  is  far  su- 
perior to  that  of  bichloride  of  mercury, 
the  acknowledged  leader  of  all  other 
antiseptics.  This  fact  was  shown  by 
experiments  made  with  a  1/100o  solution 
of  bichloride  of  mercury  on  streptococ- 
cus pyogenes,  using  the  same  method 
employed  with  iodine  solution.  It  was 
found  that  an  exposure  of  fifteen  min- 
utes, although  showing  considerable  in- 
hibitory power,  especially  on  the  first 
day,  permitted  a  good  growth  of  strep- 
tococci to  appear.  An  exposure  of 
thirty  minutes  gave  no  growth.  The 
superiority  of  iodine  is  readily  evi- 
denced by  recalling  the  fact  that  a 
comparatively  weak  solution  of  iodine, 
i.e.,  0.2  per  cent.,  gave  death  after  two 
minutes'  exposure.  It  approaches  nearly 
to  the  ideal  antiseptic  in  that  it  is  easily 
prepared  and  is  stable;  it  is  non-toxic 
and  non-irritating  in  strength  effective, 
being  only  one-fourth  as  toxic  as  bichlo- 
ride of  mercury;  it  does  not  coagulate 
albumin  or  form  inert  compounds  with 
tissues;  it  is  effective  in  a  very  brief 
time;  the  stain  it  produces  soon  disap- 
pears; and,  lastly  and  most  important, 
it  possesses  a  remarkable  penetrating 
power.  The  author  states  that  an  0.5 
per  cent,  solution  is  amply  strong 
enough  for  all  practical  usage.  G.  C. 
Kinnaman  (Journal  of  the  American 
Medical  '  Association.  September  2, 
1905). 


IODINE   IN    SURGERY. 

Iodine  is  the  safest  and  most  potent 
of  all  known  antiseptics.  In  proper  dilu- 
tion to  serve  its  purpose  as  an  antiseptic, 
it  does  not  damage  the  tissues;  on  the 
contrary,  it  acts  the  part  of  a  useful  tis- 
sue stimulant,  producing  an  active  phag- 
ocytosis, a  process  so  desirable  in  the 
treatment  of  acute  and  chronic  inflam- 
matory affections.  In  the  treatment  of 
simple  hyperplastic  goiter,  actinomyco- 
sis, and  blastomycosis,  the  local  use  of 
iodine  is  made  more  effective  by  catapho- 
resis.  Nicholas  Senn  (Surgery,  Gynae- 
cology, and  Obstetrics.  July,  1905). 

LACERATIONS    ON    THE    CERVIX    UTERI. 

Many  ills  are  the  result  of  unrepaired 
lacerations  of  the  cervix.  The  fre- 
quency and  extent  of  these  tears  may, 
to  a  certain  extent,  be  lessened  by  allow- 
ing more  time  for  dilatation  in  the  first 
stage  of  labor;  by  a  more  judicious  use 
of  the  forceps  in  time  and  force;  and 
by  the  proper  use  of  podalic  version. 
The  most  frequent  cause  of  subinvolu- 
tion of  the  uterus  and  prolonged  con- 
valescence is  unrepaired  lacerations.  In 
all  probability  many  of  the  frequently 
quoted  morbid  conditions  ascribed  to 
lacerations  are  the  result  of  infection 
of  the  lacerated  surface  rather  than  the 
laceration  itself.  Many  cases  of  severe 
haemorrhage  are  due  to  unrecognized 
cervical  lacerations. 

[mmediate  repair  in  the  hands  of  an 
able  surgeon-obstetrician  is  the  best 
moans  of  controlling  such  haemorrhage, 
and  also  of  preventing  infection  of  the 
torn  surfaces.  Primary  tracheoplasty 
is  easily  and  quickly  done,  but  a  second- 
ary repair  is  a  difficult  and  tedious  pro- 
cedure. In  case  of  failure  in  obtaining 
union  in  the  primary  operation,  the  con- 
dition of  the  woman  is  none  the  worse, 
while  if  successful,  which  is  usually  the 


466 


LEUCOCYTES  IN  MALIGNANT  GROWTHS. 


MIGRAINE. 


case  with  skillful  surgeons,  the  patient 
is  spared  many  of  the  ills  which  lacera- 
tions of  the  cervix  sooner  or  later  en- 
tail. A.  H.  Gardner  (Medical  Kecord, 
August  26,  1905). 

LEUCOCYTES   IN   MALIGNANT    GROWTHS, 
BEHAVIOR   OF. 

An  account  of  observations  relating 
to  the  peculiar  behavior  of  leucoc3rtes  in 
very  early  examples  of  carcinoma  in 
various  parts  of  the  human  body  are 
given  by  the  authors.  The  phenomena 
described  appeared  to  be  mainly,  if  not 
entirely,  restricted  to  cancer  in  its  ear- 
liest stages  and  did  not  occur  in  older 
growths,  in  metastases,  or  in  grafts  in- 
troduced into  other  individuals.  In  a 
rectal  carcinoma  of  the  size  of  a  bean 
it  was  found  that  there  was  a  very  dis- 
tinct zone  of  transition  from  the  nor- 
mal to  the  cancerous  element  round  the 
periphery  of  the  tumor.  Immediately 
within  the  outer  zone  the  leucocytic 
crowding  was  most  strikingly  apparent, 
and  in  a  number  of  cells  it  was  easy  to 
discern  the  presence  of  leucocytes  which 
had  invaded  the  epithelial  cells,  where 
they  stained  readily  as  an  inclusion. 
This  phenomenon  did  not  occur  in  the 
adjacent  healthy  tissue  nor  in  inflam- 
mations produced  artificially.  The 
most  important,  as  well  as  the  most  sin- 
gular, feature  lies  in  the  fact  that 
neither  the  leucocyte  nor  the  invaded 
tissue  cell  appeared  to  be  affected 
injuriously.  In  many  instances  it  was 
found  that  both  the  leucocyte  and  the 
tissue  cell  were  dividing  mitotically  at 
the  same  time.  The  authors  believe 
that  a  mixture  of  the  chromosomes  de- 
rived from  the  leucocyte  and  tissue  cell, 
respectively,  is  distributed  between  the 
daughter  nuclei  resulting  from  the  mi- 
tosis. In  this  way  a  complete  disturb- 
ance of  the  normal  chromosome  constit- 


uents of  the  cell  will  be  effected  and 
the  distribution  must  be  of  a  qualitative 
as  well  as  of  a  quantitative  character. 
What  its  relation  to  the  ultimate  reduc- 
tion that  occurs  in  neoplastic  cells  may 
be  is  a  subject  for  further  investiga- 
tion. J.  B.  Farmer,  J.  E.  S.  Moore, 
and  C.  E.  Walker  (Lancet,  August  8, 
1905). 

LEUKEMIA,    MIXED-CELL. 

Myeloid  leukaemia  is  due  to  a  hyper- 
plasia of  myeloid  tissue;  but  the  un- 
known causative  agent  is  irregular  in 
its  action,  so  that  any  of  the  various 
granular  types  may  predominate  or  a 
mixed-cell  blood  picture  may  result 
from  the  reversion  of  many  of  the  cells 
to  the  condition  of  the  non-granular 
undifferentiated  leucoblast  or  from  the 
hyperplasia  of  such  non-granular  cells 
normally  present  in  the  marrow  in  small 
numbers.  These  undifferentiated  leuco- 
blasts  may  assume  their  embryonic  ac- 
tivity and  secrete  granules. 

In  leukaemia  a  mixed-cell  blood  pic- 
ture may  be  due  to:  (a)  a  reversion  of 
myeloid  cells  to  the  embryonic  non- 
granular type;  and  (b)  a  reaction  or 
mechanical  disturbance  of  myeloid  tis- 
sue owing  to  lymphoid  hyperplasia  with, 
as  a  result,  the  passage  of  myelocytes 
into  the  circulation.  .It  is  to  be  under- 
stood that  it  is  left  quite  an  open  ques- 
tion as  to  whether  or  not  myeloid  and 
lymphoid  tissue  may  be  concomitantly 
affected  in  a  way  similar  to  what  occurs 
in  myeloid  and  lymphoid  leukaemias  re- 
spectively. If  such  occurred  then  we 
should  have  a  mixed  leukaemia  in  the 
strict  sense.  C.  IT.  Browning  (Lancet, 
August  19,  1905). 

MIGRAINE  AND  CANNABIS  INDICA. 

In  migraine  the  treatment  should  he 
directed  to  first,  the  neuroarthritic  con- 


NASAL  CATARRH,  TREATMENT. 


NEPHRITIS,  TREATMENT. 


467 


dition;  second,  the  organic  or  functional 
trouble  present  in  every  case;  and,  third, 
the  causes  which  provoke  the  attacks. 
The  author  meets  the  first  indication  by 
an  appropriate  alimentary  regimen,  to- 
gether with  the  systematic  use  of  can- 
nabis indica  and  hot  douches.  Cannabis 
indica  he  considers  very  valuable  for  the 
relief  of  headache.  He  meets  the  second 
by  correcting  any  fault  which  may  exist 
in  the  general  economy.  The  provoca- 
tive causes  vary  with  each  individual 
subject.  Among  them  may  be  enu- 
merated alimentary  troubles,  errors  of 
diet,  constipation,  etc.,  intoxication,  to- 
bacco poisoning,  uterine  congestion  duo 
to  menstruation,  or  other  causes.  "The 
effect  of  thermal  springs  is  praised. 
Vichy  in  particular  being  spoken  of*  very 
highly.  G.  Canon  de  la  Carriere 
(Presse  Medicale,  July  19,  1905;  New 
York  Medical  Journal  and  Philadelphia 
Medical  Journal,  August  19,  1905). 

NASAL  CATARRH.  TREATMENT  OF 
CHRONIC. 
Tn  treating  the  several  forms  of 
chronic  nasal  catarrh,  it  is  the  author's 
custom  to  have  the  patients  seated  with 
head  erect  and  the  mouth  open.  The 
anterior  nasal  cavity  is  exposed  with  a 
speculum,  the  tip  of  the  nose  elevated, 
and  the  sulphur  freely  and  thoroughly 
blown  in  with  a  strong  powder  blower. 
This  has  been  properly  done  when  the 
powder  appears  from  mouth  and  oppos- 
ite nostril  and  an  irritative  cough  re- 
sults. The  treatment  should  be  repeated 
on  the  other  side  The  posterior  nasal 
space  and  nasopharynx  may  also  be 
treated  directly  by  way  <»f  the  floor  of 
the  nose  or  fauces.  These  procedures 
should  not  be  entrusted  to  the  patient 
unless  he  is  unusually  attentive  to  bis 
own  case.  They  should  be  made  two 
or  three  times  a  week  for  a  month,  and 


once  a  week  for  the  next  two  months. 
The  local  sensations  of  sulphur  are  not 
unpleasant.  Occasionally  in  women  it 
sets  up  a  conjunctival  hyperemia 
when  used  too  profusely  or  when  ac- 
cidentally blown  on  the  face,  and  some 
women  complain  of  nasal  irritation 
and  pain;  then  it  is  best  to  use  the 
treatment  but  once  a  wTeek.  The  cases 
must  be  selected  carefully,  those  in 
which  there  is  no  other  primary  nasal 
disease,  deflection,  deformity,  or  growth 
must  be  treated  surgically.  This 
method  of  treatment  has  proved  of 
value  in  simple,  chronic,  hypertrophic, 
atrophic,  and  phlegmonous  rhinitis,  and 
in  simple  chronic  and  hyperplastic  naso- 
pharyngitis. L.  Koplinski  (Medical 
News,  August  12,  1905). 

NEPHRITIS,    MEDICAL    TREATMENT    OF. 

The  writer  thinks  that  recent  con- 
tributors to  the  therapy  of  Bright's  dis- 
ease, including  von  INToorden  and  his 
school,  confine  their  attention  too 
strictly  to  the  kidneys,  whereas  the 
disease  is  a  widespread  nutritive  dis- 
turbance involving  the  organism  as  a 
whole  with  the  nephritis  as  but  one 
manifestation.  He  urges  the  necessity 
of  careful  examination  of  the  patient 
in  all  respects,  and  the  correction  of 
any  other  functional  perversion  which 
may  be  found  to  exist  in  order  to  elimi- 
nate sources  of  systemic  toxaemia.  In- 
dividualism in  the  management  of  this 
disease  is  absolutely  necessary. 

Tbe  medical  treatment  is  discussed 
under  the  headings  of:  1.  Nephritis 
without  dropsy.  2.  Nephritis  with 
dropsy.  3.  Uraemia.  Cases  of  nephritis 
without  dropsy  are  chiefly  examples  of 
chronic  interstitial  nephritis  during  the 
stage  of  cardiovascular  compensation. 
The  main  indications  in  the  manage- 
ment of  this  type  of  chronic  nephritis 


468 


OSSIFICATION  OF  THE'  LOWER  JAW. 


are  protection  of  the  kidneys  from  irri- 
tation, especially  the  strain  imposed  by 
intercurrent  acute  toxaemias,  and  sec- 
ondly, the  maintenance  of  cardiovascu- 
lar compensation.  The  first  of  these 
two  indications  is  fulfilled  by  regulation 
of  the  patient's  diet  and  personal  hy- 
giene. The  amount  of  water  to  be  drunk 
and  the  hygiene  of  the  bowels  are  of 
particular  importance.  The  manage- 
ment of  the  cardiovascular  compensa- 
tion becomes  essential  in  the  regulation 
of  high  blood-pressure.  The  writer 
warns  against  unwarrantable  interfer- 
ence with  medicinal  measures.  Diet, 
hygiene,  and  free  elimination  of  the 
bowels  accomplish  the  purpose  best.  If 
these  fail,  and  the  patient  suffers  from 
excessive  pulse  tension,  vasodilator 
drugs  may  be  administered.  The  ac- 
tion of  the  various  nitrites,  aconite  and 
iodide,  for  the  reduction  of  blood-pres- 
sure is  discussed. 

In  nephritis  without  oedema,  digi- 
talis and  other  cardiac  stimulants  are  to 
be  withheld,  and  diuretics  are  not  only 
unnecessary  but  harmful.  When"  dropsy 
is  renal  in  origin,  diuretics  have  next 
to  no  influence.  Prolonged  rest  in  the 
recumbent  position,  restriction  of  fluid 
intake,  hypochlorization,  diaphoresis, 
colonic  irrigation,  subcutaneous  punc- 
ture, and  paracentesis  are  to  be  em- 
ployed. If  the  dropsy  is  of  cardiac 
origin,  cardiac  tonics,  rest  and  restric- 
tion of  fluids  are  the  measures  indi- 
cated. The  value  of  iron  in  Bright's 
disease  is  also  discussed-. 

In  the  prophylaxis  of  ursemia  the 
author  lays  great  stress  on  the  employ- 
ment of  purgatives  and  enteroclysis 
with  alkaline  solutions.  The  value  of 
blood-pressure  observations  in  anticipat- 
ing the  advent  of  uraemia  dwelt  on,  and 
the   action   of    venesection    and    lumbar 


puncture  in  relieving  the  high   tension 
of  uraemia  is  described. 

The  writer  deprecates  the  attitude  of 
pessimism  toward  the  prognosis  of 
Bright's  disease  which  is  held  by  so 
many  of  the  profession.  Attention  is 
called  to  Nature's  wonderful  powers  of 
adjustment  in  damaged  organic  states, 
nowhere  so  marvelously  displayed  as  in 
organic  kidney  disease,  showing  that  as- 
sistance only  is  needed,  seldom  interfer- 
ence. The  two  most  important  indica- 
tions in  the  treatment  of  chronic  ne- 
phritis are  to  protect  the  patient  from 
intercurrent  acute  toxaemias  and  to 
maintain  the  compensatory  adjustment 
in  the  circulation.  A."  E.  Elliott  (Med- 
ical News,  September  2,  1905). 

OSSIFICATION   OF   THE   LOWER   JAW. 

The  jaw  in  its  ossification  is  not  so 
complex  as  some  would  have  us  think, 
but  it  is  for  all  that  complex,  involving 
(a)  Meckel's  cartilage  at  its  anterior 
extremity,  (b)  the  membrane  on  the 
outer  side  of  Meckel's  cartilage;  (3) 
at  least  one  accessory  cartilage  which  is 
found  in  the  condyle,  neck,  and  base 
of  the  coronoid  process  of  the  jaw. 
These  statements  apply  to  each  half  of 
the  jaw. 

In  order  of  sequence,  ossification  oc- 
curs first  in  the  membrane  between  the 
mental  nerve  and  the  middle  line,  and 
extends  backward  under  the  mental 
nerve.  Next,  ossification  commences  in 
Meckel's  cartilage  about  the  tenth  week 
of  foetal  life  in  the  region  of  the  mental 
foramen  and  gradually  extends  inward. 
That  part  of  the  jaw  then  between  the 
mental  foramen  and  the  symphysis  is 
compound  in  origin,  being  partly  carti- 
laginous, partly  membranous, '  not  en- 
tirely cartilaginous...  as  Sutten  says. 
Finally,  ossification  takes  place  in  the 
accessory  mass  of  cartilage  in  the  con- 


OTITIS  MEDIA,  TREATMENT. 


PANOPHTHALMITIS. 


469 


dyle  neck  and  root  of  the  coronoid 
process  at  the  third  month. 

There  are  no  separate  centers  in  mem- 
brane for  either  the  coronoid  process  or 
for  the  angle  or  the  so-called  splenial, 
all  these  parts  being  outgrowths,  as  it 
were,  from  the  main  mass.  The  inner 
alveolar  border  is  developed  in  two  parts 
by  ingrowth  from  the  main  mass  and 
at  two  different  periods.  That  part  be- 
hind the  mental  foramen  appearing  first 
and  elongating  from  before  backward; 
that  part  in  front  of  the  foramen  ap- 
pearing later  and  growing  from  behind 
forward.  The  canal  for  the  nerves  is 
completed  by  the  growth  of  spicules 
from  one  alveolar  border  to  the  other 
over  the  top  of  the  nerves,  the  mental 
nerve  being  first  so  covered,  then  the 
incisive,  and  much  later  the  inferior 
dental  near  the  permanent  inferior  den- 
tal foramen. 

The  sockets  for  the  teeth  become"  bony 
comparatively  late,  that  for  the  canine 
appearing  first.  Meckel's  cartilage  be- 
comes incorporated  in  the  jaw  anteriorly 
by  the  development  of  upper  and  lower 
shelves,  which  gradually  close  over  it; 
behind  the  mental  foramen  these  shelves 
do  not  meet,  and  Meckel's  cartilage  is 
consequently  not  included  in  the  jaw, 
but  gradually  atrophies.  The  writer 
does  not  think  that  Meckel's  cartilage 
atrophies  to  form  the  internal  ligament 
of  the  jaw.  This  ligament  at  the  fourth 
month  can  be  seen  quite  distinctly  in 
an  ordinary  dissection  to  be  independent 
of  Meckel's  cartilage.  Edward  Fawcett 
(Journal  of  the  American  Medical  As- 
sociation. September  2,  1905). 

OTITIS   MEDIA.    TREATMENT    OE. 

Cbronic  suppurative  otitis  media  is 
nn  infectious  condition  of  the  cut  in1 
auditory  tract.  Tt  is  impossible  to  dis- 
infect this  tract  in  its  entire  length  sim- 


ply by  means  of  syringing  as  ordinarily 
performed.  No  cure  can  be  expected 
unless  this  tract  can  be  made  surgically 
clean  by  forcing  the  antiseptic  fluids 
through  from  end  to  end  of  the  entire 
tract.  It  is  necessary  to  have  a  large 
opening  in  the  drum  and  a  thoroughly 
dilated  condition  of  the  Eustachian 
tube,  both  for  the  purpose  of  drainage 
and  of  efficient  cleansing.  It  is  also 
important  to  have  a  continuous  current 
of  antiseptic  vapor  passed  through  a 
Eustachian  catheter  into  the  Eustachian 
tube  both  for  cleansing  and  dilating 
purposes.  It  is  necessary  to  treat  the 
parts  sufficiently  often  to  maintain  as 
nearly  as  possible  a  condition  of  anti- 
sepsis. ISTo  treatment  can  be  considered 
thorough  that  does  not  recognize  the  re- 
lation existing  between  pathologic  con- 
ditions in  the  nose  and  nasopharynx  and 
the  ear.  J.  G.  Huizinga  (American 
Medicine,  August  19,  1905). 

PANOPHTHALMITIS,  SYMPATHETIC  IN- 
FLAMMATION FOLLOWING. 

"While  the  occurrence  is  one  of  extreme 
rarity,  eyes  that  present  the  clinical  pic- 
ture of  panophthalmitis  may  excite  sym- 
pathetic inflammation.  Such  eyes,  how- 
ever, usually  present  microscopic  changes 
analogous  to  those  found  in  other  excit- 
ing eyes.  With  few  exceptions,  in  the 
cases  in  literature  of  sympathetic  inflam- 
mation following  phthisis  bulbi.  the  eyes 
were  of  the  class  described  by  Fuchs,  as 
atrophied  eyes.  Usually  it  is,  clinically. 
the  mild  form  of  purulent  uveitis  which 
excites.  It  is  only  after  panophthalmitis 
of  a  virulent  type  that  the  resultant 
shrunken  globe  shou'd  be  considered 
harmless. 

Where,  from  tin1  nature  of  the  infec- 
tion, the  panophthalmitis  has  been  of  a 
low  grade,  or  where,  as  a  result  of  treat- 
ment, the  inflammation  has  not  assumed 


470 


PERITONITIS,  ACUTE:   TREATMENT. 


a  virulent  type,  the  eye  should  be  con- 
sidered a  dangerous  one  and  should  be 
enucleated.  In  some  cases  where  the 
purulent  panophthalmitis  has  been  con- 
sidered the  exciting  cause,  the  original 
injury  or  disease  may  have  been  respon- 
sible. Whether  the  histologic  findings  in 
most  panophthalmitic  eyes  are  to  be  con- 
sidered, the  terminal  stage  of  the  inflam- 
mation or  the  evidence  of  a  mixed  in- 
fection is  still  undecided,  but  the  evi- 
dence points  strongly  to  the  correctness 
of  the  latter  assumption. 

Several  factors  contribute  to  render 
panophthalmitic  eyes  innoxious.  When 
the  globe  perforates,  many  of  the  micro- 
organisms are  extruded  along  with  the 
pus,  those  retained  within  the  globe  be- 
coming inactive  through  the  enormous 
pus  formation.  This  active  pyogenesis, 
by  blocking  the  posterior  lymph  spaces, 
serves  to  prevent  migration  of  the  toxic 
agents.  Finally,  the  panophthalmitis 
may  have  been  excited  by  organisms 
probably  incapable  of  inducing  sympa- 
thetic inflammation,  such  as  staphylo- 
cocci, streptococci,  and  pneumococci. 
William  Zentmayer  (Journal  of  the 
American  Medical  Association,  August 
19,  1905). 

PERITONITIS,    ACUTE:     TREATMENT. 

The  prophylaxis  of  peritonitis  is  the 
portion  of  the  question  which  is  most 
important  to  consider  and  most  fruit- 
ful in  results,  according  to  the  writer. 
If  infection  and  peritonitis  have  not 
been  prevented,  they  should  be  limited 
as  quickly  as  possible  by  an  operation. 
Pain  in  the  abdomen  results  from  irri- 
tation of  the  cerebro-spinal  nerves  in  the 
parietal  serosa  and  subserosa  in  a  chem- 
ical, mechanical,  or  infectious  manner, 
hence  a  peritonitis  may  spread  over  a 
vast  portion  of  the  serosa  and  seriously 


affect  the  wall  of  the  small  intestine 
before  it  causes  local  symptoms. 

The  author  classifies  peritonitis  into 
the  encysted,  or  peritoneal  abscess,  and 
the  free  forms;  the  latter  being  without 
adhesions.  Free  peritonitis  may  spread, 
however,  by  acute  migrating  lymphan- 
gitis in  the  subserosa,  and  by  the  move- 
ments of  the  exudation  in  the  peritoneal 
cavity.  The  malignity  of  a  given  case 
of  peritonitis  depends  (1)  on  the  eti- 
ology and  the  virulence  of  the  infection, 
(2)  on  the  portion  of  the  peritoneal 
cavity  which  is  first  infected,  (3)  on 
the  stage  of  the  disease  when  the  opera- 
tion is  performed. 

The  two  elements  in  peritonitis  which 
are  most  to  be  dreaded,  are  the  passage 
of  microbes  and  toxins  into  the  blood 
circulation,  and  intestinal  paralysis. 
Absorption  is  increased  at  the  begin- 
ning of  peritonitis,  but  it  diminishes  as 
the  exudation,  free  or  encysted,  accu- 
mulates. The  cause  of  intestinal  paral- 
ysis is  the  poisoning  of  the  wall  of  the 
intestine,  and  the  anatomical  changes 
in  the  lymph  spaces  and  in  the  ganglion 
and  nerve  cells  in  .  Auerbach's  plexus. 
The  latter  lies  between  the  peritoneum 
and  the  longitudinal  muscular  layer  of 
the  intestine,  and  if  it  is  destroyed  by 
the  toxins  the  affected  intestines  will 
probably  never  again  be  capable  of 
movement.  Intestinal  paralysis  also  oc- 
curs when  the  inflammatory  process 
causes  engorgement,  oedema,  and  infil- 
tration in  its  muscle.  As  soon  as  the 
free  passage  of  the  contents  of  the  in- 
testine is  obstructed,  microbes  and  tox- 
ins pass  freely  through  the  intestinal 
wall.  Central  and  peripheral  peritonitis 
should  be  distinguished  between,  the 
former  being  the  more  dangerous. 

The  object  of  an  operation  for  acute 
peritonitis  is :  To  remove  liquid  exu- 
dation;   to   remove   the   source   of   the 


PERTUSSIS,  LEUCOCYTOSIS  IN. 

infection  by  extirpation,  resection,  su- 
tures, plastic  operations,  tampons,  or 
drainage;  to  clean  the  infected  portions 
of  the  peritoneal  cavity;  to  empty  and 
drain  the  intestine  when  it  is  paralyzed ; 
to  provide  for  further  discharge  by 
drainage,  or  to  separate,  by  tampon  and 
drainage,  the  portions  of  the  serosa  most 
affected,  from  other  portions  of  the  peri- 
toneal cavity.  The  more  accurate  the 
local  diagnosis,  the  quicker  and  safer 
will  be  the  operation.  Lennander 
(Edinburgh  Medical  Journal,  August, 
1905). 

PERTUSSIS,  LEUCOCYTOSIS  IN. 

A  leucocytosis  is  usually  present  in  all 
stages  of  whooping-cough.  As  a  rule, 
the  number  of  leucocytes  increases  with 
the  increased  frequency  of  paroxysms 
and  becomes  less  as  the  paroxysms  be- 
come less  frequent  and  severe.  The 
mononuclear  leucocytes  are  relatively 
increased  in  all  stages  of  the  disease. 
This  leucocytosis  is  present  in  the  ca- 
tarrhal stage,  most  marked  in  the  active 
stage,  and  gradually  disappears.  In  the 
paroxysmal  stage  the  lymphocytosis  was 
clue  largely,  in  the  cases  reported,  to  the 
large  lymphocytes.  In  the  catarrhal 
stage,  however,  in  the  one  case  reported, 
and  in  Wanstall's  cases,  the  small  mono- 
nuclears were  in  excess.  C.  G.  Grulee 
and  D.  B.  Phemister  (Archives  of  Pedi- 
atrics, August,  1905). 

PULMONARY    TUBERCULOSIS,    EXAMINA- 
TION   OF    THE    BLOOD   IN. 

In  pulmonary  tuberculosis  without 
cavity  formation  a  mild  anaemia,  with 
a  decrease  in  erythrocytes  and  a  rela- 
tively greater  decrease  in  haemoglobin, 
is  constant.  From  the  standpoint  of 
prognosis  an  increase  of  the  erythro- 
cytes, in  cases  without  cavity  formation, 


RACHICOCAINIZATION. 


471 


is  of  favorable  significance.  In  ad- 
vanced cases  a  decrease  of  the  leucocytes 
is  of  unfavorable  import.  In  their  in- 
vestigations, the  authors  have  received 
the  impression  that  the  actual  increase 
of  lymphocytes  seems  to  correspond  to 
the  increase  of  resistance  on  the  part  of 
the  organism  to  the  tuberculous  infec- 
tion, but  further  study '  is  required  to 
confirm  this  deduction.  The  transi- 
tionals  seem  to  follow  the  same  rule  as 
the  lymphocytes  in  this  regard.  At  the 
beginning  of  the  investigation  the  eo- 
sinophiles  seemed  to  increase  with  the 
patient's  improvement,  but  further 
study  did  not  support  this  view.  J.  T. 
Ullom  and  P.  A.  Craig  (American 
Journal  of  Medical  Sciences,  Septem- 
ber,  1905). 

RACHICOCAINIZATION,  NEW  TECHNIQUE 
OF. 

The  writer  describes  his  technique  for 
inducing  spinal  analgesia  with  cocaine. 
Its  use  is  said  to  confer  absolute  immu- 
nity against  after-symptoms,  both  sub- 
jective, as  vomiting,  headache,  and 
backache,  and  objective,  as  elevation  of 
temperature  and  relaxation  of  sphinc- 
ters. Puncture  is  made  in  the  sarcolum- 
bar  space,  because  it  is  more  convenient, 
and  also  because  there  is  less  danger  of 
wounding  the  filaments  of  the  cauda 
equina.  The  principal  point  in  the 
technique  is  the  drawing  off  of  10  cubic 
centimeters  (2.5  drachm)  of  cerebro- 
spinal fluid  before  the  1  to  50  cocaine 
solution  is  injected.  When  the  fluid  is 
under  such  pressure,  it  spurts  from  the 
needle,  it  is  allowed  to  run  until  the 
flow  is  reduced  to  drops,  then  10  cubic 
centimeters  is  measured.  The  rule  may 
be  stated  thus:  Draw  off  10  cubic  centi- 
meters after  the  fluid  escapes  drop  by 
drop,  whether  this  is  from  the  time  of 


472       SALICYLATES  AND  KIDNEYS. 


SPINAL  CORD,  MOTOR  FUNCTION  IN. 


puncture  or  after  a  quantity  has  been 
discharged.  This  technique  has  worked 
well  in  452  cases.  M.  Le  Filliatre 
(Journal  de  Medecine  de  Paris,  July 
16  and  23,  1905). 

SALICYLATES,   ACTION  OF,   ON  KIDNEYS. 

The  writer's  experience  and  research 
have  shown  that  on  administration  of 
salicylic  acid  in  the  ordinary  moderate 
doses,  signs  of  irritation  appear  after  a 
short  time  and  last  as  long  as  it  is  be- 
ing taken.  If  salicylic  treatment  is  sus- 
pended, these  symptoms  disappear  after 
a  time,  but  as  soon  as  the  drug  is  given 
again  the  signs  of  irritation  reappear. 
The  salicylic  nephritis  disappears  quickly 
on  suspension  of  the  salicylic  treatment, 
leaving  no  bad  results,  but  when  the 
salicylic  acid  is  continued  in  small  doses, 
recovery  is  not  complete.  Loeb  and 
Knecht  arrive  at  somewhat  different  con- 
clusions. They  noted  merely  tokens  of 
absolutely  insignificant  irritation  from 
the  salicylates.  Knecht  suggests  that 
this  difference  may  be  due  to  differences 
in  diet  or  to  climatic  causes.  The  ap- 
pearance of  signs  of  irritation  after  use 
of  salicylic  acid  is  observed,  however,  in 
various  localities,  so  that  it  can  be  at- 
tributed only  to  the  drug.  It  does  not 
seem  necessary  to  lose  the  benefits  of 
salicylic  medication  on  account  of  the 
slight  nephritis  noted  after  its  use. 
Large  doses  should  be  given  without 
hesitation  if  the  severity  of  the  case  de- 
mands. All  investigations  show  that 
salicylic  acid  leaves  no  permanent  effects 
on  the  kidneys.  In  acute  cases  indicat- 
ing the  salicylates  they  are  indispensable, 
but  in  chronic  cases  they  are  of  too  little 
value  to  be  continued  very  long.  Quen- 
stedt  (Therapie  der  Gegenwart,  vol.  xlvi, 
No.  3;  Journal  of  the  American  Medical 
Association,  August  5,  1905). 


SCOPOLAMINE-MORPHINE  AS  AN  ADJU- 
VANT IN  THE  ADMINISTRATION  OF 
GENERAL    ANESTHESIA. 

The  author  administers  Vioo  grain 
scopolamine  hydrobromide  and  1/6  grain 
morphine  hypodermically,  half  an  hour 
before  operating,  using  ethyl  chloride, 
followed  by  ether,  in  small  quantity  for 
the  general  anaesthesia.  He  states  that 
he  can  say  without  reserve  that  no  re- 
sults have  been  obtained  by  any  other 
method  which  can  be  compared  with 
those  which  this  method  has  yielded. 
The  morphine  lessens  the  susceptibility 
to  shock,  the  scopolamine  raises  the 
blood-pressure,  and  thus  aids  in  pre- 
venting shock.  The  combination  of  the 
two  drugs  is,  therefore,  valuable  from  a 
prophylactic  standpoint.  The  general 
anaesthetic  is  taken,  after  the  adminis- 
tration of  the  scopolamine-morphine, 
without  fear  or  excitement.  Salivation  is 
usually  absent.  The  patient  lies  quietly 
after  being  replaced  in  bed,  and  awakens 
without  excitement.  The  quantity  of 
ether  used  by  the  author  by  this  method 
is  a  little  over  two  ounces  an  hour,  the 
Bennett  inhaler  being  used.  In  G5 
cases  in  which  the  author  had  operated 
there  was  vomiting  or  retching  on  the 
operating  table  in  only  one.  '  In  77  per 
cent,  of  the  patients  there  was  no  vomit- 
ing at  any  time.  In  one-third  of  the 
cases  there  was  one  attack  of  vomiting, 
but  there  was  only  a  small  quantity  of 
clear  mucus,  and  the  attack  did  not 
occur  in  any  case  in  less  than  two  hours 
after  the  operation.  Seelig  (Annals  of 
Surgery,  August,  1905). 

SPINAL  CORD,  LOCALIZATION  OF  THE 
MOTOR  FUNCTION  IN  THE. 
The  theories  concerning  spinal  local- 
ization, generally  accepted  to-day.  give 
each  muscle  and  muscle  group  a  definite 
center,   that    is,   a    special    collection    of 


SPLEEN,  INDICATIONS  FOR  REMOVAL  OF  PATHOLOGIC. 


473 


ganglion  cells,  from  which  all  the  move- 
ments of  this  muscle  are  innervated.  M. 
Lapinsky,  in  Deutsche  Zeitschrift  fur 
Xervenheilkunde,  considers  this  funda- 
mentally wrong  as  there  are  no  ganglion 
cells  which  do  not  normally  communi- 
cate with  their  neighboring  cells,  and 
therefore  do  not  lose  their  independence 
as  such.  He  says  that  the  spinal  cen- 
ters govern  the  individual  functions 
rather  than  the  individual  muscles,  and 
bases  this  statement  upon  the  following 
facts :  It  is  well  known  that  individual 
ganglion  cells  are  divided  among  a 
number  of  nerves  which  supply  muscles 
possessing  different  functions  and  situ- 
ated in  different  parts  of  the  extremity; 
also  that  these  nerves  have  large  num- 
bers of  ganglion  cells  supplying  them; 
thus  muscles  derive  their  nerve  supply 
from  a  number  of  anterior  roots,  each 
one  supplying  not  the  whole  muscle,  but 
only  a  part  of  it;  the  ganglion  cells  in 
dividing  themselves  thus  among  a  num- 
ber of  muscles  always  go  to  muscles 
serving  the  same  function,  even  though 
being  in  different  parts  of  the  body. 
and  that  muscles,  even  though  deriving 
their  energy  from  different  ganglion 
cells,  get  it  always  from  ganglion  cells 
supplying  muscles  having  the  same 
function.  The  nourishment  of  the  mus- 
cles also  depending  .ipon  the  cells  of  the 
anterior  horns,  each  center  must  pos- 
sess both  motor  and  trophic  functions. 
The  existence  of  such  spinal  centers  for 
a  definite  function  facilitates  the  con- 
ception of  the  development  of  compli- 
cated skin  reflexes.  The  fact  that  after 
an  irritation  of  the  foot  all  flexors  of 
the  leg  are  brought  into  action  demon- 
strates that  the  flexor  muscles  of  the 
thigh,  pelvis,  and  leg  must  be  connected 
with  one  cell  group  of  the  anterior 
horns,    and    such    a    group    possessing 


therefore  one  definite  motor  function, 
can  exert  it  either  voluntarily  or  re- 
flexly.  The  impulses  pass  to  the  spinal 
center,  regulating  the  activity  of  the 
muscle  needed  for  the  movement.  The 
acceptance  of  special  centers  in  the 
spinal  cord,  each  one  to  regulate  a  def- 
inite muscular  accord,  facilitates  the 
understanding  of  how  automatic  move- 
ments are  performed  and  explains  the 
rapidity  with  which  voluntary  and  re- 
flex co-ordinate  movements  are  per- 
formed. It  also  explains  why  a  muscle 
in  certain  conditions  will  be  able  to  per- 
form some  of  its  functions  and  not 
others,  and  why  in  muscular  atrophy  of 
spinal  origin  portions  of  different  mus- 
cles of  different  segments  only  are  af- 
fected. (Xew  York  Medical  Journal 
and  Philadelphia  Medical  Journal,  Au- 
gust 12,  1905). 

SPLEEN,  INDICATIONS  FOR  REMOVAL  OF 
THE   PATHOLOGIC. 

The  more  probable  function  of  the 
spleen  is  the  manufacture  of  red  blood- 
corpuscles,  with  a  strong  probability  of 
the  existence  of  an  internal  secretion 
which  is  of  value  in  maintaining  the 
proper  relative  proportion  of  the  ele- 
ments of  the  blood. 

Splenectomy  is  contraindicated  in 
leukaemia,  amyloid  spleen,  splenic  hy- 
pertrophy secondary  to  cirrhosis  of  the 
liver,  secondary  malignant  disease,  and 
in  the  essential  anaemias.  Splenectomy 
is  usually  preferable  to  splenopexy  in 
wandering  spleen,  which  is  almost  al- 
ways due  to  previous  hypertrophy.  In 
abscess  of  the  spleen,  if  drainage  can  be 
successfully  accomplished,  it  is  prefer- 
able to  splenectomy,  especially  if  the 
splenic  tissue  is  not  destroyed. 

In  cysts,  benign  tumors,  tuberculosis, 
and  Barcoma,  splenectomy  is  the  opera- 


474  STOMACH,  ULCER  AND  CANCER  OF. 


SYPHILIS,  PROGNOSIS  OF. 


fcion  of  choice,  unless  in  the  three  former 
conditions  resection  of  the  lower  ex- 
tremity will  remove  all  of  the  disease. 
In  rupture,  the  organ  should  usually 
be  removed.  The  operation  should  be 
done  promptly,  expeditiously,  and  with 
every  expedient  calculated  to  relieve  and 
to  prevent  shock.  In  the  severe  type  of 
malarial  spleen,  with  failure  of  any  re- 
lief of  the  malaria  or  the  extreme  splenic 
enlargement  by  medical  means,  splen- 
ectomy will  often  result  in  cure. 

In  splenic  angemia,  internal  medica- 
tion has  proven  futile.  The  only  treat- 
ment that  should  be  considered  is  splen- 
ectomy, which  should  be  done  at  as 
early  a  period  as  possible  while  the  pa- 
tient is  able  to  withstand  the  operation 
and  before  incurable 'complications  have 
arisen.  B.  B.  Davis  (Journal  of  the 
American  Medical  Association,  Septem- 
ber 2,  1905). 

STOMACH,  "ULCER  AND  CANCER  OF  THE. 

The  very  great  majority  of  ulcers  of 
the  stomach  are  located  at  the  pyloric 
end.  The  immediate  pylorus  comes 
first,  the  lesser  curvature  second.  A 
small  per  cent,  is  found  elsewhere,  few 
at  the  cardia.  The  great  per  cent,  of 
cancers  of  the  stomach  is  found  at  the 
pylorus  and  lesser  curvature  (pyloric 
end),  that  is,  the  same  locations  find 
the  greatest  number  of  each.  Quite  a 
per  cent.  (50  to  60)  of  patients  suffer- 
ing from  carcinoma  give  three  or  more 
years  of  precancerous  history.  A  grow- 
ing per  cent,  of  cancer  cases  is  found 
with  short  histories  and  ulcer  demon- 
strated as  the  earlier  lesion.  A  certain 
per  cent.,  if  small,  of  short  ulcer  his- 
tories lead  to  acute  pyloric  obstruc- 
tion where  the  ulcer  must  have  been 
present  for  quite  a  period,  and  latent. 
Ulcers  may  be  present  for  an  indefinite 
period    and   no   symptoms   follow   until 


obstruction,  perforation,  and  haemor- 
rhage appear,  if  the  acidity  is  low  or 
absent  and  the  ulcer  locates  itself  along 
the  lesser  curvature  or  near  the  pylorus. 
Cancers  may  develop  under  the  same 
gastric  conditions  and  only  manifest 
themselves  when  obstruction  or  systemic 
poisoning  makes  itself  felt.  Christopher 
Graham  (Boston  Medical  and  Surgical 
Journal,  August  31,  1905). 

SWEATING  FEET,  TREATMENT  OF. 

The  author's  remarks  apply  especially 
to  military  service.  The  feet  should  not 
be  bathed,  as  this  softens  the  skin  and 
undoes  the  effect  of  the  treatment.  This 
consists  in  first  rubbing  off  the  feet  with 
a  1  per  cent,  alcoholic  solution  of  sali- 
cylic acid,  and  then  dusting  them  with 
a  powder  containing  formalin  and  the 
"fat  powder"  recently  introduced  into 
dermatologic  practice.  The  feet  and 
socks  are  dusted  with  the  powder  twice 
a  day,  and  the  skin  soon  dries  and 
hardens.  Insoles  are  not  advisable. 
Fischer  (Miinchener  medizinische  Woch- 
enschrift,  Bd.  lii,  Nu.  20;  Journal  of 
the  American  Medical  Association,  July 
22,  1905). 

SYPHILIS,    PROGNOSIS    OF. 

The  writer  asserts  that  the  virus  of 
syphilis  is  always  of  the  same  potency, 
and  the  poisonous  dose  is  practically  the 
same,  whether  it  is  derived  from  a  se- 
vere or  mild  case  of  syphilis,  or  whether 
the  initial  sore  is  a  large  one  or  a  small 
one.  Therefore  the  prognosis  of  syph- 
ilis depends  on  the  susceptibility  of  the 
individual  infected  and  on  the  thorough- 
ness and  intelligence  with  which  the 
treatment  is  conducted.  The  location 
of  the  primary  sore  is  of  no  prognostic 
consequence,  although  some  have  held 
that  extragenital  syphilis  runs  a  more 
virulent   course  than  the  usual   genital 


TABES,  PRINCIPLES  OF  PHYSICAL  RE-EDUCATION  IN. 


475 


variety.  Certain  individuals  undoubt- 
edly enjoy  a  natural  immunity.  Severe 
cases  of  infection  are  due  not  so  much 
to  special  susceptibility  to  the  infecting 
virus  as  to  reduced  resistance,  the  dis- 
ease running  as  a  rule  a  severe  course 
in  people  suffering  from  tuberculosis, 
diabetes,  Bright's  disease,  gout,  rheu- 
matism, etc.  The  disease  is,  in  most 
cases,  curable  in  about  two  or  three 
years.  E.  W.  Taylor  (Medical  News, 
September  2,  1905). 

TABES,    PRINCIPLES    OF    PHYSICAL    RE- 
EDUCATION IN. 

The  writer's  method  of  re-educating 
the  muscular  system  in  tabes  has  been 
widely  adopted  and  has  accomplished 
wonders  in  many  cases.  The  progno- 
sis of  uncomplicated  lumbar  ataxia  is 
rendered  grave  by  the  rapidly  progres- 
sive atony  of  the  abdominal  muscula- 
ture and  intestines  and  the  severe  cys- 
titis from  the  lack  of  active  exercise  of 
the  parts.  These  serious  complications 
are  becoming  rarer  and  rarer  now,  as 
also  the  paraplegic  stages  of  tabes, 
owing  to  the  advice  to  exercise  the  mus- 
cles instead  of  to  rest  them.  Massage 
of  the  muscles  is  not  beneficial,  as  he 
had  at  first  supposed,  and  he  now  warns 
explicitly  against  it.  The  correct  appli- 
cation of  the  "exercise  therapy"  requires 
a  knowledge  of  the  normal  processes  of 
movement  in  the  parts.  Its  incorrect 
application  is  liable  to  do  harm.  The 
author  gives  a  comprehensive  picture  of 
the  physiologic  co-ordinated  movement-, 
and  describes  the  technique  of  examin- 
ing for  disturbances  in  co-ordinal  inn 
and  for  their  various  kinds  and  degrees. 
The  musculature  in  tabes  is  character- 
ized by  what  he  calls  hypotony.  The 
capacity  for  co-ordinated  movements  is 
primarily  acquired  by  practice,  and  thus 
can  be  reacquired  when  lost.    The  pulse 


is  apt  to  be  increased  by  the  exercise, 
even  when  it  lasts  only  two  or  three 
minutes.  It  should  be  normal  again 
before  attempting  another  exercise. 
Another  point  to  be  borne  in  mind  is 
the  lack  of  the  sensation  of  fatigue. 
The  writer  had  a  patient  who  could  hold 
his  arms  stretched  out  horizontally  for 
twenty-two  minutes  without  fatigue, 
notwithstanding  that  his  arms  were  so 
much  affected  by  the  tabes  that  he  could 
hardly  feed  himself.  This  lack  of  the 
sensation  of  fatigue  imposes  extra  care 
on  the  physician,  as  he  must  be  the 
judge  of  the  proper  duration  of  the  ex- 
ercise. As  a  rule,  twice  a  day  and  not 
longer  than  from  five  to  fifteen  minutes 
at  a  time,  and  in  the  severer  cases  not 
longer  than  two  or  three  minutes,  should 
be  the  limit.  Improvement  follows  in 
every  case,  but  the  amount  depends  on 
the  length  of  treatment  rather  than  on 
^he  degree  of  inco-ordination.  Several 
months  are  generally  necessary  or  else 
the  patient  falls  back  into  his  old  habits. 
Even  the  severest  cases,  if  uncompli- 
cated, give  a  good  prognosis  with  per- 
severing treatment.  Some  of  his  pa- 
tients, with  complete  loss  of  the  power 
of  standing  or  walking,  had  these  facul- 
ties entirely  restored  after  six  to  twelve 
months  of  treatment.  Extreme  hy- 
potony may  require  orthopaedic  appa- 
ratus. The  worst  prognosis  is  afforded 
by  cases  complicated  by  attacks  of  pro- 
tracted pain  or  by  gastric  or  intestinal 
crises.  Total  blindness  was  always 
hopeless  in  the  author's  experience  until 
recently,  but  within  the  last  ivw  years 
he  has  modified  his  technique  to  adapt 
it  to  these  cases,  with  surprisingly  fa- 
vorable results.  H.  S.  Frenkel  (Ber- 
liner klinische  Wochenschrift,  Bd.  xlii, 
Nu.  23;  Journal  of  the  American  Med- 
ical Association,  July  22,  1905). 


476     THYROID  GLAND,  IRON  PIGMENT  IN. 


TUBERCULOUS  PERITONITIS. 


THYROID     GLAND,     IRON     PIGMENT     IN 
THE. 

On  several  occasions  the  presence  of 
pigment,  giving  the  free  iron  reaction, 
in  the  thyroid  gland,  has  been  noticed 
by  the  authors.  They  summarize  their . 
findings  as  follows :  In  cases  of  the 
various  diseases  of  the  blood  and  in 
animals  injected  with  phenylhydrazin, 
they  have  found  pigment  in  the  thyroid 
gland.  The  greater  part  of  this  pig- 
ment gives  the  free  iron  reaction.  The 
pigment  is  most  commonly  found  in 
connective  tissue  cells  between  the  ves- 
icles. It  is  also  present,  in  small  scat- 
tered areas,  in  the  epithelium  lining  the 
vesicles  and  may  be  found  in  cells  lying 
free  among  the  colloid  material.  It  is 
most  abundant  in  the  more  cellular 
parts  of  the  thyroid  where  the  colloid 
vesicles  are  small.  G.  L.  Gulland  and 
A.  Goodall  (Lancet,  August  19,  1905). 

TUBERCULOSIS,    PULMONARY. 

The  author  has  studied  500  miscella- 
neous cases  of  pulmonary  tuberculosis, 
gathered  from  hospital,  sanatorium,  and 
private  practice,  in  order  to  throw  light 
on  certain  specific  questions.  Four  lines 
of  investigation  were  pursued:  1.  How 
pulmonary  tuberculosis  begins  —  the 
symptoms  of  its  very  first  inception — 
analysis  of  100  cases.  2.  Analysis  "of 
55  "cured  cases"  of  phthisis.  3.  Ee- 
sults  in  cases  examined  for  admission  to 
the  Adirondack  Cottage  Sanatorium,  or 
the  Annex  of  the  Liberty  Sanatorium, 
as  illustrating  the  possibilities  of  prog- 
nosis. 4.  Cases  showing  the  average 
length  of  life  of  the  poor  after  the  in- 
ception of  tuberculosis — patients  living 
under  such  hygienic  conditions  as  are 
possible  for  them  in  a  great  city.     . 

The  conclusions  to  be  drawn  from  the 
author's  study  are  that  the  chief  initial 
symptoms  of  tuberculosis  are  (a)  cough 


in  58  per  cent,  of  all  cases  (without  ex- 
pectoration, 14  per  cent. ;  with  expecto- 
ration, 42  per  cent.)  ;  (b)  haemoptysis  in 
24  per  cent,  of  all  cases,  and  (c)  fever, 
night  sweats,  or  chills  in  10  per  cent. 
In  this  connection  it  is  to  be  further 
noted  that  the  vast  majority  of  patients 
who  apparently  develop  tuberculosis 
after  thirty  years  of  age  are  in  reality 
suffering  from  a  second  attack.  Tuber- 
cle bacilli  appear  in  the  sputum  about 
three  months  and  one-third  after  the 
actual  beginning  of  the  disease  as  deter- 
mined by  the  case  histories  and  records 
of  the  physi-examinations.  In  regard 
to  the  length  of  life  among  the  poor 
after  the  beginning  of  pulmonary  tu- 
berculosis, the  author  divides  his  cases 
into  two  great  classes  with  the  following 
results:  1.  Chronic  pulmonary  tuber- 
culosis, 128  cases ;  average  duration  of 
the  disease,  one  year,  two  months,  and 
three  days.  2.  Acute  pulmonary  tuber- 
culosis, 112  cases;  average  duration 
of  the  disease,  two  months  and  four 
days.  These  results  are  not  final  or  of 
absolute  value,  but  they  serve  to  sug- 
gest a  line  of  inquiry  helpful  for  future 
investigation,  and  serve  to  show  that  the 
average  time  the  poor  are  able 'to  resist 
the  fatal  issue  of  the  disease,  with  no 
advantages  of  care,  rest,  or  good  food,  is 
a  little  under  two  years.  H.  P.  Loomis 
(Medical  Record,  July  29,  1905). 

TUBERCULOUS  ,  PERITONITIS,  RECUR- 
RENT, AFTER  INCOMPLETE  OPERA- 
TION. 

As  the  result  of  personal  experience 
and  a  study  of  the  literature  of  the  sub- 
ject, the  author  reaches  the  following 
conclusions:  Until  we  have  more  pre- 
cise methods  of  differentiation,  most 
cases  of  tuberculous" peritonitis  will  be 
operated  on  under  some  other"  diagnosis. 
Coeliotomy  and  removal  of  the  primary 


TYPHOID  FEVER,  BLOOD-PRESSURE  IN.  URETHRITIS,  TREATMENT        477 


focus  of  the  disease  offer  the  best  pros- 
pect of  cure.  The  abdomen  should  be 
thoroughly  irrigated  and  closed  without 
drainage.  A  short  course  of  x-ray  treat- 
ment immediately  following  operation  is 
advisable  in  all  cases,  but  it  is  especially 
important  in  those  cases  in  which  the 
primary  focus  has  not  been  removed. 
Should  recurrence  take  place  in  these 
cases,  a  secondary  operation — to  remove, 
if  possible,  the  primary  focus — is  advis- 
able; and  this  operation  should  be  fol- 
lowed by  a  course  of  x-ray  treatment. 
J.  B.  Shober  (New  York  Medical  Jour- 
nal and  Philadelphia  Medical  Journal, 
August  5,  1905). 

TYPHOID    FEVER,    BLOOD-PRESSURE    IN. 

In  the  forty-one  children  examined 
the  blood-pressure  was  always  below 
normal,  and  likewise  in  grippe  and  in 
tuberculous  meningitis,  but  not  in  2 
cases  of  acute  osteomyelitis.  The  pres- 
sure was  normal  or  slightly  above  in 
acute  meningitis,  in  "meningism,"  and 
also  in  endocarditis,  otitis,  pneumonia, 
etc.  In  typhoid  in  children  the  blood- 
pressure  is  absolutely  and  relatively 
much  lower  than  in  adults,  although, 
exceptionally,  hypertension  may  pre- 
vail. The  blood-pressure  has  no  diag- 
nostic or  prognostic  importance  in  ty- 
phoid fever  in  children,  but  it  reveals 
an  impending  or  present  complication. 
A  haemorrhage  is  preceded  by  an  un- 
usually high  pressure,  which  also  ac- 
companies congestions,  especially  con- 
gestion of  the  lungs.  It  may  likewise 
be  the  precursor  of  violent  delirium 
or  of  endocarditis.  The  blood-pressure 
is  not  influenced  by  gastro-intestinal 
troubles  nor  by  the  development  of  an 
abscess  nor  by  an  intercurrent  infec- 
tion or  aortic  lesion.  0.  Carrierc  and 
C.  Dancourt  (Bevue  de  Medicine.  \ul. 
xxiv.   Nos.   7   and   8.    100.-)). 


URETERAL    STONES,    DIAGNOSIS    OF. 

The  writer  states  that  all  ureteral 
stones  have  their  origin  in  the  kidney, 
with  the  exception  of  those  which  may 
form  around  foreign  body  or  an  obstruc- 
tion in  the  ureter.  The  migration  of  a 
stone  through  the  ureter  is  always  ex- 
ceedingly painful,  and  the  pain  disap- 
pears very  gradually  even  after  the  stone 
has  left  the  ureter  and  has  passed  out 
through  the  urethra.  A  stone  which  has 
lodged  in  the  ureter  may  remain  latent 
indefinitely  if  it  does  not  entirely  oc- 
clude the  lumen  of  the  ureter.  The  uri- 
nary findings  in  such  cases  are  not  dis- 
tinctive, neither  is  localized  tenderness 
or  enlargement  of  the  ureter  conclusive. 
Stones  at  the  lower  end  of  the  ureter 
may  sometimes  be  palpated  through  the 
vagina  or  rectum.  The  x-ray  enables 
one  to  discover  stones  in  any  portion  of 
the  ureter,  and  if  a  distinct,  well-de- 
fined shadow  is  found  in  the  course  of 
this  duct,  the  diagnosis  of  stone  will 
usually  be  correct  and  a  proper  basis  for 
an  operation  for  the  removal  of  the 
stone.  A  case  is  described  in  which 
such  a  shadow  was  repeatedly  observed, 
but  no  stone  could  be  found  in  the  ure- 
ter. Even  after  the  subsequent  removal 
of  the  kidney  the  cause  of  the  shadow- 
remained  unexplained.  The  ureter 
shouM  always  be  catheterized  to  deter- 
mine whether  the  shadow  lies  in  its 
course.  Harris  (Medicine,  August, 
1005). 

URETHRITIS,    LOCAL    TREATMENT    OF. 

Chronic  urethritis  is  divided  by  the 
writer  into  three  types:  Tn  the  first,  the 
inflammation  is  associated  with  gono- 
cocci :  in  the  second,  with  other  micro- 
organisms; in  the  third,  with  no  micro- 
organisms whatever.  For  the  treatment 
of  the  first  type  he  employs  free  lavage 
of  tin1   urethra   with    a   solution  of  per- 


478       URINARY  TRACT,  DIAGNOSIS  OF  DISEASES.      VULVA,  EPITHELIOMA  OF. 


manganate  of  potassium,  1  to  5000  or 
1  to  6000,  and  states  that  the  gonococci 
disappear  after  from  ten  to  fifteen  lav- 
ages. In  cases  of  the  second  type,  in  a 
similar  manner,  solution  of  the  salts  of 
mercury,  either  of  the  oxycyanide,  1  to 
4000,  are  used,  which  are  efficient  and 
painless,  or  of  the  bichloride,  1  to  20,000 
or  1  to  30,000,  which  is  more  irritating, 
but  more  effective  in  some  cases.  In 
cases  belonging  to  the  third  degree,  a 
1  to  4000  solution  of  nitrate  of  silver, 
or  a  1  to  2000  solution  of  salicylic  acid 
is  employed.  Paul  Lebreton  (Presse 
Medicale,  July  8,  1905;  New  York 
Medical  Journal  and  Philadelphia  Med- 
ical Journal,  August  12,  1905). 

URINARY  TRACT,  EARLY  DIAGNOSIS  OF 
SURGICAL   DISEASES   OF   THE. 

Localized  pain,  altered  function,  haem- 
aturia,  with  or  without  pns — these  are 
the  cardinal  symptoms  of  surgical  dis- 
ease in  the  urinary  tract.  Tumor,  ten- 
derness and  residual  urine  do  not  require 
complicated  apparatus  for  their  recog- 
nition, and  their  presence  or  absence  can 
be  determined  by  any  physician  who  will 
take  the  troiuVe  to  examine  his  patients 
properly.  These  preliminary  points  are 
simple,  sufficient  for  a  correct  diagnosis 
sometimes,  and  always  trustworthy  in 
indicating  the  urinary  tract  as  a  source 
of  trouble.  Nothing  in  surgery  requires 
more  concentrated  attention,  more  ac- 
curate observation,  or  a  finer  technique, 
than  a  complete  and  correct  preopera- 
tive diagnosis  of  the  more  obscure  con- 
ditions in  the  urinary  tract  which  stand 
between  our  patients  and  health.  Ben- 
jamin Tenney  (Journal  of  the  American 
Medical  Association,  August  19,  1905). 

VULVA,   EPITHELIOMA   OF   THE. 

Malignant    growths    of    the    external 

genitalia    in    women    are    rare.      Carci- 


noma of  the  vulva  occurs  in  approxi- 
mately 0.22  per  cent,  of  gynaecological 
'patients,  and  in  5.66  per  cent,  of  pa- 
tients suffering  from  carcinoma  of  the 
genital  apparatus.  In  a  series  of  135 
cases,  the  records  of  which  were  care- 
fully examined,  the  age  of  the  youngest 
patient  was  twenty  years.  The  greatest 
frequency  is  between  the  ages  of  61  and 
70  years. 

Mechanical  injuries  to  the  external 
genitalis  are  generally  quoted  as  among 
the  principal  causes  of  carcinoma  vulvas. 
Their  etiological  relation  to  this  disease, 
however,  is  by  no  means  generally  evi- 
dent. On  the  other  hand,  long-con- 
tinued irritation,  as,  for  instance,  that 
caused  by  a  pruritus,  undoubtedly  has 
often  to  do  with  malignant  growths  of 
the  vulva.  Leucoplakia  also  has  often 
been  noted  as  a  precursor  of  epithelioma 
vulvae. 

The  disease  usually  begins  on  the 
labium  majus,  and  is  seen  more  com- 
monly on  the  right  side.  There  are  two 
types  of  the  disease — vegetating  and  in- 
filtrating— which  may  co-exist..  There 
are  four  histological  classes:  scirrhous 
and  medullary  carcinoma,  cancroid,  and 
melanocarcinoma.  The  most- common 
symptom  is  itching.  When  ulceration 
has  taken  place  there  is  usually  pain, 
more  or  less  foul  discharge,  and  some 
bleeding.  Occasionally  there  are  pro- 
fuse haemorrhages.  Intractable  insom- 
nia often  results  from  the  itching  and 
pain.  Dysuria  is  not  very  common. 
Four  stages  are  described  by  Maurel : 
(a)  The  pretumoral  stage,  characterized 
by  an  intolerable  pruritus,  (b)  The  sec- 
ond stage,  in  which  a  tumor  with  infil- 
tration is  present,  (c)  The  period  of 
ulceration,  usually  with  speedy  involve- 
ment of  the  inguinal  glands,  (d)  In 
the  final  stacc  ulceration  becomes  more 


VULVA,  EPITHELIOMA  OF.  BOOKS  AND  MONOGRAPHS  RECEIVED.      479 

rapid.      Occasionally   metastases   occurs  patient  remained  free  from  a  recurrence 

in   the   other   viscera,    and   the    patient  for  over  six  years. 

dies  of  exhaustion.     The  average  dura-  The  best  treatment  consists  in  early 

tion  without  operation  is  about  two  years  excision  of  the  vulva,  with  extensive  dis- 

after  the  discovery  of  the  tumor;    not  section  of  the  inguinal  glands  on  both 

-                  ,                ,              ii  sides.     The  x-rays  are  of  little  value  in 

a  few  cases,  however,  last  much  longer.  J    m 

__.        „       ,.          .     .     ,     ,  .«  .    ,.  these  cases.     Occasionally  they  may  al- 

When  the  diagnosis  is  doubtful,  the  .     .  ,          .           n    .  .  .,  .,    ,,          ,        , 

0  leviate    pam    and    inhibit   the    external 

microscopic  examination  will  prove  con-  ^^  but  they  exert  nQ  influence  upon 

elusive.     Eapid   growth,   with   cachexia  the  deeper  extensions.     In  non-operable 

and  implication  of  the  inguinal  glands,  cases  the  treatment  is  similar  to  that 

is  very  suggestive.  employed    for    extensive    carcinomatous 

The  prognosis  is  bad.    Return— so  far  growths   elsewhere.       Howard   Dittrick 

as  at  present  known — is  almost  inevi-  (American  Journal  of  Medical  Sciences, 

table.    No  case  is  on  record  in  which  the  August.  1905). 


fJool<s  and  /Monographs  Received. 


The  editor  begs  to  acknowledge  with  thanks  the  receipt  of  the  following  books  and 
monographs: — 

"Color-Vision  and  Color-Blindness."  A  Practical  Manual  for  Railroad  Surgeons.  By 
J.  Ellis  Jennings,  M.D.  Second  Edition.  Thoroughly  Revised,  with  Illustrations.  132  Pages, 
Crown  Octavo.  F.  A.  Davis  Company,  Publishers,  Philadelphia.— "Annual  Report  of  the 
Office  of  Experiment  Stations  for  the  Year  ended  June  30,  1904."     United  States  Department 

of  Agriculture,  Washington,  D.  C,  1905. "A  Note  on  the  Condition  of  the  Tendo-aehillis 

Jerk  in  Diphtheria."    By  J.  D.  Rolleston,  London,  Eng.,  1905. "Asthma."     By  John  North, 

Toledo.  O.,  1901. "The  Treatment  of  Acute  Mania.     With  a  Review  of  One  Hundred  and 

Eight  Recoveries,"     By  Amos  J.  Givens,  Stamford,  Conn. "Diseases  of  Children  Occasioned 

by  Affections  of  the  Nose.    The  Necessity  for  Recognition  and  Treatment."    By  L.  J.  Lauten- 

bach,  Philadelphia,  1904. "The  Doctor's  Fee— Is  It  Fixed  and  Definite?"     By  L  J.  Lauten- 

bach,   Philadelphia,    1902. "A    Few    Thoughts    as    to    the    Cause    and    Cure    of    Catarrhal 

Deafness."     By   L.   J.   Lautenbach,  Philadelphia,    1905. "De   POrganisation  de   ^Inspection 

Medicale  Scolaire  dans  les  Villes  et  les  Campagnes."     V.  Desguin,  E.  Dewez,  et  Dupureux, 

Bruxelles,  1905. "La  Fondation  Ophtalmologique  Adolphe  de  Rothschild."     Par  Le  Docteur 

A.  Trousseau,  Paris,  1905.  "Vorhippokratische  Medizin  Westasiens,  Aegyptens  under  der 
Mediterranen  Vorarier."  Von  Baron  Dr.  Oefele,  Bad  Neuenahr.  1901. "Forest  Preserva- 
tion and  National  Prosperity."    United  States  Department  of  Agriculture,  Washington,  D.  C, 

1905. "The   Red   Gum."     By   A.   K.  Chittenden.     With   "A   Discussion   of  the  Mechanical 

Properties    of   Red    Gum    Wood."     By    W.    Kendrick    Hatt.      United    States    Department    of 

Agriculture,  Washington,  D.  C,  1905. "The  Maple  Sugar  Industry."     By  W.  F.  Fox  and 

W.  F.  Hubbard.     With  "A  Discussion  of  the  Adulterations  of  Maple  Products."     By  H.  W. 

Wiley.     United  States  Department  of  Agriculture,  Washington,  D.  C,  1905. "Experiments 

in  the  Cull  ure  of  Sugar  Cane  and  Its  Manufacture  Into  Table  Syrup.  A  Report  on  the 
Investigations  Conducted  at  Waycross  and  Cairo,  Ga.,  in  1903  and   1904."     By  II.  W.  Wiley. 

United  States  Department  of  Agriculture,  Washington,  D.  C,   1905. "Index-Catalogue  of 

the  Library  of  the  Surgeon-General's  Ofliice,  United  States  Army."     Second   Series.     Vol.  X, 

1905. 'Diseases  of  the  Skin."     By  George  Thomas  Jackson.     Fifth  Edition.     Lea  Brothers 

&  Co.,  New  York  and  Philadelphia,   1905. "The  Circumstances  and  Treatment  of  Bright's 

Disease."     By  Alfred   C.  Croftan,  Chicago,    III.,    1905. "The   Mathematics   of' the  Diabetic 

Diet."     By  Alfred  O.  Croftan,  Chicago,  111..  1904. "The  Treatment  of  Yellow  Fever."     By 


480 


BOOKS  AND  MONOGRAPHS  RECEIVED. 


Lucien  F.  Salomon,  New  Orleans,  La.,  1905. 
By  John  Uri  Lloyd,  Cincinnati,  0.,  1905. 


'Development  of  the  Pharmaceutical  Still.' 


'The  Clinical  Significance  of  Enlargement  of  the 

Liver  in  Diphtheria."    By  J.  D.  Rolleston,  London,  Eng.,  1904. "Cleft  Palate  and  Harelip." 

By  W.  Arbuthnot  Lane,  London,  Eng.,  1905. — —"The  Therapeutics  of  the  Iron  Compound." 

By   C.  D.  F.   Phillips,   1904. "Dermatitis   Seborrhoica   and   Its   Relations  to   Alopecia   and 

Other   Conditions."     By   L.   Duncan   Bulkley,  New  York,   1905. "The   Immunity   Unit  for 

Standardizing  Diphtheria  Antitoxin"  (Based  on  Ehrlich's  Normal  Serum).     By  M.  J.  Rosenau, 

Public  Health  and  Marine  Hospital  Service  of  the  United  States,  Washington,  D.  C,  1905. 

"Forest  Planting  and  Farm  Management."    By  George  L.  Clothier,  United  States  Department 

of  Agriculture,  Washington,  D.  C,   1905. "School  Gardens."     By  B.  T.   Galloway,  United 

States  Department  of  Agriculture,  Washington,  D.  C,  1905. "Some  Miscellaneous  Results 

of  the  Work  of  the  Bureau  of  Entomology."  VIII.  United  States  Department  of  Agricul- 
ture, Washington,  D.  C,  1905. — "Experiment  Station  Work."  XXX.  United  States  Depart- 
ment of  Agriculture,  Washington,  D.  C,  1905.— "The  Cottony  Maple  Scale."  By  J.  G.  Sanders, 
United  States  Department  of  Agriculture,  Washington,  D.  C,  1905. 


EDITORIAL    STAFF. 
Sajous's  Analytical  Cyclopaedia  of  Practical  Medicine. 


J.  GEORGE  ADAMI,  M.D., 

MONTREAL,  P.  Q. 

LEWIS  H.  ADLEB,  M.D., 

PHILADELPHIA. 

JAMES  M.  ANDERS,  M.D.,  LL.D., 

PHILADELPHIA. 

THOMAS  G.  ASHTON,  M.D., 

PHILADELPHIA. 

A.  D.  BLACKADER,  M.D., 

MONTREAL,  P.  ft. 

E.  D.  BONDURANT,  M.D., 

MOBILE,  ALA. 

DAVID  BOVAIRD,  M.D., 

NEW  YORK  CITY. 

WILLIAM  BROWNING,  M.D., 

BROOKLYN,  N.  Y. 

WILLIAM  T.  BULL,  M.D., 

NEW  YORK  CITY. 

CHARLES  W.  BURR,  M.D., 

PHILADELPHIA. 

HENRY  T.  BYFORD,  M.D., 

CHICAGO,  ILL. 

HENRY  W.  CATTELL,  M.D., 

PHILADELPHIA. 

WILLIAM  B.  COLEY.  M.D., 

NEW  YORK  CITY. 

FLOYD  M.  CRANDALL,  M.D., 

NEW  YORK  CITT. 

ANDREW  F.  CURRIER,  M.D., 

NEW  YORK  CITY. 
ERNEST  W.  CUSHING,  M.D., 

BOSTON,  MASS. 

GWILYM  G.  DAVIS,  M.D., 

PHILADELPHIA. 

N.  8.  DAVIS,  M.D., 

CHICAGO.  ILL 

AUGUSTUS  A.  ESHNER,  M.D., 

PHILADELPHIA. 

SIMON  FLEXNER.  M.D., 

PHILADELPHIA. 

LEONARD  FREEMAN,  M.D, 

DENVER,  COL. 

8.  G.  GANT,  M.D.. 

NEW  YORK  CITT. 

I.  MoFADDEN  GASTON,  SB.,  M.D., 

ATLANTA,  GA. 

J.  MoFADDEN  GASTON,  Jr.,  M.D., 

ATLANTA,  GA. 

E.  B.  GLEASON,  M.D.. 

PHILADELPHIA. 

EGBERT  H.  GRAN  DIN,  M.D., 
»  HEW  YORK  CITY. 


ASSOCIATE,    EDITORS. 

J.  F.  CROZER  GRIFFITH,  M.D., 

PHILADELPHIA. 

C.  M.  HAY,  M.D., 

PHILADELPHIA. 

FREDERICK  P.  HENRY,  M.D., 

PHILADELPHIA. 

L.  EMMETT  HOLT,  M.D., 

NEW  YORK  CITY. 

EDWARD  JACKSON,  M.D., 

DENVER.  COL. 

W.  W.  KEEN,  M.D., 

PHILADELPHIA. 

EDWARD  L.  KEYES,  Jr.,  M.D., 

NEW  YORK  CITY. 

ELWOOD  R.  KIRBY,  M.D., 

PHILADELPHIA. 

L.  E.  La  FETRA,  M.D., 

NEW  VORK  CITY. 

ERNEST  LAPLACF,  M.D.,  LL.D., 

PHILADELPHIA. 

R.  LEPINE,  M.D., 

LYONS,  FRANCE. 

F.  LEVISON,  M.D., 

COPENHAGEN,  DENMARK. 

A.  LUTAUD,  M.D., 

PARIS,  FRANCE. 

G.  FRANK  LYDSTON,  M.D., 

CHICAGO,  ILL. 

F.  W.  MARLOW,  M.D., 

SYRACUSE,  N.  Y. 

SIMON  MARX.  M.D., 

NEW  YORK  CITY. 

ALEXANDER  McPHEDRAN,  M.D., 

TORONTO,  ONT. 

E.  E.  MONTGOMERY,  M.D., 

PHILADELPHIA. 

HOLGEK  MYGIND,  M.D., 

COPENHAGEN,  DENMARK. 

W.  P.  NORTH RUP.  M.D.. 

NEW  YORK  CITY. 
RUPERT  NORTON,  M.D., 

WASHINGTON,  D.  0. 
H.  OBERSTEINER.  M.D., 

VIENNA,  AUSTRIA. 

CHARLES  A.  OLIVER.  M.D., 

PHILADELPHIA. 

WILLIAM  OSLER.  M.D., 

BALTIMORE.  MD. 

LEWIS  S.  P1LCHER.  M.D., 

BROOKLYN.  N.  Y 

WILLIAM  CAMPBELL  I'OSEY,  M.D., 

PHILADELPHIA. 


W.  B.  PRITCHARD.  M.D., 

NEW  YORK  CITY. 

JAMES  J.  PUTNAM,  M.D.. 

BOSTON. 

B.ALEXANDER  RANDALL.  M.D., 

PHILADELPHIA. 

CLARENCE  C.  RICE,  M.D.. 

NEW  YORK  CITY. 

ALFRED  RUBINO,  M.D., 

NAPLES,   ITALY. 

REGINALD  H.  SAYRE,  M  D., 

NEW  YORK  CITY. 

JACOB  E.  SCHADLE,  M.D., 

ST.   PAUL,  MINN. 

JOHN  B.  SHOBER,  M.D., 

PHILADELPHIA. 

J.  SOLIS-COHEN.  M.D.. 

PHILADELPHIA. 

SOLOMON  SOLIS-COHEN.  M.D., 

PHILADELPHIA. 

H.  W.  STELWAGON;  MD., 

PHILADELPHIA. 

D.  D.  STEWART,  M.D., 

PHILADELPHIA. 

LEWIS  A.  STIMSON,  M.D., 

NEW  YORK  CITY. 

J.  EDWARD  STUBBERT,  M.D, 

LIBERTY,  N.  Y. 

A.  E.  TAYLOR,  M.D, 

SAN  FRANCISCO,  CAL. 

J.  MADISON  TAYLOR.  M.D., 

.  PHILADELPHIA. 

M.  B.  TINKER.  M.D., 

PHILADELPHIA. 

CHARLES  8.  TURNBULL,  M.D, 

PHILADELPHIA. 

HERMAN  F.  VICKERY.  M.D., 

BOSTON,  MASS. 

F.  E.  WAXHAM,  M.D., 

DENVER,    COL. 

J.  WILLIAM  WHITE.  M.D, 

PHILADELPHIA. 

JAMES  C.  WILSON,  M.D, 

PHILADELPHIA. 

C.  SUMNER  WITHERSTINE,  M.D, 

_     PHILADELPHIA. 

ALFRED  C.  WOOD,  M.D., 

PHILADELPHIA. 

WALTER  WVMAN.  M.D, 

WASHINGTON,  D.  0. 


THE   MONTHLY   CYCLOPEDIA 

OF 

PRACTICAL   MEDICINE 


Vol.  XVIII. 
Old  Series. 


(Published  the  Last  of  Each  Month) 


PHILADELPHIA,  NOVEMBER,  1905. 


Vol.  VIII,  No.  11. 

New  Series. 


TABLE  OF  CONTENTS. 


PAGE 

EDITORIALS 

THE  DISCOVERT  OF  SURGI- 
CAL ANESTHESIA.  James  Mc- 
Fadden  Gaston 481 

RICKETS  AND  THE  NEBVOT/S  SYS- 
TEM.   James  Herbert  McKee 487 

THE  RELATION  WHICH  HYPER- 
TROPHY OF  THE  VARIOUS 
TONSILS  OF  WALBEYER'B 
KINO  BEASS  TO  THE  ETIOL- 
OGY OF  DI8EASE.  J.  Price- 
Brown 489 

REMARKS  ON  THE  CONSTITU- 
TIONAL TREATMENT  OF 
BHEUMATIC  CONDITIONS. 
J.    Madison    Taylor 494 

CYCLOPEDIA    OF   CURRENT 
LITERATURE 

ALBUMINURIA  AND  ADOLESCENTS. 

Clement  Dukes 499 

ALBUMINURIA  AND  DIABETES, 
CONNECTION  BETWEEN. 
Lance reaux 499 

ANGINA  FECT0BI8.     T.  Oliver 500 

ANGINA  PECTORIS,  ETIOLOGY  OF. 

James  Mackenzie 500 

ANGINA  PECTORIS,  NEW  SYMP- 
TOMS IN.    G.  A.  Gibson 501 

APPENDICITIS,  URINARY  DIS- 
TURBANCES IN.  C.  G.  Cumston,  501 

ARTERIOSCLEROSIS,  THREATEN- 
ING EPI8TAXI8  IN.    E.  Escat,  502 

ASTERIOSCLEROSIS,    HOT     BATHS 

IN.     E.  Hirchfeld 502 

ARTERIOSCLEROSIS,     TREATMENT 

OF.     E.  Romberg 503 

BRACHIAL     BIRTH     PALBY.      L.  P. 

Clark,  A.  S.  Taylor  and  T.  P. 
Prout 503 

CEREBROSPINAL  MENINGITIS, 
EAR  COMPLICATIONS  IN. 
C.  J.  Colles 504 

CIRRHOSIS  OF  THE  LIVER,  TAL- 
MA'S OPERATION  IN.  Wil- 
liam Hessert 504 

COLITIS,  HIGH-FREQUENCY  CUR- 
RENTS IN.     E.  W.  II.  Shenton.  .  505 

COLITIS,     SURGICAL    TREATMENT 

OF.    J.   E.  Summeri,  Jr 585 


PAGE 

CONSUMPTION     DIATHESIS.      T.  J. 

Mays 506 

DERMATITIS    HERPETIFORMIS  IN 

CHILDREN.     J.  T.  Brown 506 

DIPHTHERIA,  CARDIAC  DISTURB- 
ANCES FOLLOWING.  P.  W. 
White 506 

EPILEPSY,  EMOTIONAL  SHOCK  AND 
FRIGHT  AS  CAUSES  OF.  W. 
P.  Spratling 507 

EPILEPSY,     TREATMENT      OF.       A. 

Strumpell 507 

FUNGUS  POISONING.  C.  B.  Plow- 
right 508 

GOUT.     H.  Kionka '. 508 

HEMORRHOIDS.      EXTERNAL, 

FATHOLOGY  OF.     L.  J.  Krouse,  509 

HICCOUGH     OF     INFANTS.      Victor 

Thevennet 509 

INSANITY,  ACUTE,  THERAPEU- 
TICS OF.     D.  K.  Brower 509 

KERNIG'S  SIGN  AND  ITS  PATHO- 
GENESIS.     G.    B.    Uassin 510 

LARYNX,  REMOVAL    OF    FOREIGN 

BODIES  FROM.     R.  Barclay 510 

LEUCOCYTE  COUNTING,  CONVEN- 
IENT METHOD  OF.    E.  L.  Gros,  510 

LEUCOCYTE  COUNTS  IN  BRONCHO- 
PNEUMONIA, LOBAR  PNEU- 
MONIA, AND  EMPYEMA  IN 
CHILDREN.    Henry  Heiman 511 

MALARIA,    WHITE    CELLS    IN.     B. 

F.  Petroff. 512 

MBTHEMOGLOBIN  AS  A  FACTOR 
IN  CONSERVATIVE  METABOL- 
ISM.    Bernard  Oettinger 512 

NASAL    CATARRHS,     SULPHUR  IN. 

Louis  Kolipinski 512 

NERVOUS  SYSTEM,  DIAGNOSIS  OF 
DISEASES  OF  THE.  Joseph  Col- 
lins   513 

PANCREATIC     DIABETES,     ORIGIN 

OF  THE  SUGAR  IN.    E.  Pfluger,  513 

PHLEBITIS,      TREATMENT    OF.      H. 

Vaquez 514 

PNEUMONIA,  FREEZING  POINTS 
OF  BLOOD  AND  URINE  IN.  F. 
E.  Sohmidt 515 

PNEUMONIA,  COMPLICATING  SUR- 
GICAL OPERATIONS.  J.  L. 
Rothrock 516 


PAGE 

PUERPERAL  INFECTIONS,  TREAT- 
MENT OF,  BY  TURPENTINE. 
M.   Fabre 510 

RENAL  CALCULUS,  X-RAY  DIAG- 
NOSIS OF.     Morton  Smart 517 

RHEUMATIC     POISON.     F.     Le    Roy 

Satterlee 517 

SCIATICA,  TREATMENT  OF.     W.  M. 

Leszynsky 518 

SHOCK,  CONDITION  OF  THE  BLOOD- 
VESSELS DURING.  J.  D.  Mal- 
colm   518 

STOMACH,  HYDROCHLORIC  ACID 
IN  DISEA8ES  OF  THE.  R.  F. 
Chase 519 

STRICTURES  OF  THE  RECTUM, 
NON-MALIGNANT;  TREAT- 
MENT.     Howard  A.  Kelly 519 

SUPRARENAL  HEMORRHAGE  OF 
THE  NEW-BORN.  S.  Obern- 
derfer 520 

SURGICAL  CASES,  TREATMENT  OF. 

J.  E.  Cannaday 521 

TABES  DORSALIS,  MERCURY  IN. 

Maurice  Faure 521 

THROMBOSIS  OF  THE  EXTERNAL 
ILIAC  VEIN  AFTER  APPEN- 
DICECTOMY,  CAUSE  OF. 
Witzel 521 

TUBERCULOUS  CERVICAL  LYMPH 
GLANDS,  SURGICAL  TREAT- 
MENT OF.  Editorial  "Journal 
of  the  American  Medical  Associa- 
tion " 522 

TUBERCULOUS  ULCERATION  OF 
THE  ASCENDING  COLON  SIM- 
ULATING APPENDICITIS.  G. 
Grey  Turner, 523 

TYPHOID  FEVER,  PERITONITIS  IN. 

Farquhar  Macrae 523 

UTERUS,  FIBROID  TUMORS  OF  THE. 

F.  II.   Martin 523 

VARICOSE    ULCERS.      P.  Leole 524 

VERTIGO    OF   AURAL    CAUSATION. 

C.  J.  Blake 524 

WOUNDS,  INFLUENCE  OF  PNEU- 
MOCOOCI  ON  THE  HEALING 
OF.     J.  Wirt  Robinson 525 

BOOK  REVIEWS 62S 

BOOKS  AND  MONOGRAPHS  RE- 
CEIVED     527 

EDITORIAL  STAFF 628 


Editorials. 

DEPARTMENT   IN    CHARGE   OF 

J.  MADISON  TAYLOR,  A.M.,  M.D. 

THE   DISCOVERY   OF   SURGICAL   ANAESTHESIA. 


Dr.  Long's  friends  do  not  by  any  means  claim  that  he  was  the  originator  of 
anaesthesia,  or  as  it  was  known  before  this  new-coined  name  came  into  the  profes- 
sion "the  possibility  of  putting  patients  into  a  trance,"  "a  deep  terrible  dream,  by 

(481) 


482  THE  DISCOVERY  OF  SURGICAL  AN^THESIA. 

the  inhalation  oJ'  a  vapor/*  or  as  more  latterly  it  was  defined,  "loss  of  sensation 
produced  by  some  drug." 

As  I  understand  the  history  of  anaesthesia,  or  the  use  of  anesthesia,  it  is  this : 
Insensibility  or  indifference  to  pain  was  first  prodiiced  by  Indian  hemp  (cannabis 
indica),  either  inhaled  or  taken  into  the  stomach.  Fifteen  hundred  years  ago,  at 
least  fourteen,  hundred  years  before  Sir  Humphrey  Davy,  to  whom  Dr.  Eberhardt 
ascribes  the  honor  of  being  the  originator  of  modern  anaesthesia,  commenced  his 
scientific  experiments,  the  Chinese  used  hemp  for  the  purpose  of  annulling  pain. 
Mandragora  was  used  by  the  Komans  and  Greeks  in  the  form  of  a  vapor  applied  to 
the  nose  for  similar  purposes.  In  England,  three  hundred  years  before  the  time  of 
Davy,  Bullion  wrote  of  the  possibility  of  putting  patients  to  sleep,  to  be  cut  for 
stone,  under  a  combination,  mandragora,  opium,  etc.,  in  shape  of  vapor,  to  be  applied 
to  the  nose.     This  idea  soon  became  obsolete. 

About  this  time,  John  Baptista  Portia,  an  Italian,  speaks  of  "a  quintessence, 
extracted  from  medicines  by  a  somniferous  process  and  kept  in  leaden  vessels,  per- 
fectly closed,  lest  the  aura  should  escape."  When  it  was  used,  "the  cover  being 
removed,  it  is  applied  to  the  nostrils  of  the  patient,  who  is  instructed  to  draw  a  long 
breath  till  he  plunges  into  a  profound  sleep;  at  times  it  requires  great  effort  to 
wake  him."  He  writes:  "These  things  are  plain  to  the  skillful  physician,  but  un- 
intelligible to  the  wicked." 

In  1800  Sir  Humphrey  Davy  suggested  nitrous  oxide  or  "laughing  gas"  as  an 
anaesthesic.  But  Dr.  Pearson,  in  1795,  used  the  vapor  of  sulphuric  ether  to  relieve 
spasmodic  affections  of  respiration,  thereby  indirectly  relieving  pain. 

The  mere  fact  that  ether  could  produce  insensibility  was  shown  by  several 
American  physicians — Goodwin,  in  1822;  Mitchell,  in  1832;  Jackson,  in  1833; 
Wood  and  Bache,  in  1838.  But  it  was  first  used  by  Dr.  Crawford  W.  Long,  of 
Georgia,  to  prevent  pain  in  a  surgical  operation  performed  on  a  Mr.  Venable  in  the 
extraction  of  a  tumor  during  the  month  of  October,  1842.  Next  by  Dr.  Morton, 
a  dentist,  in  Boston,  in  1846.  News  of  the  success  in  the  use  of  ether,  as  an  anaes- 
tic,  soon  reached  Europe,  and  Mr.  Lister,  an  eminent  surgeon  of  England,  and  a 
Mr.  Kobson,  a  dentist,  at  once  operated  on  patients,  rendered  insensible  by  the 
inhalation  of  sulphuric  ether.  Within  about  one  year  from  this  time,  Sir  Edward 
Y.  Simpson,  of  Edinburgh,  began  to  use  chloroform  for  the  same  purpose. 

At  the  time  of  Dr.  Long's  first  practical  application  of  sulphuric  ether,  in 
1842,  for  anaesthetic  purposes  in  surgery,  he  was  a' young  man,  having  practiced 
medicine  only  two  or  three  years.  He  was  diffident,  and  as  all  medical  gentlemen 
of  his  day  were,  he  was  averse  to  public  notoriety  of  any  sort  whatever.  He  felt  it 
beneath  the  dignity  of  a  Southern  gentleman  to  parade  his  name  in  the  newspapers 
of  the  day.    Especially  did  a  Southern  practitioner  of  medicine  feel  that  there  was 


THE  DISCOVERY  OF  SURGICAL  ANESTHESIA.  483 

an  odium  attached  to  his  name  in  any  such  connection.  Well  do  I  remember  how 
averse  Dr.  Long  was  to  having  his  discovery  published.  His  first  public  notice  of 
this  discovery  was  published  in  the  Southern  Medical  and  Surgical  Journal  in 
1849,  at  the  earnest  and  most  persistent  solicitation  of  Dr.  L.  A.  Dugas,  the  editor, 
and  Dr.  Paul  F.  Eve,  professor  of  surgery  in  the  Medical  College  of  Georgia.  He 
wanted  no  publicity  in  the  matter,  saying  as  a  Christian  gentleman,  "My  only  wish 
about  it  is  to  be  regarded  as  a  benefactor  to  my  r^ice."  I  was  a  student  in  the 
college  at  the  time  (November,  1848),  and  it  is  with  pleasure  I  can  give  an  extract, 
verbatim,  from  Dr.  Eve's  speech,  as  he  introduced  to  a  class  a  tall,  diffident,  young 
country  doctor.    Dr.  Eve  said : — 

"Our  guest  to-day  comes  unheralded.  No  great  honors  are  heaped  upon  his 
head.  He  is  a  plain,  practical  doctor.  He  comes,  however,  well  equipped  for  the 
duties  of  his  profession.  He  is  learned,  painstaking,  observant.  He  has  already 
mastered  a  scientific  solution,  that  when  properly  learned,  will  entirely  revolutionize 
the  field  of  surgery.  I  introduce  to  you,  young  gentlemen,  Dr.  Crawford  W.  Long, 
whom  posterity  will  honor  as  the  very  first  man  to  apply  practical  anaesthesia  to 
surgical  operations.  I  may  not  live  long  enough  to  see  the  time,  but  young  gen- 
tlemen under  the  sound  of  my  voice  will  see  Dr.  Long  crowned  as  the  greatest 
benefactor  of  suffering  humanity.  To  him  will  be  erected  a  monument  in  the 
grateful  hearts  of  mankind  all  over  the  world,  more  enduring  than  brass,  and  lasting 
than  marble." 

This  extract  bears  date  November,  1848,  fifty  years  ago.  To-day  I  remember 
the  incident  as  though  it  had  happened  only  yesterday. 

During  the  session  of  the  United  States  Congress  of  1854,  Hon.  Junius  Hill- 
yer,  member  from  Georgia,  not  only  introduced,  but  successfully  carried  through 
almost  unanimously,  a  resolution  recognizing  the  claims  of  Dr.  Long  as  the  orig- 
inator of  anaesthesia  in  surgery.  But,  owing  to  too  great  a  sectional  feeling,  the 
resolution  failed  to  pass  the  Seriate. 

In  1859  Dr.  Dugas,  still  editor  of  the  Southern  Medical  and  Surgical  Journal, 
also  at  the  same  time  professor  of  surgery  in  the  medical  department  of  the  Uni- 
versity of  Georgia,  writes:  "We  are  free  to  acknowledge  that  Dr.  Long  has  very 
clearly  established  the  fact  that  in  1842  and  '43  he  had  performed  several  painless 
surgical  operations  under  the  inhalation  of  ether.  Dr.  Long's  modesty  and  disin- 
terestedness have  concurred  to  make  him  satisfied  with  his  own  consciousness  of 
merit.  '  Nothing  would  give  me  more  real  satisfaction  than  to  see  the  honor  of  this 
discovery  fixed  upon  the  brow  of  Crawford  W.  Long,  a  citizen  of  our  own  native 
State." 

In  an  address  before  the  alumni  of  the  University  of  Georgia,  Alexander 
Hamilton  Stephens,  speaking  of  the  great  men  whom  this  institution  at  various 


484  THE  DISCOVERY  OF  SURGICAL  ANESTHESIA. 

times  had  graduated,  said  of  Dr.  Long:  "It  had  given  to  the  world  Dr.  Crawford 
W.  Long,  the  discoverer  of  practical  anaesthesia  applied  to  surgery,  which  to-day 
has  alleviated  more  suffering  than  anything  yet  ever  discovered.  Germany,  France, 
England,  and  Eussia  all  now  acknowledge  Dr.  Long's  claim  to  the  title.  Congress 
had  invited  each  State  in  the  Union  to  forward  the  statues  of  two  of  its  benefac- 
tors to  be  placed  in  the  Art  Gallery  at  Washington.  Georgia  could  not  do  better 
than  to  send  those  of  General  Oglethorpe,  the  founder  of  the  pauper  colony  of 
Georgia,  and  Dr.  Crawford  W.  Long,  the  discoverer  of  anaesthesia  as  applied  to 
surgery." 

Immediately  after  the  address  of  Mr.  Stephens  above  referred  to,  the  physi- 
cians of  Athens  held  a  meeting  and 

"Resolved,  That  we  earnestly  request  that  the  next  legislature  of  Georgia 
make  an  appropriation  for  the  purpose  of  erecting  a  suitable  monument  to  Dr. 
Crawford  W.  Long,  as  the  discoverer  of  anaesthesia  in  surgery,  to  be  located  on  the 
University  grounds." 

Hon.  Henry  W.  Grady,  of  whom  all  America  is  proud,  a  native  of  Athens, 
was  familiar  with  the  discovery  of  anaesthesia  from  its  very  inception,  in  a  speech 
once  said:  "To  Dr.  Crawford  W.  Long  undoubtedly  belongs  the  honor  of  giving 
to  the  world  the  priceless  boon  of  anaesthesia  in  surgery." 

The  Texas  Medical  Times  says:  "Upon  the  venerable  head  of  Dr.  Crawford 
W.  Long  let  us  place  a  wreath  of  laurels  as  a  simple  but  significant  token  of  our 
love  and  gratitude  for  having  bestowed  upon  the  world  its  greatest  benefaction." 
Dr.  J.  H.  Goss,  of  Athens,  says :  "Let  every  one  who  has  been  under  the  influ- 
ence of  the  surgeon's  knife,  but  the  sting  of  which  has  been  relieved  by  ether,  shout 
'Long5  and  loud  for  the  greatest  man  who  ever  lived  in  the  Empire  State  of  the 
South." 

Dr.  L.  G.  Hardman,  of  Commerce,  offered  to  "give  $500  to  begin  a  subscription 
with  which  to  build  a  monument  in  honor  of  Dr.  Long,  to  be  placed  in  the  county 
where  Dr.  Long  first  performed  a  surgical  operation  under  the  influence  of  ether." 
The  Medical  News  says:  "The  leading  medical  journals,  both  North  and 
South,  have  unqualifiedly  expressed  the  opinion  that  Dr.  Crawford  W.  Long  ante- 
dated all  others  in  operating  upon  patients  with  the  use  of  ether  by  several  years." 
Our  own  Dr.  Luther  B.  Granby,  late  United  States  surgeon,  wrote  "that  be- 
yond the  possibility  of  a  doubt  Dr.  Long  antedated  all  others  in  the  use  of  anaes- 
thesia in  surgery." 

Dr.  Eoswell  Park,  President  McKinley's  physician,  says:  "Kindly  therefore 
let  me  add  whatever  influence  my  opinion  may  carry  to  the  expressions  that  to  Dr. 
Crawford  W.  Long  undoubtedly  belongs  the  benefit  of  testimony  that  he  was  the 
first  to  use  anaesthetics  in  surgery." 


.THE  DISCOVERY  OF  SURGICAL  ANESTHESIA.  485 

The  Georgia  Medical  Association  (then  known  as  the  Georgia  State  Medical 
Society),  during  its  annual  session  in  1850,  unanimously  passed  the  following 
resolution : — ■ 

"Resolved,  That  it  is  the  opinion  of  this  Society  that  Dr.  Crawford  W.  Long 
was  the  first  person  who  used  sulphuric  ether  as  an  anaesthetic  in  operations,  and 
as  an  act  of  justice  to  him  individually,  and  to  the  honor  of  the  profession  of  our 
own  State,  we  most  earnestly  recommend  him  to  present  at  once  his  claims  to 
priority  in  the  use  of  this  most  important  agent  to  the  consideration  of  the  Amer- 
ican Medical  Association  at  its  next  meeting." 

The  Medical  Association  of  Louisiana  unanimously  resolved : — 

"That  we  unite  with  our  brethren  of  Georgia  and  the  whole  South  in  recom- 
mending that  one  of  the  proposed  statues  to  be  erected  by  the  State  of  Georgia  be 
dedicated  to  the  memory  of  Dr.  Crawford  W.  Long,  whom  we  regard  with  pride  and 
admiration,  not  only  as  one  of  the  South's  most  illustrious  sons,  but  one  of  the 
greatest  benefactors  that  America  has  given  to  the  world.  His  claims  for  recog- 
nition and  gratitude  of  his  fellow-men  rest  upon  the  benefactions  to  mankind  which 
are  not  limited  by  the  boundaries  of  his  State  or  nation,  but  as  vast  as  humanity 
itself.'" 

To  these,  and  similar  endorsements,  fully  as  strong,  I  can  add  at  least  fifty 
more  from  the  very  best  surgeons,  physicians,  and  medical  journals,  not  only  of 
America,  but  of  almost  every  country  in  the  civilized  world.  Such,  for  instance,  as 
Dr.  Hugh  M.  Young,  surgeon  to  Johns  Hopkins  University;  Dr.  William  L.  Eod- 
man,  professor  of  surgery  in  the  Medico-Chirurgical  College,  of  Philadelphia;  Dr. 
W.  W.  Keen,  an  author  of  "American  Text-Book  of  Surgery,"  and  last,  but  by  no. 
means  least,  the  Doctors  Gaston,  of  Atlanta,  who  say:  "From  the  history  of  anaes- 
thesia it  is  evident  to  the  impartial  student  that  the  idea  of  utilizing  ether  in  sur- 
gical operations  originated  in  a  doctor's  mind  and  not  a  chemist's.  The  most  fitting- 
way  of  celebrating  the  semi-centennial  of  the  discovery  of  anaesthesia  in  surgery  will 
be  when  the  name  of  Dr.  C.  W.  Long  receives  recognition  in  some  substantial  form.'" 

Dr.  J.  McFadden  Gaston,  Sr.,  was  for  at  least  a  half  century  a  leading  sur- 
geon, both  of  this  country  and  of  Brazil.  In  his  own  native  South  the  members  of 
his  profession  entrusted  to  him  many  important  positions.  At  one  time  he  was 
president  of  the  Southern  Surgical  and  Gynaecological  Association,  vice-president 
of  the  American  Surgical  Association,  and  author  of  "Gaston's  Operation."  He 
was  ranking  surgeon  at  the  battle  of  Manassas,  and  held  an  important  position 
throughout  the  whole  civil  war.  After  the  suspension  of  the  Confederacy  he  spent 
sixteen  years  in  Brazil.  Beturning  home,  he  was  then  for  man}  years  professor  of 
surgery  in  the  Southern  Medical  College  of  Atlanta. 

As  another  instance  of  the  "eternal  fitness  of  things,"  Dr.  J.  McFadden  Gas- 
ton, Jr.,  to-day  occupies  both  the  chairs  of  surgery  and  chemistry  in  the  Southern 


486  THE  DISCOVERY  OF  SURGICAL  ANAESTHESIA. 

Medical  Training  School,  a  recently  established  institution,  under  favorable  au- 
spices, in  this  city.  The  above  remark  of  "utilization  of  anaesthesia  originated  in 
a  doctor's  mind,  and  not  a  chemist,"  was  made  by  him  several  years  before  the  above 
happy  combination  of  chairs.     (E.  J.  Massey,  M.D.) 

The  above  communication  by  Dr.  R.  J.  Massey,  Nestor  of  medicine  in  Georgia, 
is  a  very  important  historical  production.  I  do  not  know  of  any  subject  upon 
which  I  can  write  a  signed  editorial  more  pertinently. 

The  discovery  of  surgical  anaesthesia  has  been  the  subject  of  criticism  and 
comment  for  the  last  decade  by  a  great  number  of  physicians,  surgeons,  and  chem- 
ists.   It  is  time  that  the  truth  should  have  been  sifted  out  of  error.     Attention  has 
•  been  directed  to  a  letter  published  in  the  Atlanta  News  over  the  signature  of  Pro- 
fessor Everhardt,  a  chemist  who  has  given  the  subject  some  attention,  from  the 
standpoint  of  the  early  suggestion  of  nitrous  oxide  and  sulphuric  ether  by  Sir 
Humphrey   Davy   and   Michael   Faraday.     He   draws   the   conclusion   that   to    Sir 
Humphrey  Davy  and  Michael   Faraday  belong  the  achievements  of  modern  sur- 
gery, beginning  with  the  use  of  nitrous  oxide  and  ending  with  that  of  sulphuric- 
ether  and  chloroform.     He  is  surprised  that  there  should  be  given  to  Crawford  W. 
Long  the  credit  for  the  discovery  of  the  surgical  anaesthesia  obtained  from  sulphuric 
ether.    In  order  to  properly  understand  the  difference  between  a  bare  suggestion  of 
sulphuric  ether  as  a  possibility  in  surgery,  and  the  actual  removal  of  a  tumor  under 
anaesthesia,  we  have  only  to  note  that  the  same  reasoning  should  apply  to  all  of 
Edison's  discoveries  and   all   of  the   chemical   and   electro-chemical   discoveries  of 
this  age.     For  these  two  men,  Sir  Humphrey  Davy  and  Michael  Faraday,  were  the 
pioneers,  without  whom  chemistry  and  electro-chemistry  would  be  almost  without 
chart  or  compass.    Surgical  anaesthesia  would  probably  be  in  the  same  condition.    The 
actual  application  of  chloroform  by  Simpson  and  of  ether  by  Long  were  great  achieve- 
ments regardless  of  whatever  had  been  suggested  as  a  possibility  by  Davy  or  Faraday. 
The  drugs  were  potential  of-  great  good  to  humanity,  but  it  required  skill,  courage, 
ami  <urgical  knowledge  to  apply  them.    The  actual  performance  of  an  operation  either 
upon  the  cadaver  or  upon  lower  animals,  or  upon  living  human  beings,  is  neces- 
sary to  establish  the   claims  of  priority.      It   is   very  probable  that  if   Professor 
Everhardt  should   investigate  still   further  back,   he   would  find  "records  of   these 
same  drugs  in  the  old  Egyptian  lore,  or  in  the  hoary  past  he  might  find  inscriptions 
that  he  might  interpret,  in  the  light  of  to-day,  to  have  given  to   Long  his  idea. 
This  does  not  really  mean  anything.     There  is  nothing  new  under  the  sun,  when 
viewed  in  the  way  Professor  Everhardt  views  this  subject.     The  fact  that  Dr. 
Crawford  W.  Long  removed  from  a  man  named  Venable  a  tumor  and  that  he  had 
no  pain  in  undergoing  this  operation,  is  the  great  fact  that  led  to  the  use  of  ether 
by  Morton  and  all  others  who  followed  Long.     There  may  have  been  other  opera- 


RICKETS  AND  THE  NERVOUS  SYSTEM.  487 

tions  performed  under  ether  in  years  gone  by  that  we  knew  nothing  of,  but  we 
can  only  go  by  the  historical  facts  and  the  dates. 

This  should  be  sufficient,  and  let  those  who  wish  investigate  the  facts  for 
themselves. 

James  McFadden  Gaston.* 


RICKETS  AND  THE   NERVOUS  SYSTEM. 

"What  is  rickets?"  parents  often  query.  And  is  it  not  one  of  the  ironies 
of  fate  that  the  most  common  of  all  infantile  diseases  should  be  so  little  known  to 
educated  laymen?  But  may  we  blame  them?  Xot  without  inviting  the  charge  of 
professional  ignorance;  for  by  many  medical  men  rickets  is  considered  still  a  dis- 
ease of  the  osseous  system  alone,  as  it  was  when  G-lisson  described  it  more  than  two- 
and-a-half  centuries  ago.  That  it  may  be  recognized  long  before  these  gross  distor- 
tions of  bones  take  place,  is  often  unknown  or  forgotten;  that  it  may  work  much 
injury  upon  other  tissues  without  producing  bow-legs,  knock-knees,  etc.,  is  again 
far  from  common  knowledge.  At  hand  is  a  letter  from  an  able  physician  in  an- 
other State,  inquiring  as  to  the  cause  of  a  baby's  large  head,  stating  that  the 
patient  has  neither  rickets  nor  hydrocephalus,  and  yet  giving  a  clear  account  of  a 
case  of  rickets  as  one  sees  it  so  often  in  private  practice. 

To  the  pediatrist,  though  it  still  presents  etiologic  problems  of  importance, 
rickets  is  a  metabolic  disorder.  The  innutrition  affects,  or  is  capable  of  affecting, 
every  structure  in  the  body,  not  excepting  that  great  liquid  tissue,  the  blood.  But  if 
the  modern  pediatrician  were  asked :  "Upon  what  tissues  does  this  disease  exert 
its  most  serious  effects?'"  I  think  that  the  reply  would  be:  "Upon  those  of  the 
nervous  system." 

It  is  the  purpose  of  the  writer  to  point  out  some  of  the  nervous  phenomena  that 
are  seen  in  rachitic  children,  and  this  at  the  risk  of  reciting  what  is  well  known  by 
specialists,  and  should  be  known  by  general  practitioners. 

Such  so-called  functional  nervous  affections  as  laryngismus  stridulus,  rotary 
spasm  (gyrospasm),  nodding  spasm,  and  tetany  are  almost  invariably  observed  in 
infants  presenting  sufficiently  well-marked  evidence  of  rickets.  More  than  this, 
these  conditions  disappear  with  the  betterment  of  the  patient's  nutritive  condition. 

In  an  article  upon  "Functional  Enuresis,"  published  nearly  a  decade  ago,  the 
writer  called  atention  to  the  frequency  with  which  this  troublesome  disorder  pre- 
sented itself  in  rickety  subjects. 

Then  how  often  convulsions  are  seen  in  babies  suffering  from  rickets.  The 
infantile  nervous  system  is  far  more  sensitive  to  external  stimuli,  far  more  inco- 

*  Professor  of  Principles  and  Practice  of  Surgery,  Southern  Medical  Training  School, 
Atlanta,  Ga. 


488  RICKETS  AND  THE  NERVOUS  SYSTEM. 

ordinate  in  its  response  to  stimulation  than  the  nervous  mechanism  of  the  adult. 
Nor  is  the  exciting  importance  of  the  so-called  "reflex  disturbances"  to  be  denied. 
But  do  gastro-intestinal  causes,  intestinal  worms,  adherent  prepuces,  hypermetropic 
astigmatism,  adenoids,  dentition,  etc.,  cause  eclampsia  neonatorum  in  otherwise 
healthy  babies?  Not  as  a  rule.  There  is  usually  some  underlying,  anterior,  or  pre- 
disposing cause;  and  most  frequently  that  cause  is  rickets.  ^  "As  a  predisposing 
cause  of  convulsions  in  infancy,  rickets  take  the  first  place."     (Holt.) 

Nor  is  this  all.  It  seems  to  be  generally  conceded  that  eclampsia  neonatorum 
may  gradually  merge  into  idiopathic  epilepsy  itself.  The  so-called  convulsive 
eclamptic  or  epileptic  habit  will  have  then  been  formed.  Only  a  few  years  ago, 
while  visiting  at  Elwyn,  Dr.  Barr  remarked  to  the  writer:  "It  is  astonishing  how 
many  of  our  epileptic  adults  had  eclampsia  in  infancy."  And  in  a  much  restricted 
field  of  work  this  has  been  the  repeated  observation  of  the  writer.  Thus  rickets 
would  seem  a  cause,  indirect  and  remote  though  it  be,  of  certain  cases  of  epilepsy. 

It  has  seemed  to  him,  too,  that  this  disease  of  nutrition  plays  an  occasional 
etiologic  role  in  the  production  of  the  nervous  or  neurotic  temperament.  He  does 
not  for  an  instant  disparage  the  causative  importance  of  nervous  heredity,  of  bodily 
ills,  nor  of  faulty  training;  but  lie  is  practically  convinced  that  the  last  two  stimu- 
late more  efficiently  these  neurotic  outgrowths  when  they  operate  upon   rachitic 

soil. 

As  a  cause  of  "backwardness"  rickets  must  also  take  a  high  place.  Motor  and 
sensory  devlopment  may  be  much  delayed  in  the  rickety  infant,  just  as  dentition 
is  retarded.  But  is  not  the  acquirement  of  speech  likewise  delayed?  It  is  not  un- 
usual for  such  babies  to  learn  to  talk. after  they  are  two  years  old.  This  thought 
might  be  enlarged  upon,  as  in  the  rickety,  hyperplasia  of  lymph-adenoid  tissue  is 
prone  to  occur.  S<>  as  a  predisposing  cause  of  adenoid  growths  in  the  naso-pharynx 
(so  often  an  etiologic  factor  in  the  production  of  backwardness)  rickets  may  again 
loom  large  in  the  background. 

It  has  been  the  good  fortune  of  the  writer  to  study  five  cases  of  Mongolian 
imbecility,  where  the  patients  were  very  young.  In  every  case  well-marked  stig- 
mata of  rickets  were  present.  To  ascribe  to  this  nutritive  disease  the  production 
of  the  mental  deficiency  is  not  intended.  Enough  proof  is  not  at  hand.  But  every 
one  of  these  infants  improved  mentally  when  the  proper  treatment  for  rickets  was 
instituted. 

In  passing,  it  might  be  mentioned  that  in  every  case  of  amaurotic  family 
idiocy  carefully  reported,  mention  of  the  existence  of  rickets  lias  also  been  made. 
Of  course  this  statement  is  not  meant  to  imply  a  relation  of  cause  and  effect. 

Certain  authorities  view  rickets  as  a  cause  of  hydrocephalus,  but  as  this  is  a 
moot  question,  it  receives  only  mention  here. 


HYPERTROPHY  OF  VARIOUS  TONSILS  OF  WALDEYER'S  RING.  489 

Tn  conclusion  let  it  simply  be  said  that  the  man  who  recognizes  rickets  early, 
who  treats  it  early  by  intelligent  dietetic  and  hygienic  measures,  perforins  an  im- 
portant service  for  the  individual  and  the  race. 

James  Herbert  McKee.* 


THE  RELATION  WHICH  HYPEETEOPHY   OF  THE  VARIOUS 

TONSILS  OF  WALDEYER'S  RING  BEARS  TO  THE 

ETIOLOGY  OF  DISEASE. 

This  ring  is  composed  of  masses  of  lymphoid  tissue  situated  in  the  pharynx 
and  connected  with  each  other  more  or  less  by  lymph  channels.  The  constituent 
parts  of  the  ring  are  the  pharyngeal  tonsil;  the  two  faucial  tonsils,  located  on 
either  side  between  the  pillars  of  the  fauces,  and  the  lingual  tonsil,  lying  on  the 
posterior  fourth  of  the  tongue  on  either  side  of  the  glosso-epiglottic  fold  and  behind 
the  circumvallate  papilla*.  Owing  to  the  separation  into  two  lateral  halves,  which 
sometimes  occurs  in  the  latter,  some  writers  look  upon  it  as  double.  The  same 
might  be  said  of  the  pharyngeal  tonsil,  but  for  all  practical  purposes  these  are  single 
bodies,  and  may  be  considered  as  such. 

Besides  these  various  tonsils,  there  is  also  situated  within  each  ventricle  of 
the  larynx  a  minute  area  of  adenoid  tissue.  But  as  it  requires  for  physiologic  pur- 
poses the  demonstration  of  the  microscope,  and  has  little  if  any  bearing  upon  the 
health  of  the  individual,  it  may  logically  be  left  out  of  . the  circle  of  Waldeyer's 
ring;  as  also  may  the  small  amount  of  lymphoid  tissue  which  in  some  instances 
develops  in  the  middle  turbinal  region  of  the  nose. 

In  foetal  life  the  tonsils  rarely  advance  beyond  a  rudimentary  stage,  hence  at 
birth  the  post-pharynx  is  usually  smooth;  the  space  between  the  faucial  pillars  free 
from  glandular  enlargement,  and  the  base  of  the  tongue  marked  only  by  the  normal 
development  of  the  circumvallate  papillae. 

This  is  the  condition  usually  found,  even  in  cases  in  which  serious  hyper- 
trophy of  the  different  tonsils  subsequently  takes  place.  The  period  of  develop- 
ment of  the  pharyngeal  and  faucial  tonsils  is  between  the  first  and  eighth  years. 
while  the  lingual  tonsil  rarely  manifests  itself  to  a  notable  degree  until  near  the 
period  of  puberty.  Still,  in  rare  instances,  both  the  pharyngeal  and  faucial  tonsils 
arc  well  formed  at  the  period  of  birth — a  sure  indication  of  subsequent  hyper- 
trophy. 

The  tonsils  are  physiologic  structures  of  a  lymphoid  character;  and  when  nor- 
mally developed  are  essential   l"  the  physical  well-being  of  the  individual.     It   is 

*  Professor  of  Pedriatrics  in  the  Philadelphia  Polyclinic  and  in  the  Woman's  Medical 
College  of  Philadelphia. 


490  HYPERTROPHY  OF  VARIOUS  TONSILS  OF  WALDEYER'S  RING. 

only  when  they  grow  to  larger  than  normal  size,  and  the  tissues  of  which  they  are 
composed  lose  their  proper  balance,  that  they  become  a  menace  to  health  and 
demand  interference  on  the  part  of  the  physician  or  surgeon. 

Tonsillar  tissue  is  composed  of  follicles.  Each  follicle  consists  of  a  collection 
of  lymphoid  or  adenoid  cells  packed  closely  together,  containing  a  central  endo- 
thelial reticulum  and  forming  a  unit.  These  units  are  grouped  together,  being 
separated  from  each  other  by  a  similar  endothelial  network,  consisting  of  fine 
trabecule  of  connective  tissue  elements,  containing  plasma  and  lymphoid  cells. 
In  the  different  tonsils  these  adenoid  follicles  are  variously  massed,  and  are  cov- 
ered by  mucous  membrane  of  squamous  or  columnar  character.  In  the  case  of 
the  pharyngeal  tonsil,  ciliated  epithelium  partially  covers  the  columnar. 

On  the  free  surface  the  mucous  membrane  is  of  a  compound  nature,  equal  in 
density  to  the  surrounding  mucosa;  but  in  the  sulci  and  invaginations  which  are 
present  in  a  more  or  less  degree  in  all  the  tonsils — parts  that  are  less  exposed  to 
external  irritation — the  membrane  is  much  thinner,  looser  in  texture,  and  pos- 
sesses less  power  of  resistance. 

In  certain  points,  however,  while  composed  in  the  main  of  tissues  that  are 
histologically  alike,  the  various  tonsils  differ  from  each  other  in  structure  as  well 
as  function. 

The  pharyngeal  tonsil,  situated  on  the  posterior  and  superior  wall  of  the  naso- 
pharynx, consists  of  adenoid  tissue  held  together  by  fine  trabecule  of  connective 
filaments.  It  is  frequently  glomerate;  but  sometimes  racemose  and  divided  into 
many  segments.  When  the  lymphoid  tissue  of  which  it  is  composed  invades  tlie 
region  of  the  Eustachian  tube  and  the  fossa  of  Rosenmuller,  it  is  called  the  tubal 
tonsil,  although  really  only  aji  extension  of  the  pharyngeal.  The  mucous  mem- 
brane is  usually  thin  and  formed  of  columnar  epithelium,  superimposed  in  part  by 
a  layer  of  cilia.  The  gland  in  its  developed  stage  is  richly  supplied  with  blood. 
When  normal  the  size  is  never  large  enough  to  interfere  with  respiration.  Devel- 
opment is  accomplished  by  the  eighth  or  tenth  year.  Atrophy  then  commences  and 
is  complete  by  the  end  of  adolescence. 

'  The  pharyngeal  tonsil  differs  from  the  faucial  and  lingual  in  being  located 
in  a  region  comparatively  free  from  germ  life,  the  inspired  air  being  filtered  of 
bacteria  during  its  passage  through  the  nasal  cavities.  The  secretions  of  the 
numerous  glands,  of  which  the  tonsil  is  partially  composed,  likewise  act  as  a  cov- 
ering to  protect  against  attack  from  morbific  agencies;  while  the  invaginations  of 
mucous  membrane,  being  shallower  than  those  located  in  the  faucial  tonsil,  are 
less  likely  to  favor  retention  and  decomposition  of  any  foreign  matter  that  per- 
chance may  find  a  lodgment  in  the  naso-pharynx. 


HYPERTROPHY  OF  VARIOUS  TONSILS  OF  WALDEYER'S  RING.  491 

These  facts  refer  to  the  normal  pharyngeal  tonsil  which  pursues  its  develop- 
ment between  the  first  and  the  eighth  years.,  and  disappears  by  atrophy  during  the 
period  of  early  maturity. 

The  faucial  tonsils,  while  coinciding  with  the  pharyngeal  in  regard  to  period 
of  development  and  atrophy,  differ  from  it  in  several  important  points.  The  crypts 
are  wider,  deeper,  and  more  numerous.  Owing  also  to  the  oft-repeated  action  of 
the  pillars  of  the  fauces  they  favor  both  secretion  and  absorption.  The  loose  retic- 
ulum in  the  deep  invaginations  readily  admits  the  passage  of  bacteria  into  the 
lymph  channels.  At  the  same  time  there  is  constant  exposure  to  the  passage  of 
bacilli  of  various  forms  in  the  act  of  deglutition,  which  does  not  occur  in  the  case 
of  the  phar}mgeal  tonsil. 

The  lingual  tonsil,  composed  of  a  series  of  rounded  elevations  or  follicles  of 
adenoid  tissue,  situated  on  the  base  of  the  tongue,  rarely  develops  to  any  observable 
degree  during  child  life,  being  practically  absent  up  to  the  adolescent  period.  In 
it  the  lacunas  are  short  and  wide-mouthed,  and  the  construction  racemose.  The 
mucosa  within  the  crypts  being  composed  of  dense,  stratified  epithelium,  there  is 
less  likelihood  of  absorption  through  its  meshes  than  is  the  case  in  the  faucial 
tonsil.  Eetention  of  lacunar  contents  is  practically  impossible,  as  the  fluids  that 
are  so  frequently  swallowed  wash  not  only  the  surface,  but  the  crypts  likewise. 

It  is  not,  however,  when  the  lymphoid  masses,  located  in  the  pharynx  and 
designated  tonsils,  are  in  a  normal  condition,  that  they  injuriously  affect  life,  but 
when  they  are  abnormally  developed.  It  is  the  presence  of  h}rpertrophy  that 
assumes  the  threatening  aspect,  and  from  what  has  already  been  said,  it  is  manifest 
that  the  effects  differ  directly  with  the  location  of  that  hypertrophy. 

1.  Although  it  may  be  considered  an  established  rule  for  the  pharyngeal  tonsil 
in  the  child  to  pass  through  a  course  of  development  and  atrophy,  yet  in  a  large 
majority  of  instances  the  development  is  normal,  creating  neither  symptoms  nor 
functional  disturbances.  In  the  minority,  however,  both  occur,  a  sure  indication 
that  Nature  has  passed  her  legitimate  bounds,  and  that  hypertrophy  has  developed. 

Many  causes  may  contribute  to  this  effect.  Probably  constitutional  dyscrasia 
is  entitled  to  the  first  place.  In  syphilitic  and  tubercular  conditions,  and  in 
hereditary  tendency  toward   lymphatic  development,  we  have  primal  factors. 

As  exciting  causes,  damp  conditions  of  climate,  residence  in  unhealthy  locali- 
ties, constant  breathing  of  impure  or  dust-laden  air,  ill-regulated  exercise,  poor 
food,  defective  clothing,  may  be  considered  as  the  chief. 

Even  when  abnormal  enlargement  has  taken  place,  the  growth  being  composed 
simply  of  hypertrophy  of  normal  i issue,  no  systemic  injury  would  result  but  for 
the  obstruction  to  respiration  which  its  presence  induces.  In  this,  the  consequences 
may  be  very  serious,  for  it  converts  the  nasal  breathing,  the  only  natural  method. 


492  HYPERTROPHY  OF  VARIOUS  TONSILS  OF  WALDEYER'S  RING. 

into  the  oral.  In  the  former  the  air  is  heated,  saturated,  and  purified,  while  pass- 
ing through  the  nasal  passages,  putting  it  into  a  fit  condition  to  enter  the  lungs; 
while  in  the  latter  it  is  dry  and  often  impure  when  reaching  the  pharynx  and  larynx, 
and  as  a  result  is  the  cause  of  many  forms  of  irritative  disease. 

The  presence  of  an  enlarged  pharyngeal  tonsil  has  also  in  many  instances  a 
serious  effect  upon  aural  respiration,  as  the  pressure  of  a  tubal  hypertrophy  upon 
the  Eustachian  tube  not  infrequently  so  closes  its  lumen  that  the  air  cannot  pass 
through  to  the  middle  ear. 

The  result  is  absorption  of  the  air  within  the  drum,  collapse  of  the  drum 
membrane  upon  the  ossicles,  and  not  infrequently  bacterial  invasion  and  suppura- 
tion of  the  middle  ear. 

As  a  further  result  of  interference  with  normal  breathing,  oxygenation  of  the 
blood  becomes  less  perfect  and  resistance  less  sustained. 

2.  In  hypertrophy  of  the  faucial  tonsils,  although  the  etiology  and  the  period 
of  life  are  the  same  as  in  the  development  of  adenoids,  the  systemic  effects  are  dif- 
ferent. The  faucial  tonsils  possess  in  much  larger  degree  the  power  of  both  secre- 
tion and  absorption.  They  admit  bacteria  freely  into  their  crypts,  favoring  their 
passage  through  the  loose  connective  tissue  which  separates  the  follicles  into  the 
lymph  and  venous  channels,  thus  contaminating  the  blood-supply.  They  are  also 
exposed  open-mouthed  to  the  great  army  of  germ  life  which  passes  into  the  prima 
vice  during  deglutition,  a  danger  that  the  pharyngeal  tonsil  escapes.  It  is  possible, 
too,  that  the  palato-glossal  and  palatopharyngeal  muscles,  which  enclose  the  tonsil, 
may,  during  the  countless  times  in  which  they  press  upon  it,  not  only  aid  secretion, 
but  favor  absorption  as  well. 

It  is  during  the  period  of  childhood  that  the  faucial  tonsils  assume  their 
greatest  hypertrophy,  and  it  is  during  that  period  that  exanthematous  diseases 
prevail  to  the  widest  extent.  The  question  is,  what  relation  does  the  one  fact  bear 
to  the  other  ?  Is  it  not  due  to  the  innumerable  avenues  open  to  the  entrance  of 
bacteria  through  the  soft  spongy  faucial  tonsils?  Clinical  evidence  has  proved  that 
children  possessing  large  soft  tonsils  are  not  only  more  frequently  attacked  by 
scarlatina,  measles,  diphtheria,  etc.,  than  are  children  of  a  similar  age  whose  tonsils 
are  normal,  but  that  the  attacks  are  much  more  likely  to  be  of  avirulent  and  fatal 
type  in  the  one  than  the  other.  Do  not  these  facts  indicate  that  the  child  possess- 
ing the  hypertrophy  has  more  avenues  through  which  the  bacilli  can  enter  the 
system,  and,  also,  that  he  possesses  less  power  of  resistance? 

In  cases  of  tonsillar  hypertrophy  extending  into  adult  life,  the  constant  oral 
breathing  renders  the  tonsils  very  susceptible  to  inflammatory  action.  In  these 
successive  attacks  of  tonsillitis,  the  crypts,  particularly  near  the  proximal  sides,  arc 
filled  with  exfoliated  epithelial  cells,  polynuclear  neutrophiles,  bacteria,  lymphoid 


HYPERTROPHY  OF  VARIOUS  TONSILS  OF  WALDEYER'S  RING.  493 

cells,  and  in  many  cases,  fibrin,  resulting  in  a  gradual  hypertrophy  of  connective 
tissue  elements  with  a  tightening  of  the  cryptal  orifices.  Although  the  condition 
may  be  slow  in  development,  it  is  progressive,  leading  to  the  growth  of  fibrous  tissue 
at  the  expense  of  adenoid. 

This  may  be  attended  by  two  results.  When  the  successive  inflammatory 
attacks  induce  final  adhesion  of  the  lacunar  orifices,  and  of  the  outer  ends  of  the 
cryptal  walls,  cyst-like  cavities  are  likely  to  occur  in  the  deeper  structures,  which 
may  be  filled  with  pathological  debris  and  bacteria.  When  the  occlusion  is  not 
complete,  saprophytic  invasion  through  what  remains  of  the  cryptal  orifices  is  likely 
to  result,  with  decomposition  of  the  lacunar  contents. 

Hence,  in  adult  life,  the  permanently  enlarged  tonsil  is  likely  to  present  a 
hard  fibrous  surface,  whose  closed  crypts,  on  the  one  hand,  may  be  distended  by 
cyst-like  cavities  filled  with  putrescent  matter;  or,  on  the  other,  possessed  of  open 
cavities  with  narrow  outlets,  through  which  are  forced  by  the  action  of  the  faucial 
muscles  foul,  cheese-like  masses  undergoing  putrefaction.  In  cither  case  the  decom- 
position process  is  the  result  of  prolonged  retention,  and  in  either  case  is  apt  to 
produce  a  condition  of  physical  debility. 

It  is  thus  an  accepted  fact  that  micro-organisms  reach  the  circulatory  system 
through  minute  blood-vessels  and  lymphatics,  and  that  one  of  the  principal  avenues 
of  entrance  is  through  the  crypts  of  the  faucial  tonsil.  Hence,  it  is  believed  that 
the  various  bacteria  of  the  exanthemata  may  enter  in  this  way,  as  also  do  the 
bacillus  of  Pfeiffer  in  influenza,  and  the  diplococcus  in  rheumatism. 

It  follows  that  when  in  early  life  the  tonsils  are  enormously  enlarged,  with 
multiplied  and  deepened  crypts,  and  widely  extended  and  attenuated  mucosa,  the 
dangers  of  infection  are  at  the  highest,  and  the  physician  should  lie  fully  cog- 
nizant of  the  possible  result  should  he  allow  such  adverse  conditions  to  remain. 

3.  Hypertrophy  of  the  lingual  tonsil  differs  materially  in  its  effects  upon  the 
system  from  the  two  already  discussed.  It  usually  develops  at  a  period  of  life  in 
which  the  pharyngeal  and  faucial  tonsils  have  not  only  performed  their  doubtful 
functions,  but  have  also  passed  through  their  retrograde  metamorphosis  and  dis- 
appeared. Quite  possibly  the  presence  of  a  lymphoid  cachexia,  may  be  an  important 
factor  in  its  development,  and  it  may  occur  only  in  individuals  Who  have  pre- 
viously suffered  to  a  more  or  less  degree  from  adenoid  or  faucial  hvpertrophy; 
nevertheless,  its  history  and  the  effects  upon  the  physical  system  are  so  markedly 
its  own  thai  it,  is  worlhv  of  a  separate  place  in  the  study  of  the  lymphoid   ring. 

As  said  before,  the  lacunae  in  the  lingual  tonsil,  even  when  developed  into  a 
condition  of  hypertrophy,  are  so  short,  so  widely  open,  and  so  freely  washed  by  the 
oft-repeated  swallowing  of  fluids,  that  retention  of  bacteria  and  decomposition  of 
substances  within  the  crypts  cannot  very  well  occur.  So  thai  there  seems  to  be 
.little  probability  of  septic  infection  occurring  from  retained  excreta. 


494  CONSTITUTIONAL  TREATMENT  OF  RHEUMATIC  CONDITIONS. 

Hence,  the  evils  which  hypertrophy  of  the  lingual  tonsil  give  rise  to  are  chiefly 
of  a  local  character.  They  consist  of  a  feeling  of  swelling  at  the  base  of  the  tongue, 
the  presence  of  mucus  in  the  throat,  the  sensation  of  a  foreign  body  in  the  glosso- 
epiglottic  notch,  and  disturbance  of  the  normal  voice — the  last  mentioned  being 
particularly  noticeable  in  the  case  of  singers  and  speakers. 

This  category  of  symptoms  and  effects,  which  owe  their  existence  in  so  large 
a  degree  to  the  presence  of  hypertrophy  in  the  various  segments  of  the  pharyngeal 
tonsillar  ring,  clearly  indicate  the  advisability  of  eliminating,  as  far  as  possible, 
this  element  in  the  etiology  of  disease.  While  we  recognize  the  fact  that  these 
tonsils  are  in  some  way  necessary  to  the  proper  and  efficient  development  of  the 
individual,  that  they  perform  some  function  in  the  animal  economy,  no  matter 
how  obscure  that  function  may  be,  we  at  the  same  time  realize  that,  when  hyper- 
trophied,  they  introduce  an  element  of  danger  that  distinctly  threatens  the  well- 
being  and  sometimes  the  life  of  the  patient,  and  that  it  is  our  duty  to  relieve  him 

of  the  onus  of  unnecessary  risk. 

J.  Price-Brown, 

Toronto. 


REMARKS   ON  THE   CONSTITUTIONAL  TREATMENT   OF 
RHEUMATIC  CONDITIONS. 

Much  information  exists  on  the  systematic  care  of  rheumatic  conditions,  but 
each  one  needs  to  review  this  exceedingly  diverse  data  and  formulate  certain  prin- 
ciples of  action  which  shall  serve  him  as  practical  guides  in  treatment  of  problems. 
Recently  a  flood  of  articles  has  appeared  in  the  journals  on  this  subject,  many 
of  them  admirable  and  suggestive.  It  seems  to  be  definitely  determined  that  the 
main  underlying  factor  is  a  derangement  in  the  proteid  metabolism. 

Inasmuch  as  many  of  these  sufferers  are  below  par  in  their  general  health, 
the  fact  which  needs  to  be  held  before  the  mind  is  that  rest  of  body  and  brain  is 
essential  along  with  abundant  yet  suitable  diet,  supplemented  by  judicious  methods 
of  life  regulation,  until  the  nutrition  of  the  individual  becomes  well  balanced. 

Enough  has  already  been  said  about  the  diet,  but  no  fixed  rules  as  to  choice  of 
food  can  be  applied  indiscriminately.  The  object  to  be  aimed  at  is  to  prevent  food 
items  burdening  the  organism  with  complicated  factors  of  nutrition  from  intake  to 
elimination.  Simplicity  is  the  object  always,  though  variety  from  day  to  day  is 
important  to  sustain  appetite  and  relish.  Special  care  should  be  exercised  in  main- 
taining the  functions  of  the  elaborating  glands  at  the  normal,  and,  above  all,  the 
action  of  the  great  ductless  glands,  in  order  that  there  shall  be' the  least  possible 
complications  in  the  vasomotor  Sphere. 


CONSTITUTIONAL  TREATMENT  OF  RHEUMATIC  CONDITIONS.  495 

In  brief,  where  the  system  appears  to  be  depleted,  full  feeding  is  needed  for 
a  time,  and  this  can  best  be  accomplished  through  the  use  of  vegetable  foods, 
cereals,  and  especially  green  things,  with  a  cautious  permission  of  raw  fruits,  when 
thoroughly  ripe  'and  in  season,  but  when  out  of  season  or  doubtful,  cooked. 

As  has  been  suggested,  the  most  important  rule  is  to  insist  upon  extreme  care  in 
mastication  until  the  bolus  of  food  shall  be  reduced  to  so  fine  a  mass  that  it  can 
be  no  longer  held  in  the  mouth,  but  is  involuntarily  swallowed.  Next  to  avoid  swal- 
lowing any  coarse  particles  whatsoever.  When  this  is  done,  as  Fletcher  has  shown 
us,  there  will  be  attained  an  extraordinary  sanity  of  taste  through  the  exercise  of 
which  the  individual  can  safely  guide  himself  in  his  choice. 

Guidance  is  essential  on  the  part  of  the  physician,  much  more  careful  than 
can  be  accomplished  through  mere  outlining  permissible  articles  and  excluding 
others.  Thorough  conferences  must  be  held  between  the  patient  and  physician  so 
that  erroneous  tastes  shall  be  modified  and  wholesome  ones  encouraged ;  changes 
being  suggested  from  time  to  time  consonant  with  the  condition  reached. 

In  the  use  of  red  meats,  usually  forbidden,  it  may  be  said  that  at  first,  where 
there  is  hypo-nutrition,  these  are  useful  and  should  be  taken  rare,  broiled,  or  roasted, 
chewing  the  mass  and  swallowing  only  the  soluble  parts,  excluding  rigidly  the 
fibrous  residue.  There  is  no  virtue,  in  my  judgment,  in  omitting  red  meats  and 
permitting  white,  or  fowl,  or  fish.  Again,  all  sweets  are  usually  forbidden,  on  the 
assumption  that  they  induce  the  formation  of  organic  acids.  It  is  more  probable, 
however,  that  the  harmful  influence  of  excess  of  sweets  is  due  to  the  excess  of  carbon 
dioxide  resulting  from  their  combination ;  analogous  to  the  action  of  alcohols, 
though  less  intense.  In  my  opinion  this  is  usually  a  matter  of  indifference,  pro- 
vided the  taste  has  become  normal  and  they  be  not  used  to  the  exclusion  of  other 
needed  substances.  Alcohol,  of  course,  should  not  be  encouraged,  nor  tea  nor 
coffee. 

Eecently  our  attention  has  been  called,  especially  by  Metchnikoff,  to  the  value 
of  lactic  acid  in  neutralizing  the  putrefactive  changes  in  the  lower  bowel.  This 
confirms  our  long  recognized  preference  for  the  use  of  buttermilk  and  the  fer- 
mented preparation  of  milk,  koumyss,  keffir,  zoolak,  and  matzoon.  Superior  to 
these  is  the  old-fashioned  "bonny  clabber"  or  milk  which  lias  turned  sour  and  be- 
come clotted.  Some  experience  in  the  use  of  this  lias  convinced  me  that  lactic  acid 
possesses  a  definite  value  in  intestinal  digestion. 

The  aim  of  all  our  dietetic  regulations  for  the  purpose  of  overcoming,  not 
only  digestive  derangements,  but  metabolic  disturbances,  is  to  arrange  that  just 
enough  food  shall  be  taken  for  the  needs  of  the  economy,  and  in  such  form,  espe- 
cially such  form,  as  the  patient  himself  is  capable  of  reducing  it  by  mastication, 
that  no  secondary  derangement  shall  follow.  foT  by  this  means  they  ran  nearly  all 


496  CONSTITUTIONAL  TREATMENT  OF  RHEUMATIC  CONDITIONS. 

be  prevented.  This  seems  a  simple  matter  when  sketched  out,  but  demands  the 
utmost  care  and  judgment  on  the  part  of  the  physician  until  the  patient  becomes 
thoroughly  educated  as  to  his  needs  and  digestive  capacities. 

Eest  is  essential  where  exhaustion  is  evident,  but  this  by  no  means  should 
prevent  the  employment  of  healthy  exercises,  carefully  supervised,  whereby  the 
balance  of  circulation  shall  be  attained,  the  periphery  kept  compensatorily  well 
supplied  with  blood,  and  the  lymph  channels  maintained  in  their  fullest  activity. 
Exercise  is  absolutely  essential  in  all  conditions  of  acidosis  and  commensurate  with 
the  integrity  of  the  organs. 

Inasmuch  as  the  skin  in  all  these  cases  is  peculiarly  sensitive,  it  is  essential  to 
encourage  every  precaution  to  retain  its  normal  tone.  Hence,  after  active  exercise, 
and  equally  so  after  passive  exercises,  the  skin  should  be  cleansed  immediately  by 
friction  and  change  of  undergarments;  therefore,  the  simple  rule  of  demanding 
that  a  patient  take  exercises  two  or  three  times  a  day  and  afterward  use  the  pre- 
caution indicated  of  dry  rubbing,  immediately  followed  by  rest  lying  down,  will 
secure  the  best  results.  Although,  curiously  enough,  some  of  the  most  authoritative 
writers  declare  that  exercises  must  be  passive,  as  no  others  are  advisable,  yet  the 
opinion  among  the  wiser  men,  especially  those  who  have  been  themselves  sufferers, 
is  that  exercises  in  all  normal  directions,  full  active  stretchings,  and  in  addition 
judicious  manipulations  deliberately  employed,  are  essential  to  the  recovery  of 
systemic  tone  as  well  as  for  local  relief  and  nutritive  repair. 

A  most  important  discovery,  for  discovery  it  is,  although  it  has  been  alluded 
to  by  others,  yet  no  one  has  given  us  so  clear  a  notion  of  the  particular  item  of 
exhaustion  which  is  found  in  the  degenerative  states  of  acidosis  as  Dr.  Edward  C. 
Kirk.  Max  Verworn  pointed  this  out  in  connection  with  his  views  on  the  need  of 
maintaining  the  normal  alkalinity  of  the  blood.  Dr.  Kirk  has  shown  us.  that  in 
arthritism  there  is  a  rapid  phosphatic  loss  by  reason  of  the  continued  high  acidity. 
In  cases  of  excessive  accumulation  of  carbonic  acid  in  the  blood  plasma  other  epithe- 
lial structures  beside  those  of  the  kidney  "become  affected  and  are  concerned  in  the 
chemical  reactions  which  result  in  the  formation  and  elimination  of  acid  phos- 
phates due  to  the  mass  action  of  carbonic  acid  upon  the  basic  phosphates.  His 
researches  are  especially  in  connection  with  the  acid  exudations  from  the  buccal 
mucous  glands  and  from  the  skin  of  arthritics.  The  high  acidity  of  the  urine  he 
regards  as  the  exponent  of  the  high  carbonic  acid  content  in  the  blood  plasma,  and 
in  the  excretions  of  the  kidneys;  every  degree  of  increased  acidity  in  the  urine 
representing  an  equivalent  loss  of  phosphorus.  In  outline  his  views  may  be  ex- 
pressed as  follows : — 

Imperfect  metabolism  in  arthritics  is  always  attended  by  intperfect  or  insulli- 
cienl  oxidation,     [mperfed  oxidation  results  in  the  accumulation  within  the  blood 


CONSTITUTIONAL  TREATMENT  OF  RHEUMATIC  CONDITIONS.  497 

plasma  of  carbonic  acid  gas.  Carbonic  acid  gas  (CO.),  in  the  presence  of  water, 
becomes  carbonic  acid  (H2C03).  Carbonic  acid  decomposes  the  physically-alkaline 
disodium  phosphate  (Na2HP04)  of  the  blood  into  the  physically-acid  monosodium 
phosphate  (NaHPOJ,  the  reaction  being  35Ta2HP04  +  HoC03  =  NaHP04  + 
N"aHC03. 

(Chemically  both  these  are  acid  salts;  the  sodium  acid  carbonate  is,  however, 
alkaline  to  test  paper.) 

The  diacid  phosphate  is  eliminated  by  the  kidneys  as  a  normal  part  of  their 
function,  and  the  sodium  acid  carbonate  or  bicarbonate  (which  is  physically-alka- 
line) is  returned  to  the  blood  plasma,  restoring  the  latter  to  its  normal  degree  of 
alkalinity. 

"Where,  however,  through  faulty  metabolism,  carbonic  acid  is  produced  in  ab- 
normal quantities,  as  in  gouty  diatheses,  or  where  the  kidneys  are  incapable  of 
eliminating  all  the  sodium  diacid  phosphate  formed,  other  glands  and  epithelial 
structures,  such  as  the  buccal,  or  even  the  skin,  perform  the  work  of  elimination; 
the  buccal  glands,  for  example,  yielding  an  acid  exudate  in  the  mouth  that  slowly 
erodes  the  teeth.  This  erosion  is  not  caused  by  uric  acid,  which  is  also  formed  in 
these  cases,  but  by  the  sodium  dihydrogen  phosphate  resulting  from  imperfect  cel- 
lular metabolism,  which  latter  is  the  predisposing  cause  of  both  the  erosion  and 
excessive  uric  acid  production. 

The  dangers  to  the  economy  in  these  chemical  changes  lie  not  aloue  in  the 
production  of  the  acid  salt  and  its  erosive  action  on  the  teeth,  but  also  in  the 
metabolic  conditions  that  give  rise  to  it.  The  production  of  these  abnormal  end 
products  is  an  effect  and  not  a  cause;  their  presence  in  the  blood  is  a  danger-signal 
telling  of  insufficient  or  imperfect  oxdation  of  the  cellular  tissues,  ami  this  is  a 
direct  result  of  defective  metabolism. 

So  valuable  is  this  point  of  view  that  1  have  personally  found  it  of  saving 
efficacy  in  many  instances  where  the  degree  and  quality  of  depression,  mental  as 
well  as  physical,  was  profoundly  discouraging. 

The  chief  problem  is  to  determine  what  form  of  phosphorus  is  most  desirable. 
Theoretically,  the  organic  product,  lecithin,  is  the  ideal  tissue  food.  This  is  a 
highly  complex  fat  containing  substance  in  which  phosphorus  is  present  in  organic 
combination.  It  occurs  in  the  yolk  of  the  egg  and  in  brain  substance,  where  it  is 
bound  up  with  neucleo-proteid.  but  in  the  isolated  form  it  is  proteid  free. 

Clinicians  frequently  use  tin  egg  yolks  as  an  auxiliary  food  where  hypernutri- 
tion  is  desired,  but  in  many  instances  it  is  objectionable  as  a  mere  source  of 
lecithin  or  phosphorus  supply  because  by  the  use  of  sufficient  number  of  the  yolks 
of  eggs,  to  get  the  required  amount  of  phosphorus,  there  is  taken  into  tin-  organism 
an  excess  of  other  materials,  notably  the  proteids,  which  place  a  strain  upon  the 


498  CONSTITUTIONAL  TREATMENT  OF  RHEUMATIC  CONDITIONS. 

digestion  and  especially  upon  that  of  arthritics  which,  in  cases  under  discussion, 
may  already  be  too  fully  supplied  with  unelaborated  forms  of  nitrogen. 

Certain  of  the  manufacturing  chemists  have  isolated  lecithin  and  placed  it  in 
a  satisfactory  form,  and  this  is  definitely  the  best  means  known  at  present  for  the 
administration  of  phosphorus.  Then,  again,  we  have  the  glycerophosphates,  a 
convenient  and  excellent  form,  but  not  altogether  stable  unless  it  be  shown  that  we 
are  getting  in  any  given  preparation  the  acid  glycerophosphates. 

It  is  difficult  to  make  suitable  choice  among  the  rival  products  of  the  manu- 
facturing houses,  but  they  are  becoming  improved  all  the  time,  and  doubtless  we 
shall  soon  have  one  or  several  which  will  meet  all  requirements. 

The  field  for  the  employment  of  these  phosphates  is  so  large  that  while  using 
them  we  may  safely  omit  most  other  forms  of  tonic  medication.  Furthermore,  in 
the  present  doubt  respecting  the  best  form  of  phosphorus  supply,  it  may  be  well  to 
change  a  preparation  from  time  to  time,  and  by  this  means  the  best  results  follow 
in  my  hands.  In  any  event  it  seems  important  to  be  ever  on  the  watch  for  those 
states  of  depression,  especially  the  mental,  which  may  not  be  apparent,  but  which 
frequently  arise  in  conjunction  with  the  acidoses.  My  experience  leads  me  to  rec- 
ommend that  in  chronic  conditions  of  acidosis  of  long  standing  phosphorus  may  be 
taken  with  advantage  for  a  week,  or  possibly  two  weeks,  in  the  month,  for  several 
months  or  a  year. 

It  is  important  to  allude  to  one  other  remedy  which  promises  to  be  of  use  in 
improving  tissue  oxidation,  viz.,  thyroid  medication.  Parhon  and  Papinian  (Presse 
Medicale,  1905,  No.  1)  have  reported  the  profound  relief  of  chronic  rheumatic 
conditions  practically  cured,  after  failure  of  other  measures,  by  the  use  of  thyroid 
extract.  They  quote  Lancereaux,  Claisse,  and  others  who  have  reported  similar 
experiences.  Functional  insufficiency  of  the  thyroid  has  been  shown  to  be  followed 
by  defective  elimination.  They  think  that  the  thyroid  gland  takes  some  part  in  the 
assimilation  of  lime;  hypo-function  provides  favorable  conditions  for  the  develop- 
ment of  chronic  rheumatism  and  certain  forms  of  nephritis.  Yiala  has  called  atten- 
tion to  the  action  of  thyroid  treatment  in  the  stimulation  of  the  circulation,  increase 
in  the'  secretion  and  elimination  of  effete  matters,  reducing  weight  in  proportion  to 
superactivity  of  the  metabolic  processes,  and  the  attenuation  or  disappearance  of 
joint  symptoms. 

It  is  evident  that  we  are  dealing  with  complicated,  often  obscure,  conditions 
of  under-oxidation,  subkatabolism ;  hence  it  is  necessary  to  proceed  slowly  and  be 
content  with  a  steady  uniform  gain  through  a  period  of  months  or  years. 

J.  Madison  Taylor.* 

*  Formerly  Neurologist  to  the  Howard  Hospital. 


ALBUMINURIA  AND  ADOLESCENTS. 


ALBUMINURIA  AND  DIABETES.    499 


Cyclopaedia  of  Current  literature. 


ALBUMINURIA    AND    ADOLESCENTS. 

When  the  albuminuria  of  adolescents 
is  recognized  and  treated,  there  is  little 
likelihood  of  its  proving  the  precursor 
of  organic  disease  of  the  kidneys,  even 
when  its  duration  has  been  many  years. 
The  general  treatment  resolves  itself 
into  so  reasonable  a  regulation  of  life  as 
to  ensure  the  highest  state  of  vitality 
during  adolescence :  Work,  while  it  may 
be  ample,  must  not  be  excessive;  and 
work  is  always  excessive  during  the  years 
of  growth  when  sleep  is  insufficient.  The 
hours  of  both  must  be  determined  ac- 
cording to  age.  Exercise  should  be  re- 
creation rather  than  physical  drill, 
which,  by  the  pleasurable  sensations,  in- 
creases the  tone  of  the  whole  nervous 
and  vascular  system;  and  such  exercise 
should  be  daily.  Food  should  be  suf- 
ficient for  the  provision  of  growth,  as 
well  as  the  renewal  of  wear  and  tear, 
bearing  in  mind  that  the  adolescent  re- 
quires more  food  than  the  adult,  and  the 
girl  more  than  the  boy.  on  account  of 
her  greater  rapidity  of  growth.  The 
duties  of  I  In1  scavengers  of  the  body 
should  be  so  disciplined  as  to  be  brought 
under  the  habitual  control  of  the  will. 
Natural  action  should  not  be  replaced 
by  the  perpetual  stimulus  of  aperient 
for  this  vicarious  duty  obviously  con- 
firms the  intestines  in  sluggishness  of 
work',  and  tends  to  convert  a  temporary 
inactivity  into  a  permanent  abandon- 
ment of  function.  Clement  Dukes 
(British  Medical  Journal,  October  7. 
1905). 

ALBUMINURIA   AND   DIABETES,   CONNEC- 
TION  BETWEEN. 

Albuminuria  has  frequently  been  ob- 
served by  the  writer  in  bis  cases  of  gouty. 


herpetic  diabetes,  while  it  was  never 
noted  in  his  40  cases  of  pancreatic  dia- 
betes. The  glycosuria  alone  does  not 
entail  albuminuria.  When  the  latter 
occurs  it  may  be  connected  with  arterio- 
sclerosis with  consequent  lesions  of  kid- 
neys and  heart,  or  it  may  be  of  epithe- 
lial origin  due  to  some  intercurrent 
affection,  tuberculosis  in  particular. 
There  is  a  third  form,  in  which  the 
albuminuria  alternates  with  the  glyco- 
suria, and  like  the  latter,  is  subordinate 
to  some  nervous  disorder.  The  author 
gives  examples  of  each  form,  and  adds 
that  the  physician  should  examine  the 
condition  of  the  kidneys  and  nervous 
system  in  such  a  patient,  rather  than  de- 
termine the  exact  proportion  of  albumin. 
This  will  give  him  a  clue  both  for  treat- 
ment and  for  prognosis.  There  are 
three  groups  of  circumstances  in  which 
this  decision  is  of  great  value:  When 
parents  bring  their  sons  to  the  consultant 
with  the  statement  that  their  physician 
has  told  them  that  the  lads  are  albu- 
minuric and  must  be  kept  on  a  milk- 
diet,  and  that  they  must  stop  their  col- 
lege work.  Study  of  the  albuminuria 
and  its  accompaniments  reveal  that  it  is 
not  due  to  a  kidney  lesion,  and  conse- 
quently that  these  precautions  are  un- 
necessary. Time  shows  that  the  lads  de- 
velop spontaneously  into  good  health 
and  their  albuminuria  vanishes.  In 
other  cases  life  insurance  is  refused  to 
men  apparently  in  good  health,  under 
pretext  of  albuminuria.  The  kidneys  are 
sound  and  the  insurance  company  may 
be  prevailed  on  to  reconsider  its  objec- 
tion. Lanccreaux  (Bulletin  de  1'Acad- 
emie  de  Medecine,  Yr.  lxix.  No.  30; 
Journal  of  the  American  Medical  Asso- 
ciation,  September  23,   1905). 


500 


ANGINA  PECTORIS. 


ANGINA  PECTORIS,  ETIOLOGY  OF.' 


ANGINA  PECTORIS. 

The  writer  states  that  it  is  customary 
to  divide  cases  of  angina  pectoris  into 
organic  and  functional,  or  true  and  false 
angina;  in  the  true  form  the  lesions 
generally  found  are  aortitis,  syphilitic 
or  otherwise,  diseased  coronary  arteries, 
myocarditis,  fatty  degeneration  and  val- 
vular disease;  while  under  the  func- 
tional form  are  included  the  purely  neu- 
rosal  types  met  with  in  women,  the  re- 
flex forms  from  abnormal  conditions  of 
the  stomach  and  abdomen,  toxic  forms 
in  women  from  disease  of  the  thyroid 
and  in  men  from  tobacco,  alcohol,  or 
high  living.  To  these  may  be  added 
jSTothnagers  vasomotor  type.  There  is 
also  angina  sine  dolor e,  where  there  is 
no  pain,  but  an  indescribable  sensation 
over  the  heart;  this  is  associated  with 
varying  forms  of  cardiac  disease  ending 
in  death. 

Three  elements  play  an  important 
part  in  angina  pectoris — muscular  ex- 
ertion, mental  emotion,  and  digestive 
disturbances.  Movement  of  any  kind, 
facing  a  cold  wind,  worry,  gastrointes- 
tinal disturbances — all  increase  the  lia- 
bility to  precordial  pains.  During  the 
paroxysm  the  face  may  be  either  pale 
or  flushed.  The  pulse  varies;  it  may 
become  quick,  small,  and  hard,  or  cease 
to  be  felt  in  the  radial  artery.  Usually 
the  sternal  pain  is  severe,  but  its  place 
may  be  taken  by  a  slight  fainting  feel- 
ing. Consciousness,  however,  is  seldom 
lost,  except  in  the  final  attack,  when 
death  comes  through  syncope.  Tbe 
pain,  which  may  be  of  a  boring  or  burn- 
ing character,  is  most  acutely  felt  at  the 
manubrium  sterni  and  the  prsecordium 
whence  it  may  radiate  down  both  arms, 
usually  the  left.  Just  when  tbe  pain  is 
almost  unbearable  it  begins  to  decline. 
and  a  cold  and  unpleasant  perspiration 
breaks  nut  over  the  forehead   and   ex- 


tends to  the  arms  and  legs.  Occasion- 
ally a  murmur  may  be  heard  over  the 
cardiac  area.  There  may  be  some  dysp- 
noea and  even  oedema  of  the  lung.  Eruc- 
tation often  follows  an  attack,  and  as 
pain  over  the  stomach  often  precedes  the 
paroxysm,  the  stomach  is  usually  re- 
garded as  the  cause  of  the  trouble  by 
the  patient.  In  pseudo-angina  the  pain 
may  be  extremely  severe,  but  the  per- 
sonal element  plays  a  large  part.  In 
most  cases  no  cardiac  lesions  can  be  de- 
tected. The  face  is  flushed,  and  there 
is  marked  throbbing  of  the  heart  and 
blood-vessels.  In  vasomotor  angina  pal- 
pitation, precordial  pain,  faintness, 
coldness  of  the  extremities,  lividity.  and 
perspiration  are  the  main  features. 
Anything  which  suddenly  induces  con- 
traction of  the  peripheral  arteries  will 
bring  on  an  attack.  Sexual  excess  often 
produces  pseudoangina  in  both  men 
and  women.  In  pseudoangina  a  good 
prognosis  can  usually  be  given,  but  in 
true  angina  it  is  always  grave — yet  in 
some  instances  appropriate  treatment 
will  give  relief,  ward  off  attacks,  and 
prolong  life. 

Nitrite  of  amy!  stands  at  the  head  of 
all  drugs  for  giving  immediate  relief; 
the  peripheral  arteries  are  opened  up 
and  the  strain  taken  off  the  heart.  When 
there  are  signs  of  a  failing  heart,  dig- 
italis or  strychnine  must  be  combined 
with  the  nitrites.  Where  the  arteries 
are  in  an  advanced  stage  of  disease,  amvl 
nitrite  has  but  little  effect,  and  often 
does  harm.  TTere  only  morphine  will 
give  relief.  In  all  cases  of  true  angina 
the  relatives  should  be  informed  of  the 
serious  nature  of  the  attacks.  T.  Oliver 
(Lancet.  September  10.  100.1). 

ANGINA  PECTORIS.   ETIOLOGY  OF. 

From  the  consideration  of  the  fact 
that  angina  pectoris  occurs  in  lesions  of 


ANGINA  PECTORIS,  NEW  SYMPTOMS  IN. 


APPENDICITIS. 


501 


great  diversity,  some  condition  common 
to  all  must  be  the  cause  of  the  symp- 
toms. The  fact  that  angina  pectoris  ap- 
pears only  after  the  heart  muscle  has 
been  long  exposed  to  excessive  strain 
points  to  the  cause  being  situated  in  the 
muscle.  All  the  functions  of  the  mus- 
cle fibers  save  that  of  contractility  can 
be  shown  to  be  intact  in  many  cases  that 
suffer  from  angina  pectoris.  The  alter- 
nating action  of  the  heart  is  a  demon- 
strable sign  of  exhausted  contractility, 
and  its  presence  is  always  associated 
with  symptoms  that  are  included  in  the 
symptom  complex  of  angina  pectoris. 
Thf  same  exciting  cause — extra  strain 
on  the  heart — may  provoke  both  the  an- 
gina pectoris  and  the  alternating  action 
and  both  may  disappear  with  removal 
of  the  cause.  The  inference  to  be  drawn 
from  the  consideration  of  these  facts  is 
that  the  symptoms  that  are  included  in 
the  term  ''angina  pectoris"  are  so  closely 
associated  with  an  impairment  of  the 
function  of  contractility  of  the  muscle 
fibers  of  the  heart  that  in  all  probabil- 
ity angina  pectoris  will  be  Pound  to  be 
an  evidence  of  the  impairment  of  the 
function  of  contractility.  James  Mac- 
kenzie (British  Medical  Journal,  Oc- 
tober  ;,    1905). 

ANGINA   PECTORIS.    NEW   SYMPTOMS   IN. 

A  case  of  angina  pectoris  presenting 
some  hitherto  undescribed  symptoms  is 
related  by  the  author.  The  patient  was 
a  man  of  45,  and  presented  as  the 
first  symptom  of  angina  pectoris,  pain 
in  the  eliesl  and  left  arm,  and  breath- 
lessness  on  exertion.  It  was  found  that 
(lie  arterial  pressure  was  always  high, 
varying  from  L60  millimeters  to  170 
millimeters  llg.  The  pressure  was 
raised  during  the  paroxysm  of  pain,  and 
the  pulsation  of  the  heart  was  regular 
and  not  rapid.    The  patient  complained 


id'  constant  pain  over  the  back,  extend- 
ing down  to  the  ninth  intercostal  space, 
and  in  front,  extending  down  over  the 
clavicle  as  far  as  the  eighth  intercostal 
space.  It  also  involved  the  outer  aspect 
of  the  left  arm  and  forearm,  and  in 
the  hand;  it  was  felt  in  the  thumb  and 
in  the  index  and  middle  fingers.  The 
skin  of  the  chest,  back,  arm,  and  fore- 
arm, on  the  left  side,  was  hyperaesthetic 
to  every  form  of  stimulus,  while  abso- 
lute anaesthesia  was  present  in  the  radial 
portion  of  the  left  hand,  with  the  ex- 
ception of  a  small  area  on  the  palmar 
surface,  the  size  of  a  three-penny  piece. 
The  sternomastoid,  trapezius,  pectoralis, 
deltoid,  and  supinator  muscles  were 
more  tender  on  the  left  side  than  on  the 
right;  elsewhere,  there  were  no  sensory 
disturbances.  The  triceps  and  supinator 
jerks  were  increased  on  the  left  side, 
while  the  myotatic  irritability  in  the 
deltoid  and  in  the  muscles  of  the  outer 
aspect  of  the  left  arm  and  forearm  were 
increased.  The  faradic  and  galvanic  ex- 
citability were  also  increased.  The  left 
arm  was  weaker  than  the  right,  the 
dynamometer  registering  50  on  the  left 
side  and  130  on  the  right.  The  circum- 
ference of  the  arm  and  forearm  was  less 
on  the  left  side  than  on  the  right.  An- 
other interesting  symptom  was  the  prom- 
inence of  the  left  eye,  the  pupil  of  which 
was  larger  than  that  of  it^  fellow.  "While 
numbness  of  the  arm  has  been  observed 
in  angina  pectoris,  the  anaesthesia  de- 
scribed is  unique.  The  wasting  of  the 
muscles,  the  author  believes,  to  be  anal- 
ogous of  the  conditions  found  in  ar- 
thritic muscular  atrophy.  (1.  A.  Gibson 
(  Brain,  Spring,  p.  52,  1905). 

APPENDICITIS.  URINARY  DISTURBANCES 
IN. 

Attention    is  called  by  the  writer  to 

some  of  the  urinary  disturbances  which 


502      ARTERIOSCLEROSIS,  EP1STAX1S  IN.     ARTERIOSCLEROSIS,  HOT  BATHS  IN. 


accompany  appendicitis  and  afford  one 
of  the  most  confusing  of  clinical  pic- 
tures. The  exceptional  anatomical  posi- 
tion of  the  appendix  may  bring  it  in 
relation  with  the  bladder  behind  the 
pubes,  or  it  may  be  found  low  down  in 
the  pelvic  excavation,  or  the  cul-de-sac 
of  Douglas.  .  This  relation  to  the  blad- 
der may  cause  a  class  of  functional  dis- 
turbances without  pus  formation,  such 
as  retention  of  urine,  tenesmus,  dysuria, 
or  an  acute  or  subacute  cystitis.  Sup- 
purative lesions  may  occur,  or  there 
may  be  a  formation  of  urinary  calculi. 
Swartz  reported  the  case  of  a  young  man 
of  twenty  years  who  had  three  suppurat- 
ing attacks  of  appendicitis  which  ter- 
minated in  abscess  formation  which  was 
opened  in  the  umbilical  region.  Ench 
time  besides  the  ordinary  symptoms  of 
appendicitis  the  patient  had  violent  pain 
in  urinating  and  frequent  micturition. 
The  patient  called  attention  to  the  sim- 
ilarity in  the  symptoms  that  he  experi- 
enced in  the  previous  attacks  of  appen- 
dicitis. Upon  operating  the  appendix 
was  found  in  the  form  of  a  cord  sur- 
rounded by  indurated  omentum  extend- 
ing from  the  iliac  fossa  to  the  abdominal 
wall,  midway  between  the  umbilicus  and 
pubes,  in  close  relation  with  the  bladder. 
C.  G.  Cumston  (American  Journal  of 
Urology,  August,  1905). 

ARTERIOSCLEROSIS,         THREATENING 
EPISTAXIS    IN. 

The  writer  has  had  opportunity  to 
make  careful  rhinoscopic  examination  in 
43  cases  of  threatening  epistaxis  in  ar- 
teriosclerotic subjects.  It  has  revealed 
that  the  bleeding  came  from  sclerous 
degeneration  of  the  artery  of  the  nasal 
septum.  Tli is  sphenopalatine  artery  di- 
vides generally  into  several  branches  and 
runs  a  superficial  course  in  the  lower 
part  of  the  septum.     The  author  gives 


illustrations  of  the  points  where  the 
haemorrhage  usually  occurs  and  also 
where  secondary  haemorrhage  may  be 
expected.  When  the  haemorrhage  does 
not  yield  to  the  ordinary  measures,  the 
application  of  cotton  saturated  with  hy- 
drogen dioxide  is  advised.  This  is  left 
for  twenty-four  hours  or  longer  in  se- 
vere cases.  When  removed  the  points 
can  be  thermocauterized  or  chromic  acid 
may  be  applied  and  the  nose  tamponed. 
When  the  tampon  is  finally  removed  the 
patient  must  be  supervised.  He  should 
carry  cotton  constantly  with  him  in  case 
of  a  recurrence,  and  should  refrain  from 
blowing  his  nose.  Penghawar  is  partic- 
ularly useful  for  a  provisional  tampon. 
Adrenalin  should  be  avoided  in  arterio- 
sclerosis. If  it  is  impossible  to  discover 
the  focus,  the  entire  wall  of  the  septum 
should  be  cauterized  and  the  passage 
tamponed  with  penghawar  or  cotton. 
Posterior  tamponing  should  be  com- 
pletely rejected.  E.  Escat  (Presse  Med- 
icale,  September  9,  1905;  Journal  of 
the  American  Medical  Association,  Oc- 
tober 14,  1905). 

ARTERIOSCLEROSIS,    HOT    BATHS   IN. 

The  systematic  employment  of  hot 
baths  is  recommended  by  the  writer  as 
a  satisfactory  treatment  of  arterioscle- 
rosis. The  effect  of  the  hot  bath  on  the 
patient  suffering  from  arteriosclerosis  is 
fourfold :  1.  It  alters  the  distribution 
of  blood-pressure  by  unloading  the  in- 
ternal organs  and  hy  increasing  the  vas- 
cularization of  the  skin;  hence,  it  af- 
fords prompt  relief  in  many  of  the  cases 
of  pain  associated  with  internal  gout, 
that  frequent  source  of  arteriosclerosis. 
2.  It.  increases  combustion.  3.  It  in- 
creases the  elimination  of  waste  prod- 
ucts. 4.  By  opening  the  channels  of 
the  skin,  it  reduces-  the  pressure  of  the 
blood  by  bleeding  the  patient  into  the 


ARTERIOSCLEROSIS,  TREATMENT. 


BRACHIAL  BIRTH  PALSY. 


503 


skin.  In  every  instance  it  is  necessary 
to  ascertain  exactly  the  reaction  of  the 
individual.  One  may  safely  begin  with 
a  temperature  of  102  degrees  if  the  pa- 
tient is  not  above  55  or  60;  in  women 
it  is  safer  to  begin  at  100  degrees.  The 
time  of  immersion  should  not  be  less 
than  ten  minutes,  although  the  writer 
rarely  had  to  exceed  that  time.  The  de- 
termining factor  in  the  management  of 
the  patient  is  the  condition  of  the  left 
heart,  the  quality  and  loudness  of  the 
first  and  second  aortic  sounds.  Without 
a  vigorous  left  heart  the  hot  bath  must 
be  used  with  caution.  The  indiscrimi- 
nate use  of  the  hot  bath  is  warned  against 
when  there  is  not  a  good  systematic  pres- 
sure and  a  vigorous  systolic  output  to 
start  with.  While  these  two  conditions 
obtain  in  arteriosclerosis,  favorable  re- 
sults will  follow  the  treatment  indi- 
cated. E.  Hirschfeld  (Australasian 
Medical  Gazette,  July  20,  1905). 

ARTERIOSCLEROSIS,    TREATMENT    OF. 

The  writer  reiterates  the  necessity  for 
gentle,  persevering  measures  in  arterio- 
sclerosis, avoiding  the  abrupt  changes  in 
medicines  and  diet.  The  efficacy  of 
small  doses  of  potassium  iodide  has  been 
established,  and  recent  researches  show 
that  this  drug  reduces  the  viscosity  of 
the  blood  by  acting  on  the  corpuscles, 
making  it  more  fluid  without  diluting 
it.  He  prescribes  it  five  times  a  day  in 
doses  of  .1  or  .3  grams  to  be  kept  up 
for  two  or  three  years,  with  suspension 
one  week  in  each  month  and  one  month 
after  every  three.  Gastric  disturbances 
should  be  avoided  by  refraining  from 
all  acids  in  the  food  and  drinks  while  it 
is  being  taken.  The  author  sometimes 
orders  it  with  sodium  bicarbonate,  1" 
be  given  in  milk.  Tts  use  is  directly 
warned  againsl  in  cases  of  nreemic 
oedema  of  the  lung  occurring  under  the 


picture  of  cardial  asthma,  and  also 
whenever  the  arteriosclerosis  is  compli- 
cated with  any  manifestations  of  ex- 
ophthalmic goiter.  In  other  cases  the 
benefit  may  even  include  retrogression 
of  organic  lesions,  although  it  is  impos- 
sible to  expect  retrogression  of  thrombo- 
sis in  a  vessel  in  the  brain  or  of  fibrous 
degeneration  of  the  heart  muscle  or  con- 
tracted kidney.  It  is  of  the  greatest 
importance  to  reduce  to  the  minimum 
the  demands  on  the  arteries.  Sufficient 
sleep  is  also  to  be  insured,  even  with 
drugs  at  first.  E.  Romberg  (Deutsche 
medicinische  Wochenschrift,  August  31, 
1905;  Journal  of  the  American  Med- 
ical Association,  October  14,  1905). 

BRACHIAL  BIRTH  PALSY. 

The  cause  of  the  laceration  type  of 
birth  palsy  is  tension  on  the  nerve 
trunks,  which  first  ruptures  the  nerve 
sheath  and  then  the  nerve  fibers.  The 
prevention  of  this  serious  lesion  of  the 
cervical  nerve  trunks  rests  with  the  ob- 
stetrician, who  should  not  overstretch 
the  child's  neck  in  the  process  of  deliv- 
ery. 

The  persistence  of  the  palsy  is  clearly 
explained  by  the  pathological  findings, 
viz. :  (a)  Rupture  of  the  perineural 
sheath  with  haemorrhage  into  its  sub- 
stance, resulting  in  the  formation  of 
haematomata  or  haematomatous  infiltra- 
tion into  the  neighboring  tissues,  (b) 
The  cicatricial  contraction  following  or- 
ganization of  the  blood  clot  and  repair 
of  the  rent  in  the  perineural  sheath. 
The  connective  tissue  thus  formed  in-, 
drills  and  presses  upon  the  nerve  bun- 
dles, strangulating  them  and  preventing 
regeneration  of  the  nerve  fibers.  In 
sonic  instances  the  same  result  is  accom- 
plished by  the  turning  inward  of  the 
perineural  sheath  upon  the  nerve  bun- 
dles, 


504 


CEREBROSPINAL  .MENINGITIS. 


CIRRHOSIS  OF  LIVER. 


The  nature  of  the  lesion  in  all  cases 
demands  excision  of  the  damaged  areas 
and  suture  of  the  divided  ends  as  soon 
as  it  is  proven  that  spontaneous  repair 
will  not  take  place.  The  plan  of  treat- 
ment is  then  the  same  as  that  for  pe- 
ripheral nerve  injuries  elsewhere.  In 
all  cases  such  treatment  as  will  prevent 
contractures  and  deformities  and  main- 
tain muscle  tone  in  the  paralyzed  limb 
should  he  systematically  used  until 
either  spontaneous  recovery  occurs  or 
operation  is  done.  (Traumatic  neuritis 
is  a  contraindication  to  active  treat- 
ment.) It  is  obvious  that  the  above 
measures  should  be  continued  after  op- 
eration. 

The  proper  time  for  surgical  inter- 
ference is  not  yet  definitely  fixed.  It 
appears,  however,  to  be  much  later  than 
two  or  three  months  after  birth,  as  ad- 
vised in  Kennedy's  report.  At  the  pres- 
ent time  one  year  would  seem  to  be  a 
reasonable  delay  before  operation.  Suf- 
ficient time  has  not  elapsed  in  the  ma- 
jority of  the  cases  in  this  series  for  final 
results  to  have  appeared.  L.  P.  Clark. 
A.  S.  Taylor,  and  T.  P.  Prout  (Amer- 
ican Journal  of  Medical  Sciences,  Oc- 
tober. 1905). 

CEREBROSPINAL  MENINGITIS,  EAR 
COMPLICATIONS  IN. 
From  the  published  statistics  of  more 
recent  observers,  the  writer  shows  that 
it  is  exceedingly  common,  and  states  that 
both  European  and  American  statistics 
prove  that  a  fifth  to  a  sixth  of  all  cases 
.of  acquired  deafness  are  due  to  cerebro- 
spinal fever  alone,  while  at  times  the 
proportion  caused  by  this  disease  has 
been  much  greater.  The  opinions  of 
authorities  vary,  however,  as  to  the 
aural  affection  itself  and  the  seat  of  the 
lesion.  Some  consider  that  the  lesion  is 
a  centra]  one,  hut  it  is  more  probable, 


and  is  now  generally  accepted,  that  an 
inflammatory  condition  of  the  labyrinth 
is  the  causative  factor.  The  pathology 
of  the  lesion  is  described,  and  reference 
is  made  to  the  frequent  occurrence  of 
acute  otitis  media  in  eerebro-spinal  fever 
as  another  though  less  important  cause 
of  deafness.  The  prognosis  of  the  deaf- 
ness is  stated  to  be  a  very  grave  one.  and 
treatment  is  unsatisfactory,  though  good 
results  have  been  reported  from  the  re- 
duction of  the  labyrinthine  pressure  by 
the  use  of  pilocarpine.  Of  11  cases  of 
eerebro-spinal  meningitis  recently  ex- 
amined by  the  author,  in  only  two  were 
subjective  or  objective  evidences  of  ear 
disease  to  be  detected.  C.  J.  Colles 
(Medical   Record,   September  9,   1905). 

CIRRHOSIS     OF     THE     LIVER,     TALMA'S 
OPERATION    IN. 

The  Talma  operation  does  not  cure 
cirrhosis  of  the  liver  in  advanced  stages, 
but  may  in  about  40  per  cent,  of  selected 
cases  ameliorate  some  of  the  symptoms, 
viz.,  ascites  and  haemorrhage.  Cases 
where  the  liver  was  enlarged  gave  a 
lower  mortality  and  a  higher  percentage 
of  improvement  than  cases  of  atrophic 
liver.  Biliary  cirrhosis  associated  with 
enlarged  liver,  jaundice,  fever, -and  some 
ascites  is  best  treated  by  cholecystostomy 
and  drainage1  of  the  bile  tracts.  Many 
of  the  cases  which  were  greatly  improved 
by  the  operation  differed  in  no  way  from 
some  of  those  not  improved,  thus  giving 
no  guide  for-  future  selection  of  suitable 
cases. 

Suture  of  the  omentum  between  the 
layers  of  the  abdominal  wall  gives  a 
lower  mortality  and  a  higher  percentage 
of  improvement  than  merely  suture  to 
the  parietes.  Splenopexy  may  supplant 
omentopexy.  Cases  for  operation  should 
lie  selected  careful ly-with  regard  to  the 
indications  and  contraindications.     Ad- 


COLITIS,  HIGH-FREQUENCY  CURRENTS   IN. 


COLITIS,  TREATMENT.      505 


vanced  cases  should  not  be  operated  on 
as  a  last  resort.  Drainage  increases  the 
danger  of  septic  peritonitis.  The  opera- 
tion is  not  indicated  for  ascites  due  to 
other  causes  than  cirrhosis,  and  is  con- 
traindicated  in  the  presence  of  renal  or 
cardiac  disease  and  when  evidence  docs 
not  exist  that  sufficient  functional  liver 
substances  remain  to  maintain  life. 
William  Hessert  (Medicine,  September, 
1905). 

COLITIS,     HIGH-FREQUENCY     CURRENTS 
IN. 

The  writer  was  consulted  in  an  obsti- 
nate case  of  colitis,  for  which  the  x-rays 
were  employed  for  about  a  month,  but 
with  no  effect.  The  patient  had  been 
suffering  from  the  complaint  for  over  a 
year,  and  the  stools  always  contained 
blood  and  mucus.  As  a  forlorn  hope 
high-frequency  treatments  were  em- 
ployed, the  applications  being  first  given 
through  the  hands,  followed  by  fifteen- 
minute  local  applications,  sometimes 
from  the  low  tension,  sometimes  from 
the  resonator,  the  patient  improving 
generally.  A  prolonged  course  of  treat- 
ment was  employed,  the  patient  attend- 
ing regularly  on  alternate  days.  Grad- 
ually the  symptoms  became  less,  the 
diarrhoea  diminished,  and  the  blood  and 
mucus  were  less  abundant.  .\i  the  end 
of  nine  months  the  patient  was  fully 
recovered.  In  three  other  cases  of  the 
ulcerative  form  of  colitis  there  was 
marked  improvemenl  at  the  end  of  a 
similar     period,     and     one     which     was 

treated  tor  six  weeks  obtained  slight  re- 
lief. Of  the  mucous  form  of  colitis  four 
were  treated,  three  of  whom  were  cured 
and  one  greatly  improved.  E.  YV.  H. 
Shenton  (Archives  of  the  RoentgeD  Ray, 
August,  L905). 


COLITIS,    SURGICAL    TREATMENT    OF. 

The  author  states  that  physiologists 
are  beginning  to  recognize  the  necessar- 
ily important  part  the  appendix,  caecum, 

and   ascending  colon   take   in    digestion. 
The  fad  of  the  day  seems  to  be  that  the 
whole  co!on  is  simply  a  sewer  canal,  but 
its  importance  in  digestion  is  proven  by 
its  glandular   structure.     Any   interfer- 
ence of  function  reacts,  producing  either 
appendicitis   or  colitis.     An   interesting 
and  important  topic  is  the  observation. 
by   means   of   the   x-rays   and   bismuth- 
impregnated  food,  that  antiperistalsis  is 
a  constant  factor  in  the  digestive  process 
of  the  large  intestine.     This  admits  of 
thorough  mixing  and  absorption  of  the 
contents.     Also  experiments  on  the  dis- 
position of  nutrient  enemata,  similarly 
conducted,  demonstrated  that  these  were 
ultimately  carried  to  the  csecum,  absorp- 
tion taking  place  chiefly  above  the  de- 
scending   colon.      Anything    which    dis- 
turbs the  antiperistalsis  is  apt  to  induce 
an  inflammation   of   the  colon.      Surgi- 
cally, colitis  is  divided  into  three  classes  : 
primary    bacterial,    secondary    bacterial, 
and   that   induced    by    mechanical    inter- 
ference.     UpOIl    these    causes    liiuu'CS    the 
surgical   treatment,   and    if   carried    out 
intelligently,  will  he  successful.     It  will 
not  do  to  conline  all  cases  to  a  right  in- 
guinal   colostomy.      This    vv^as    first    se- 
lected for  bacteriological  cases,  hid  even 
here   C.ibson's  operation   has   many  ad- 
vantages.    In  the  appendicular  forms  of 
colitis    removal   of   the   appendix-    is    all 
that   is   required    in   the  explosive   form. 
Whereas,    in    the    neurasthenic    type    of 
Deaver  not  only  should  the  appendix  be 
removed,    hut    Cibson's    fistula    ought    to 
he  established.     Tf  this  does  not  produce 
a   return  to  health  then  some  operation 
for  exclusion  must  be  done.     J.  E.  Sum- 
mers.   Jr.    (Annals    of    Surgery,    Julv, 
L905). 


506 


CONSUMPTION. 


DIPHTHERIA,  CARDIAC  DISTURBANCES  IN. 


CONSUMPTION    DIATHESIS. 

The  vagus  reflex  is  always  present  in 
pulmonary  consumption,  being  present 
in  about  SO  per  cent,  of  healthy  people 
who  have  a  family  history  of  consump- 
tion. In  healthy  persons  without  a  fam- 
ily history  of  consumption  the  vagus  re- 
flex is  universally  absent,  provided  there 
is  no  family  or  personal  taint  of  alcohol- 
ism, insanity,  or  other  neuroses.  In  the 
development  of  the  vagus  reflex,  dizzi- 
ness, dyspnoea,  coughing,  and  sweating 
are  produced.  The  intensity  of  the 
vagus  reflex,  or,  in  other  words,  the 
number  of  symptoms  that  accompany  its 
development,  other  than  those  which 
manifest  themselves  locally  in  the  neck, 
seems  to  be  dependent  on  the  number  of 
consumptive  deaths  that  have  occurred 
in  the  immediate  family.  The  vagus  re- 
flex, by  projecting  the  family  history  of 
the  potential  consumptive  into  the  pres- 
ent, not  only  becomes  a  valuable  sign  in 
the  diagnosis  and  prognosis  of  pulmo- 
nary consumption,  but  foreshadows  that 
which  is  not  otherwise  evident  to  the 
senses,  and  thus  also  becomes  an  impor- 
tant factor  in  the  prophylaxis  and  treat- 
ment of  this  disease.  T.  J.  Mays  (Phy- 
sician and  Surgeon,  September,  1905). 

DERMATITIS    HERPETIFORMIS    IN    CHIL- 
DREN. 

In  a  considerable  number  of  cases  of 
dermatitis  herpetiformis  as  it  occurs  in 
children,  the  element  of  multiformity  is 
wholly  lacking,  the  disease  showing  it- 
self by  the  recurrence  of  groups  of  ves- 
icles and  bulbv  without  other  lesions. 
In  a  majority  of  cases  the  subjective 
symptoms,  such  as  itching,  burning, 
pain,  and  tingling  are  either  absent  or 
very  slightly  accentuated,  so  thai,  it 
seems  to  the  writer,  this  feature  cannot 
bp  considered  one  of  the  four  cardinal 
symptoms  of  the  disease  in  children. 


Vaccination  may,  in  certain  cases,  be 
the  exciting  cause  of  the  eruption,  not 
in  the  sense  of  an  infection,  but  as  one 
of  probably  many  agents  which  may 
produce  this  train  of  symptoms  in  cer- 
tain people.  Certain  regions  of  the  body 
are  especially  affected  by  the  eruption, 
viz. :  the  parts  about  the  nose,  mouth, 
and  eyes,  the  backs  of  the  hands  and 
wrists,  the  backs  of  the  ankles  and  feet, 
and  the  genital  region.  Unna's  hydroa 
puerorum  is  to  be  placed  by  itself,  either 
as  a  distinct  variety  of  dermatitis  her- 
petiformis, or  as  an  independent  affec- 
tion. J.  T.  Brown  (Journal  of  Cutane- 
ous Diseases,  September,  1905). 

DIPHTHERIA,     CARDIAC     DISTURBANCES 
FOLLOWING. 

The  cardiac  disturbance  after  diph- 
theria usually  presents  the  picture  of  a 
mitral  insufficiency  with  irregular  heart 
action  and  few  symptoms.  Occasional 
cases  have  rapid  pulse  or  cardiac  irregu- 
larity without  any  other  signs.  Mod- 
erate disturbance  of  the  heart  is  very 
common  after  diphtheria  and  in  a  large 
number  of  cases  persists  from  two  to  six 
months  after  the  original  illness.  In 
many  cases  the  cardiac  lesion  does  not 
clear  up  in  the  first  half  year,  but  lasts 
much  longer;  some  ultimately  recover; 
others  probably  do  not.  The  duration  of 
the  heart  trouble  is  usually  in  propor- 
tion to  the  severity  of  the  original  ill- 
ness. The  fact  that  children  often  have 
few  heart  symptoms  after  diphtheria 
must  not  mislead  the  physician  as  to 
the  importance  of  the  injury  to  the 
heart. 

Cardiac  disturbance  of  long  duration 
following  diphtheria  may  be  entirely  re- 
covered from.  Tt  is  not  necessary  to  give 
up  hope  of  recovery  in  individual  long 
cases.  The  treatment  of  this  condition 
consists  in  a  sufficient  period  of  rest  in 


EPILEPSY,  SHOCK  AND  FRIGHT  IN. 


EPILEPSY,  TREATMENT. 


507 


bed,  and  then  in  watching  the  effects  of 
mild  exercise  on  the  heart  for  several 
months  at  least  and  grading  it  to  meet 
individual  requirements.  F.  W.  White 
(Journal  of  the  American  Medical  As- 
sociation, October  21,  1905). 

EPILEPSY.  EMOTIONAL  SHOCK  AND 
FRIGHT  AS  CAUSES  OF. 
Emotional  shock  and  fright,  as  causes 
of  epilepsy,  do  not  receive  the  attention 
they  should,  according  to  the  writer. 
Epilepsy  may  supervene  immediately 
after  the  application  of  such  a  cause  or 
be  delayed  for  some  time.  The  re-ap- 
plication of  the  primary  cause  often  in- 
duces successive  attacks  similar  in  na- 
ture. Predisposition  usually  exists  in 
all  such  cases.  In  1323  cases  the  writer 
found  emotional  shock  or  fright  to  have 
been  the  cause  in  62  cases,  5.5  per  cent. 
Of  these  patients,  22  were  males  in  a 
total  of  814,  and  40  were  females  in  a 
total  of  509,  being  3  per  cent,  of  the 
former  and  8  per  cent,  of  the  latter. 
This  shows  such  causes  to  be  nearly 
three  times  as  active  among  men  as 
among  women.  This  greater  suscepti- 
bility of  women  is  present  from  child- 
hood. During  the  first  ten  years  of  life 
there  were  14  cases  due  to  this  cause 
among  814  males,  and  15  cases  among 
519  females.  Aiter  the  twentieth  year 
there  was  only  one  case,  in  either  sex. 
Tt  appears  from  the  studies  in  question 
that  emotional  shock  or  fright  most 
often  leads  to  epilepsy  in  the  female  sex. 
and  that  these  factors  are  most  apt  to 
be  active  about  Hie  age  of  puberty.  W. 
P.  Spratling  (American  Medicine,  Sep- 
tember 16,  1905  V 

EPILEPSY.    TREATMENT    OF. 

The  author  remarks  that  the  majority 
of  his  epileptic  patients  had  already  been 
treated    for    years    by    other    physicians 


before  they  came  to  him,  and  had  taken 
quantities  of  the  bromides  without  ap- 
parent benefit.  His  experience  has  con- 
vinced  him  that,  as  a  rule,  the  sympto- 
matic results  of  this  drug  have  been 
overestimated,  while  its  injurious  by- 
effects  have  been  underestimated.  In  a 
recent  case  he  does  not  give  the  bro- 
mides nor  in  cases  in  which  the  inter- 
vals are  two  or  three  months,  or  longer. 
When  the  attacks  are  very  frequent  he 
gives  bromide,  but  verv  cautiously, 
watching  for  its  general  as  well  as  for 
its  symptomatic  effect.  The  mental  de- 
cline which  some  accept  as  the  inevitable 
result  of  the  epilepsy  in  certain  cases, 
he  thinks,  is  much  more  liable  to  be  due 
to  chronic  bromine  intoxication.  In 
place  of  bromine  he  gives  belladonna 
and  zinc  oxide.  They  have  sometimes 
succeeded  after  failure  of  bromine;  es- 
pecially in  petit  mal  the  latter  has  ren-' 
dered  him  good  service  at  times.  An 
infusion  of  valerian,  particularly  before 
retiring,  has  also  been  found  beneficial 
by  some  patients. 

In  discussing  the  subject  of  exercise 
for  epileptics,  the  writer  states  that  one 
(»f  his  patients  took  a  mountain  pedes- 
trian tour  and  afterward  felt  better  than 
for  years.  The  fact  is  emphasized  that 
the  epilepsy  is  only  a  symptom,  and  that 
the  general  and  psychic  condition  must 
be  studied  as  much  as  this  one  symptom. 
The  writer  suggests  that  possibly  the 
epileptic  seizure  may  be  a  sudden  dis- 
charge of  all  the  accumulated  tonicity 
("spannkrafte")  in  the  motor  centers. 
This  suggests  further  the  possibility  that 
it  might  be  possible  to  prevent  the  seiz- 
ures by  calling  on  and  fatiguing  the 
motor  ceniers  until  there  is  no  possibil- 
ity for  their  tonicity  to  accumulate. 
Treatment  by  muscular  exercise  cer- 
tainlv  has  some  theoretic  grounds,  and 
he  is  now  ordering  therapeutic  gymnas- 


508 


FUNGUS  POISONING. 


GOUT. 


tic  exercises  for  some  of  his  patients.  If 
the  cramps  occur  specially  in  a  certain 
limb,  he  has  the  patient  exercise  the 
groups  of  muscles  involved.  The  au- 
thor has  no  special  successes  to  report 
from  this  exercise-therapy,  and  it  should 
always  be  strictly  individualized,  abso- 
lute rest  being  indicated  for  some  pa- 
tients. A.  Striimpell  (Deutsches  Archiv 
f.  klinische  Medizin,  Bd.  lxxxiv,  Nu. 
1-4;  Journal  of  the  American  Medical 
Association,  September  30,  1905). 

FUNGUS   POISONING. 

The  great  majority  of  mushrooms  and 
other  fungi  are  not  poisonous,  and  the 
vast  majority  of  deaths  caused  by  fungi 
are  due  to  one  species,  and  one  species 
alone.  This  is  the  Amanita  pkalloides, 
and  it  owes  its  lethal  power  not  to  an 
alkaloid,  but  to  a  toxalbumin — phallin. 
The  author  has  been  able  to  trace  it  as 
the  cause  of  four  deaths  in  his  vicinity. 
The  most  commonly  observed  symptoms 
are  vomiting,  not  occurring  for  several 
hours  (ten  to  twelve)  after  eating  the 
fungus,  diarrhoea,  pain  in  the  abdomen, 
cramps  of  the  stomach  and  diaphragm, 
intense  thirst,  cold  sweats,  collapse, 
sometimes  headache,  delirium,  more  or 
less  complete  suppression  of  urine.  sHght 
but  distinct  jaundice  in  severe  cases, 
subnormal  temperature,  and  sometimes 
cramps  in  the  limbs.  The  post-mortem 
signs  are  absence  of  cadaveric  rigidity. 
marked  hypostatic  discoloration,  inflam- 
mation of  the  gastro-intestinal  mucous 
membrane,  localized  ecchymoses  of  the 
liver,  alimentary  canal,  pleura,  and 
lungs,  enlarged  solitary  glands,  fatty 
defeneration  of  the  liver,  fluidity  of  the 
blood,  and  hyperemia  of  the  meninges. 
Usually  the  patient  has  been  vomiting 
and  purging  long  before  he  ic  seen,  so 
that  an  emetic  is  not  necessary.  To  re- 
lieve the  great  suffering  morphine  is  al- 


most sure  to  be  required.  To  decompose 
any  phallin  left  in  the  stomach,  potas- 
sium permanganate  should  be  tried. 
The  cup-like  base  of  the  stem,  the  per- 
manently white  under-suri'ace  and  gills, 
the  shining  pale-greenish  or  yellowish- 
white  top,  and  the  fact  that  it  never 
grows  far  away  from  trees,  especially 
oak  trees,  should  enable  any  one  to  rec- 
ognize this  most  virulent  fungus.  C.  B. 
Plowright  (British  Medical  Journal, 
September  9,  1905). 

GOUT. 

The  writer  describes  a  number  of  in- 
teresting experiments  on  the  origin  and 
nature  of  gout  which  he  has  been  con- 
ducting with  Frey.  He  found  degen- 
erative processes  constant  in  the  liver 
and  kidneys  of  mice  fed  exclusively  on 
meat.  He  also  noted  the  total  absence 
of  the  glycocol-destroying,  urea-form ing 
ferment  in  the  liver  of  gouty  subjects. 
He  does  not  believe  that  pathologic 
changes  in  the  liver  are  necessary  for 
the  production  of  gout,  but  that  func- 
tional disturbances  must  certainly  exist. 
functional  disturbances  in  the  liver  are 
very  liable  to  entail  disturbances  in  tin1 
urea  metabolism.  The  absence  of  the 
glycocol-destroying  and  urea-forming 
ferment  in  the  liver  may  be  congenital 
or  may  be  the  result  of  improper  diet  or 
of  constitutional  poisoning.  The  reme- 
dies which  have  proved  useful  in  gout 
owe  this  property  probably  to  their 
beneficial  action  on  the  functions  of  the 
liver.  Colchiein  and  benzoic  and  sali- 
cylic acids  are  powerful  cholagogues, 
and  they  thus  improve  ibe  conditions  of 
the' circulation  in  the  liver.  This  is  also 
accomplished  by  certain  purgatives,  hy- 
drochloric acid.  etc.  Benzoic,  salicylic, 
and  quinic  acids  have  a  further  bene- 
Rcial  action  in  that  they  bind  the  glyco- 
col  and  thus  prevent  its  exerting  a  pre- 


HEMORRHOIDS.  EXTERNA  L. 


INSANITY,  ACUTE. 


509 


cipitating  action  on  the  uric  acid  in  the 
organism.  The  presence  of  glycocol 
with  a  large  amount  of  urea  entai  s  pre- 
cipitation of  urates.  When  there  is  a 
gouty  tendency,  that  is.  a  lack  of  glyco- 
col-destroying  ferment,  urates  are  pre- 
cipitated. This  occurs  in  cartilage  and 
cqnnective  tissue  when  edycocol  is  eren- 
crated  in  them  by  nutritional  disturb- 
ances. H.  Kionka  (Deutsche  medizin- 
ische  Wochenschrift,  July  20,  1905; 
Journal  of  the  American  Medical  Asso- 
ciation, September  16,  1905). 

HEMORRHOIDS.     EXTERNAL:       PATHOL- 
OGY  OF. 

The  writer  concludes  that  the  walls 
of  the  hemorrhoidal  veins  must  undergo 
some  pathological  change  before  a 
thrombotic  hemorrhoid  can  develop : 
these  changes  being  present,  any  undue 
pressure  may  cause  an  aneurismal  dila- 
tation of  the  veins.  When  the  internal 
coal  of  the  vessel  is  altered,  there  is 
more  tendency  for  coagulation  to  occur. 
Sexual  activity  increases  intravenous 
pressure  and  thus  favors  the  condition: 
it  is  therefore  a  disease  of  adult  life. 
The  clot  is  always  found  in  the  diseased 
vessel  and  never  in  the  perivenous  con- 
nective tissue.  L.  J.  Krouse  (Medical 
Record,  September  16,   1905). 

HICCOUGH    OF   INFANTS. 

Tn  an  apparently  normal  infant,  hic- 
cough occurs  as  a  reflex  from  the  stom- 
ach, and  indicates  a  surcharged  condi- 
tion of  that  organ.  Tf  may  happen  be- 
cause the  stomach  is  particularly  sus- 
ceptible, or  because  too  large  a  quantity 
of  food  has  hern  ingested  and  lias  con- 
sequently produced  distention.  After 
serious  digestive  troubles,  hiccough  is 
an  indication  that  (he  stomach  lias  re- 
sumed its  normal  functions.  11-^  value 
as  a  favorable  sign  i<  only  relative.     ll< 


signification  i»  to  a  certain  degree  of 
the  same  order  as  the  regurgitation 
which  is  a  so  observed  in  apparently 
healthy  infant.-  which  have  been  l'n\  too 
much  or  irregularly.  Jt  indicates  at 
least  that  a  sufficient  quantity  has  been 
ingested  to  reach  the  limit  of  the  diges- 
tive capacity  of  the  stomach.  Victor 
Thevennet  (Lyon  Medical,  August  27, 
1 905;  Xew  York  Medical  Journal  and 
Philadelphia  Medical  Journal.  Septem- 
ber 30,  1905). 

INSANITY,  ACUTE,  THERAPEUTICS  OF. 

Insanity  is  a  profound  error  in  gen- 
eral metabolism,  according  to  the  writer, 
which    may   sometimes  be   overcome   by 
alteratives — mercury,    potassium    iodide, 
and    the   chloride   of   gold   and    -odium. 
In  considering  the  therapeutics  of  acute 
insanity,    the    physician    must    bear    in 
mind   the  necessity   of  attention   to  the 
general   constitutional   state   of  the   pa- 
tient.    Bheumatism.   gout,   tuberculosis, 
and   syphilis   require   special    considera- 
tion.     Special    attention    must    also    be 
given  to  elimination  by  the  bowels  and 
kidneys.     Intestinal    fermentation,   when 
present,  must   be   diminished    by    intes- 
tinal   antiseptics.    n\'    which    the    write]' 
believes  that  salol  and  zinc  sulphocarbo- 
late  are  among  the  best.     Disorder  of  the 
gastro-intestinal  tract  is  one  of  the  mosl 
common  errors  in  these  cases.     Colonic 
impaction  is  common,  and   is  frequently 
overlooked.     Relief  of  this  condition  by 
aloetics   and    flushing,   when    this   is  re- 
sorted  to  early,   will   often    change  the 
whole  aspect  of  the  case.     The  author 
insists  upon   the   importance  of  a   gen- 
erous diet  for  bhese  patients,  and  stale- 
that  if  the  menial  condition  of  the  pa- 
tient interferes   with    this,    forced    feed- 
ing should  he  resorted  1".     in  case  this 
is  necessary,   the  nasal   tube  should   be 
used,  unless  there  is  some  condition  in 


510 


KEKNIG'S  SIGN  AND  PATHOGENESIS. 


LEUCOCYTE  COUNTING. 


the  nose  which  would  interfere  with  its 
use;  in  that  case,  the  oesophageal  tube 
will  have  to  be  used.  Attention  is  called 
to  the  necessity  of  controlling  the  in- 
somnia and  caution  in  the  use  of  chloral 
and  of  hyoscin  hydrobromate  is  advised. 
D.  E.  Brower  (American  Medicine,  Sep- 
tember 23,  1905). 

KERNIG'S  SIGN  AND  ITS  PATHOGENESIS. 

From  a  study  of  the  published  ob- 
servations relating  to  Kernig's  sign,  the 
author  draws  the  following  conclusions 
regarding  its  causation:  In  Kernig's 
sign  we  have,  first  of  all,  to  do  with 
stretching  of  the  sciatic  nerve.  In  the 
healthy  state  this  stretching  seems  not 
to  produce  any  pathologic  conditions; 
but  in  disease  when  the  nerve  itself  is 
affected  or  the  nerve  roots  are  affected — 
which  undoubtedly  takes  place  in  acute 
meningitis  —  the  stretched,  affected 
roots  react  correspondingly,  the  poste- 
rior roots  by  producing  pain,  and  the 
motor  roots  by  producing  contraction 
of  the  corresponding  muscles,  in  the 
case  of  the  sciatic  nerve,  the  flexor  mus- 
cles. The  pain  arising  from  the  stretch- 
ing of  the  posterior  roots  makes  the  pa- 
tient instinctively  keep  away  from  fur- 
ther stretching  of  the  posterior  roots. 
as  it  happens,  for  instance,  in  disloca- 
tions when  the  muscles  respond  with 
strong  contraction  to  any  active  or  pas- 
sive movements  in  the  dis^cated  joints. 
The  occasional  occurrence  of  the  sign  in 
typhoid  fever  may  be  explained  by  the 
fact  that  the  meninges  are  frequently 
affected  in  typhoid  fever,  so  that  the 
sign  is  due.  not  to  the  fever,  but  to 
the  concomitant  meningitis.  "Regarding 
oilier  published  cases  in  which  Kernig's 
sign  was  present  in  the  npparent  absence 
of  meningitis,  it  is  hard  to  prove  that 
in  those  cases  the  meninges  were  not 
affected,    so    that,    commonly.    Kernig's 


sign  may  be  considered  as  a  standard 
sign  of  inflammatory  meningeal  lesions, 
and,  as  being  due  to  irritation  of  the 
spinal  roots,  produced  by  the  stretching 
of  the  sciatic  nerve.  G.  B.  Hassin 
(Medical   Eecord,   September  9,   1905). 

LARYNX,  REMOVAL  OF  FOREIGN  BODIES 
FROM. 

Attention  is  called  by  the  writer  to 
the  immediate  difficulty  with  which  one 
may  have  to  contend  in  attempting  forc- 
ibly to  remove  a  foreign  body,  especially 
a  cockleburr,  from  the  larynx,  that  of 
the  intense  reflex  laryngeal  spasm  which 
may  be  excited  thereby  against  the  sharp 
spines  of  the  cockleburr.  In  attempting 
the  removal  of  such  a  foreign  body,  the 
author  invokes  the  aid  of  an  antagonistic 
reflex — a  reflex  not  only  antagonistic  to, 
but  far  more  imperious  than,  that  of  the 
demand  of  the  body  for  oxygen  after 
forced,  prolonged  expiration.  The  tis- 
sues of  the  larynx  are  anaesthetized  with 
a  cocaine  solution.  The  patient  is  in- 
structed to  attempt  to  phonate  the  vowel 
"a,"  the  laryngeal  mirror,  and  the 
Fauvel  forceps  having  been  introduced 
previously.  The  cockleburr  is  seized 
firmly  just  as  the  patient  phonates.  and 
is  held  immovably  until  the-  patient 
grows  desperate  for  air.  when  she  is 
ordered  to  breathe.  The  larynx  relaxes 
into  the  position  of  forced  inspiration 
and  as  it  does  so  a  slight  wigwag  mo- 
tion of  the  forceps  will  instantly  bring 
away  the  cockleburr  without  the  loss  of 
a  single  one  of  its  spines  and  without 
wounding  the  laryngeal  tissues.  "R. 
Barclay  (Medical  Fortnightly.  Septem- 
ber 11.  1905). 

LEUCOCYTE       COUNTING.       CONVENIENT 
METHOD   OF. 

The  writer  designates  this  as  the 
acetic  acid   and   gentian   violet   method. 


LEUCOCYTE  (HUNTS  IN   BRON<  HO  PNEUMONIA.  ETC. 


511 


The  solutions  used  are:  (1)  Aqueous 
solution  acetic  acid,  5  to  1000,  30 
grains;  (2)  saturated  alcoholic  solu- 
tion of  gentian  violet,  10  drops.  The 
best  instrument  to  use  for  the  count  is 
llayem's  hsematimeter.  In  addition, 
one  must  have  a  pipette  for  measuring 
20  centimeters  of  blood.  Also  one  for 
measuring  .5  cubic  centimeter  of  the 
acetic-gentian-violet  solution.  Another 
necessary  accessory  is  a  small  •  glass- 
stoppered  tube,  containing  about  1  cubic 
centimeter,  in  which  the  mixture  is  kept 
to  be  examined  either  at  the  bedside  of 
the  patient  or  at  the  doctor's  office  any 
time  between  one-half  hour  to  three  hours 
after  the  blood  has  been  drawn.  The 
acetic  acid  dissolves  the  red  blood-cor- 
puscles, and  the  leucocytes  alone  appear 
in  the  microscopic  field.  The  gentian 
violet  is  not  strong  enough  to  color 
strongly  the  whole  leucocyte,  but  it 
makes  the  nuclei  very  visible  and  allows 
one  not  only  readily  to  make  the  count, 
but  also  rapidly  to  determine  the  rela- 
tive number  of  uninuclear  and  multi- 
nuclear  cells.  E.  L.  ftros  (New  York 
Medical  Journal  and  Philadelphia  Med- 
ical Journal,  September  16.  1905). 

LEUCOCYTE  COUNTS  IN  BRONCHO-PNEU- 
MONIA. LOBAR  PNEUMONIA.  AND 
EMPYEMA  IN  CHILDREN. 
A  well-marked  leueocytosis  is  presenl 
in  the  broncho-pneumonia  of  children, 
and  is  independent  of  the  amount  of 
lung  involved.  The  degree  of  leueocy- 
tosis in  broncho-pneumonia  stands  in 
no  relation  to  the  heighl  of  the  tempera- 
ture. Though  there  are  some  excep- 
tions, yet  in  broncho-pneumonia  the 
general  rule  is  that  failure  <>f  the  leuco- 
cyte count  jo  drop  when  the  pulmonary 
signs  disappear  indicates  either  a  com- 
plication or  a  fatal  termination  of  the 
illness. 


A  constant  and  considerable  leueocy- 
tosis may  regularly  be  expected  in  the 
lobar  pneumonia  of  children.  The  de- 
gree of  leueocytosis  is  about  the  same  as 
in  broncho-pneumonia  (broncho-pneu- 
monia: average  leueocytosis  in  19  case-. 
33,900;  lobar  pnemonia:  average  leu- 
eocytosis in  24  cases,  31,700).  The  leu- 
eocytosis in  lobar  pneumonia  differs 
from  that  in  broncho-pneumonia  in 
that  the  white  blood-count  is  higher 
when  the  pulmonary  involvement  is 
greater.  If  in  lobar  pneumonia  two  or 
more  lobes  be  involved,*  a  relatively  high 
blood-count  may  be  looked  for.  The 
leueocytosis  in  lobar  pneumonia  fur- 
nishes no  clue  as  to  the  height  of  the 
temperature.  An  increasing  leueocyto- 
sis is  the  general  rule  in  the  lobar  pneu- 
monia of  children,  reaching  the  maxi- 
mum just  before  the  crisis.  While  fail- 
ure to  drop  before  the  crisis  may  indi- 
cate a  complication,  yet  this  may  he  of 
special  significance.  The  precritical 
drop  in  the  lobar  pneumonia  of  children 
is  inconstant,  of  little  or  no  prognostic 
value,  and  cannot  be  utilized  as  means 
of  determining  the  time  of  crisis. 

There  is  a  high  leueocytosis  at  the 
onset  of  empyema  in  children.  In  gen- 
eral it  may  be  said  that  the  diagnostic 
value  of  the  leueocytosis  in  the  pulmo- 
nary affections  of  children  is  limited. 
Tn  certain  instances,  however,  the  leu- 
cocyte count  is  of  great  diagnostic  aid. 
When,  for  example,  in  lobar  pneumonia, 
resolution  and  the  drop  in  1ho  leueocy- 
tosis have  occurred,  and  there  are  pres- 
ent signs  exciting  suspicion  that  em- 
pyema will  be  a  sequela,  then  blood- 
counts  should  frequently  be  made  at 
regular  intervals.  A  sharp  rise  in  the 
count,  provided  that  other  causes  of  leu- 
eocytosis can  be  excluded,  is  then  strong 
presumptive  evidence  of  a  supervening 
empyema.  Henry  Heiman  (Archives  of 
Pediatrics,   October,    1905). 


512 


MALARIA,  WHITE  CELLS  IN. 


NASAL  CATARRH,  SULPHUR  IN. 


MALARIA,   WHITE   CELLS   IN. 

The  behavior  of  the  white  cells  in  a 
variety  of  forms  of  malaria  were  inves- 
tigated by  the  writer,  with  especial  ref- 
erence to  leucocytosis.  His  conclusions 
are  as  follows:  The  lencocytic  reaction 
in  malaria  at  the  beginning  of  the  dis- 
ease takes  the  form  of  a  slight  increase 
in  the  number  of  white  cells  over  the 
normal,  while  in  the  further  course  of 
the  malady' there  is  a  diminution  in  the 
total  number  of  white  eel's,  owing  to 
the  increased  cytolysis  in  the  plasma  and 
the  organs.  Upon  recovery  from  ma- 
laria, the  number  of  white  cells  becomes 
normal  and  the  number  of  eosinophils 
is  increased.  Accompanying  malarial 
cachexia,  there  is  a  constant  and  marked 
hypoleucocytosis.  The  digestion  leuco- 
cytosis is  absent  during  the  attacks,  ow- 
ing to  the  loss  of  appetite,  and  reap- 
pears when  the  appetite  improves.  Some 
forms  of  white  cells  (the  eosinophils, 
and  possibly  the  polynuclear  and  mono- 
nuclear), are  possessed  of  positive  chem- 
iotaxis  toward  the  full-grown  forms  of 
parasites  of  malaria,  and  are  capable  of 
dest  roving  them.  It  is  probable  that 
this  destructive  property  of  the  leuco- 
cytes is  employed  by  the  organism  in  its 
battle  against  malarial  parasites.  In 
chronic  malaria,  the  extensive  destruc- 
tion of  white  cells  is  probably  also  a 
means  of  defense.  B.  F.  Petrol!' 
(Roussky  Yrateh,  July  23,  1905;  New 
York  Medical  .Journal  and  Philadelphia 
Medical  Journal.  September  30,  1905). 

METHiEMOGLOBIN  AS  A  FACTOR  IN  CON- 
SERVATIVE    METABOLISM. 

The  writer  believes  a  patient  may  be, 
and  indeed  is,  often  benefited  by  an  in- 
duced methsemoglobrnaemia  effected  by 
drugs  now  empirically  employed,  by 
oxidizing  through  this  means  the  sub- 
oxidized  leucomains  which  are  found   in 


time  of  disease  to  accumulate  in  abnor- 
mal amounts  in  the  blood.  These  pow- 
erful reducing  agents  are  able  to  take  0 
from  metlnemoglobin,  although  the  tis- 
sues cannot.  The  partial  asphyxia  of 
disease,  as  evidenced  by  dyspnoea  and 
cyanosis,  has  as  one,  if  not  exclusive 
cause,  the  increased  amount  of  oxygen 
required  by  the  system  to  oxidize  the 
tissues  plus  the  leucomains  or  other  like 
basic  reducing  substances,  with  which 
need  the  lungs  cannot  keep  pace.  With 
an  induced  methemoglobinemia  in  just 
that  degree  that  may  be  required  to  suf- 
ficiently oxidize  the  basic  substances, 
thereby  preparing  them  for  elimination 
or  for  further  use  in  the  animal  econ- 
omy, two  paramount  results  are  ob- 
tained: 1.  The  oxyhemoglobin  is  con- 
served for  use  of  the  tissues.  2.  Some 
oxyhemoglobin  is  produced  within  the 
tissues,  and  herein  vicarious  function 
for  an  embarrassed  pulmonary  respira- 
tion is  established.  Bernard  Octtinger 
(Journal  of  the  American  Medical  As- 
sociation, September  16,  1905). 

NASAL  CATARRHS,   SULPHUR  IN. 

Excellent  results  have  been  obtained 
by  the  writer  in  the  treatment  of  prac- 
tically all  forms  of  chronic  nasal  ca- 
tarrhs, by  insufflating  sulphur  into  the 
nose  and  pharynx.  The  best  galenical 
preparation  for  this  purpose  is  the  official 
sulphur  preeipitatuin,  U.  S.  1'.  Of 
course,  if  the  nasal  trouble  is  of  con- 
stitutional origin  or  dependent  upon 
some  anatomical  defect,  the  sulphur  will 
only  act  as  a' palliative.  The  author  ad- 
vises using  the  insufflations  two  or  three 
times  a  week  tor  the  first  month  and 
once  a  week  for  the  next  two  months. 
Bonis  BTolipinski  (Medical  News,  Au- 
gust 12,  1905). 


NERVOUS  SYSTEM,  DISEASE  OF.        PANCREATIC  DIABETES,  SUGAR   IN.      513 


NERVOUS  SYSTEM,  DIAGNOSIS  OF  DIS- 
EASES OF  THE. 
The  diagnosis  of  nervous  diseases  is 
almost  wholly  dependent  upon  observa- 
tion and  interpretation.  Some  nervous 
diseases  can  be  diagnosticated  from  a 
consideration  of  the  patient's  statements 
alone,  hut  the  physician  who  relies  upon 
such  data  in  order  to  make  a  diagnosis 
must  very  often  err,  no  matter  how- 
great  his  experience  or  how  profound  his 
clinical  acumen.  If  patients  who  suf- 
fer from  nervous  diseases  are  subjected 
to  well-known  methods  of  examination 
and  the  results  of  such  examinations 
recorded  and  then  thought  given  to  their 
interpretation,  particularly  in  the  light 
of  the  time  and  way  in  which  they  oc- 
curred, there  are  scarcely  any  of  the 
ordinary  organic  or  functional  diseases 
of  the  nervous  system  that  will  not  read- 
ily he  recognized.  The  reason  why 
nervous  diseases  are  considered  to  be  a 
strange  country  by  the  general  practi- 
tioner, is  because  there  is  an  inherited 
conviction  that  such  diseases  are  ex- 
tremely obscure;  because  there  is  an 
acquired  conviction  that  in  order  to  un- 
ravel the  intricacies  of  such  diseases,  a 
comprehensive  knowledge  of  the  an- 
atomy and  physiology  of  the  nervous 
system  is  required;  and  finally,  because 
many  physicians  do  not  take  the  trouble 
to  acquaint  themselves  with  the  simple 
methods  of  testing  for  the  existence  of 
nervous  disease.  Any  medical  man  who 
will  put  himself  outside  of  these  three 
limitations  or  obsessions,  will  have  no 
more  difficulty  in  dealing  satisfactorily 
with  nervous  diseases  than  he  has  with 
any  other  disease  in  the  province  of  in- 
ternal medicine.  Joseph  Collins  (Med- 
ical Record,  September  16,  1905). 


PANCREATIC  DIABETES,  ORIGIN  OF  THE 
SUGAR    IN. 

A  burning  question  in  physiology  to- 
day, according  to  the  author,  is  whether 
the  large  amounts  of  sugar  excreted  in 
pancreatic  diabetes  are  derived  from  fat 
or  albumin,  or  from  both.  In  order  to 
answer  this  question  a  careful  investiga- 
tion was  made  by  the  writer.  Dogs  were 
fed  upon  large  quantities  of  proteid 
food,  which  contained  neither  carbohy- 
drate nor  fat.  Such  food  was  found  to 
he  codfish,  which  in  winter  and  spring 
contains  no  glycogen  nor  glucosides, 
and  only  traces  of  fat.  With  such  a  diet 
pancreas-free  dogs  excrete  for  months 
such  large  quantities  of  sugar  (amount- 
ing to  30  per  cent,  of  the  body-weight) 
that  the  sugar  cannot  possibly  be  de- 
rived from  the  glycogen  or  other  form 
of  carbohydrate  stored  up  in  the  body. 
The  excreted  sugar,  moreover,  weighs 
more  than  the  proteid  substance  of  the 
body.  The  sugar,  therefore,  is  derived 
either  from  the  fat  of  the  organism  or 
from  its  proteid  and  that  of  the  food. 
The  immense  amount  of  sugar,  however, 
did  not  exceed  that  which  might  theo- 
retically be  derived  from  the  fat  stored 
in  the  body.  In  spite  of  the  abundant 
albuminous  diet  the  dogs  emaciated  to 
the  very  hones,  as  if  they  had  been 
starved,  and  only  the  brain  and  heart 
remained  intact.  One  marked  difference 
between  these  and  dogs  that  were  act- 
ually starved  is  that  in  the  former  the 
fa!  alone  mostly  disappears.  ,\  second 
difference  is  that  in  the  diabetic  animal 
at  death  the  weight  of  the  liver  exceeds 
that  of  the  liver  of  the  healthy  animal. 
The  enormously  large  diabetic  liver  has 
the  normal  chemical  composition,  and 
thus  behaves  exceptionally  like  the  brain 
and  heart  of  starved  animals.  This  is 
explained  by  the  fact  that  the  liver  by 
continuous  effort  in  its  struggle  for  ex- 


514 


PHLEBITIS,  TREATMENT  OF. 


istence  with  other  organs,  particularly 
for  food,  maintains  its  functional  ca- 
pacity. The  most  plausible  explanation 
of  diabetes  is  that  the  formation  of  sugar 
is  the  work  of  the  cell-substance  of  the 
liver,  by  which  not  only  glycogen,  but 
also  fat,  is  transformed  into  sugar. 
Every  stimulation  of  the  liver  cell, 
either  by  innervation,  or  by  carbon  di- 
oxide, phloridzin,  adrenalin,  or  other 
poison,  increases  the  production  of 
sugar.  If  the  organism  is  fed  on  large 
quantities  of  proteid,  then  the  liver 
must  naturally  work  over  many  nitro- 
genous derivatives  of  albumin.  The 
more  proteid  is  thus  offered  to  it,  the 
more  its  cells  are  stimulated,  and  thus 
its  sugar-forming  function  is  increased. 
The  administration  of  ammonium  car- 
bonate similarly  stimulates  the  liver 
cells.  Besides,  the  administration  of 
large  amounts  of  proteid  increases  the 
entire  bulk  of  the  liver  cells.  It  may 
thus  be  understood  how  in  different  in- 
dividuals very  different  quantitative  re- 
lations exist  between  proteid  metabolism 
and  sugar-formation,  and  why,  at  the 
lowest  ebb  of  albuminous  metabolism, 
any  poison  or  other  irritation  acts  as  a 
stimulus  of  the  liver  cells,  increasing  the 
sugar-production,  without  an  accom- 
panying rise  in  the  metabolism  of  pro- 
teids.  E.  Pfliiger  (Pfl tiger's  Archiv, 
May  15.  1905;  Medical  News.  Septem- 
ber 23.   1905). 

PHLEBITIS,    TREATMENT    OF. 

The  writer  outlines  the  treatment 
suitable  for  obliterating  phlebitis  of  the 
largo  veins,  for  subacute  venous  septi- 
caemia, and  for  recurring  phlebitis.  Im- 
mobilization in  the  former  should  be 
absolute.  A  cast  is  not  used,  but  the 
leg  is  held  immovable  by  strips  across 
it  at  the  knee  and  above  and  below,  the 
strips  being  pinned    firmly  to  the  mat- 


tress. Another  strip  should  hold  the 
foot  immovable  at  a  right  angle  to  the 
leg.  A  strip  across  the  lower  part  of 
the  trunk  should  likewise  be  pinned  to 
the  mattress  or  tied  to  the  side-bars  of 
the  bed.  This  technique  allows  super- 
vision of  the  various  parts  of  the  limb 
without  raising  it,  as  would  be  neces- 
sary with  a  cast. 

Sedative  applications'  at  first  are  fol- 
lowed by  fomentations  with  a  natural 
saline  water  for  three  or  four  hours, 
the  part  powdered  with  talcum,  chalk, 
magnesia,  and  resorcin  powder  in  the 
interim.  When  the  temperature  has 
been  normal  for  twenty  days,  and  the 
veins  are  indolent  to  palpation  and  the 
oedema  is  retrogressing,  then  partial  pas- 
sive mobilization  may  be  commenced, 
limited  to  ankle  and  toes.  From  the 
twenty-seventh  to  the  thirty-fifth  day 
the  muscles  may  be  massaged,  and  at 
this  time  the  knee  and  the  trunk  can 
be  released.  By  the  fortieth  day  the 
patient  can  be  allowed  to  take  a  few 
steps.  An  elastic  stocking  should  not 
be  worn  at  first,  but  merely  a  light 
bandage  wound  from  the  foot  to  the 
thigh  before  the  patient  is  allowed  to 
get  up.  This  promotes  the  establish- 
ment of  collateral  circulation.  A  crutch 
should  not  be  allowed,  as  this  favors 
vicious  attitudes. 

Subacute  venous  septicaemia  or  mul- 
tiple, relapsing  phlebitis,  requires  dif- 
ferent treatment,  measures  to  combat 
varicose  congestion  and  to  prevent  the 
entrance  of  germs  into  the  enlarged 
veins.  The  slightest  phlebitis  of  this 
nature  demands  rest  in  bed  with  im- 
mobilization for  twenty  days,  followed 
by  passive  movements  of  the  joints ;  the 
rest  of  the  limb  does  not  require  mo- 
bilization or  massage,  and  these  meas- 
ures arouse  the  phlebitis  again.  An 
elastic  stocking  is  needed  when  the  pa- 


PNEI  M0N1A,  FREEZING  POINTS  OF  BLOOD  AND  URINE  IN. 


515 


tient  gets  up.  Surgical  intervention 
should  be  reserved  for  protracted  phleb- 
itis with  successive  emboli  from  disin- 
tegration of  the  clot  and  danger  of  sep- 
ticaemia. It  is  also  indicated  in  case  of 
circumscribed,  infected  varicose  ulcers. 
Each  reawakening  of  the  subacute  ve- 
nous phlebitis  should  be  treated  like  a 
new  focus,  and  mobilization  should  not 
be  commenced  until  twenty  days  after 
the  temperature  has  returned  to  normal. 
Local  treatment  should  be  the  same  as 
previously  mentioned.  The  fomenta- 
tions are  especially  effectual  in  aiding 
resolution  in  these  cases,  as  the  veins  and 
perivenous  surrounding  tissue  are  ac- 
cessible. 

In  recurring  phlebitis  in  gouty  sub- 
jects, immobilization  is  still  the  rule, 
for  mobilization,  massage,  etc.,  do  more 
harm  than  good.  Postphlebitic  acci- 
dents are  generally  the  result  of  ab- 
surdly long  immobilization,  from  three 
to  twelve  months.  The  pain  and  oedema 
are  best  treated  by  mild  hydrotherapy, 
effleurage,  and  electricity.  Massage  un- 
der hot  running  water  acts  on  the 
trophic  trouble  and  on  the  muscu- 
lar atrophy  common  in  postphlebitic 
oedema.  The  author  asserts  that  this 
delicate  but  energetic  treatment  which 
he  recommends  for  the  various  forms  of 
phlebitis  effects  cures  without  causing 
a  train  of  sequela?.  H.  Vaquez  (Semaine 
Medicale,  July  26,  1905;  Journal  of 
the  American  Medical  Association.  Sep- 
tember 16,  1905). 

PNEUMONIA.       FREEZING       POINTS       OF 
BLOOD    AND   URINE   IN. 

From  a  study  of  the  subject,  the  au- 
thor has  found  that  there  is  an  absolute 
lowering  of  the  freezing  point  of  blood 
in  pneumonia.  The  freezing  point  low- 
ering of  the  blood  depends  in  some  way 
either  <m  the  extent  of  consolidation  of 


the  lung  or  on  the  height  of  the  tem- 
perature, or  both.  This  lowering  of  the 
freezing  point  of  the  blood  is  greater 
than  would  be  accounted  for  by  the  in- 
creased venosity  of  the  blood,  due  to 
deficient  aeration  in  the  lungs.  The 
concentration  of  the  blood  increases,  as 
shown  by  the  lowered  freezing  point,  as 
the  disease  progresses  up  to  the  time  of 
crisis.  Some  time  is  necessary  for  the 
elimination  of  the  excessive  accumula- 
tion of  products  in  the  blood.  Hence, 
several  days  elapse  before  the  freezing 
point  of  the  blood  rises  again  to  normal. 
In  those  cases  where  the  heart  weakens 
perceptibly,  the  freezing  point  of  the 
blood  becomes  lower.  In  the  fatal  cases 
in  which  the  heart  gives  out,  the  freez- 
ing point  of  the  blood  is  extremely  low. 
The  lowered  freezing  point  of  the  blood 
is  apparently  not  due  to  deficient  kid- 
ney function,  but  may  be  due  to  the  in- 
ability of  the  kidney  to  excrete  the  ex- 
cessive products  of  metabolism. 

As  regards  the  urine,  the  freezing 
point  in  pneumonia  is  considerably  low- 
ered. This  lowering  is  greater  than 
would  be  accounted  for  by  a  mere  con- 
centration of  normal  urine.  The  chlo- 
ride excreted  are  constantly  diminished, 
due  to  a  decrease  in  amount  taken  in 
(Sollmann).  The  freezing  point  of  the 
urine  times  the  number  of  cubic  centi- 
meters voided  is  increased.  The  quan- 
tity of  urine  is  decreased,  whereas  the 
freezing  point  is  lower. 

The  lowering  of  the  freezing  point  of 
the  urine  is  not  due  to  chloride,  but  to 
metabolic  molecules  excreted.  The 
freezing  point  of  the  urine  does  not  rise 
to  normal  until  after  that  of  the  blood. 
that  is,  several  days  after  the  crisis. 
The  specific  gravity  of  the  urine  is  not 
an  accurate  index  to  the  concentration 
of  the  urine.  The  freezing  point  of  the 
urine  bears  no  constant  relation  to  that 


516     PNEUMONIA  AND  SURGICAL  OPERATIONS.        PUERPERAL  INFECTIONS. 


of  the  blood  normally,  for  in  a  case  with 
a  freezing  point  of  blood  at  — 0.54°  C. 
the  freezing  point  of  the  urine  may  nor- 
mally be  lower  than  in  a  case  in  which 
the  freezing  point  of  the  blood  is — 0.57° 
C.  or  vice  versa.  F.  E.  Schmidt  (Jour- 
nal of  the  American  Medical  Associa- 
tion, September  23,  1905). 

PNEUMONIA     COMPLICATING     SURGICAL 
OPERATIONS. 

As  a  preventive  measure,  the  writer 
states  that  it  should  be  a  fixed  rule  that 
no  patient  who  has  at  the  time  an  acute 
coryza,  tonsillitis,  or  bronchitis  should 
be  given  an  anaesthetic,  except  in  case 
of  absolute  necessity.  Not  only  is  it 
desirable  under  such  circumstances  to 
avoid  the  irritant  effect  of  the  vapor  of 
the  anaesthetic,  but  under  such  condi- 
tions there  is  likely  to  be  an  increased 
virulence  of  the  micro-organisms  in  the 
air  passages.  Ether  should  be  given  in 
the  least  possible  concentration,  and.  to 
avoid  aspiration  of  the  secretions  of  the 
mouth,  the  patient's  head  should  be 
kept  low  and  turned  to  one  side,  in 
order  to  allow  the  secretions  to  flow  out 
of  the  mouth.  Previous  to  the  admin- 
istration of  the  anaesthetic  the  mouth 
should  receive  attention  and  the  teeth 
should  be  carefully  cleansed,  after  which 
an  antiseptic  mouth  wash  should  be 
liberally  used.  The  stomach  should  be 
empty,  and  in  case  of  operation  on  that 
organ,  lavage  should  precede  the  opera- 
tion. If  necessary  to  use  chloroform  in 
the  presence  of  gas  or  lamp  light,  the 
room  should  he  well  ventilated.  In  case 
of  weak  circulation,  it  is  very  desirable 
to  proven!  hypostatic  congestion.  Such 
patients  should  have  their  position  fre- 
quently chanced,  and  as  soon  as  possible 
should  be  raised  to  the  half-sitting 
posture.  The  importance  of  meteorism 
as    a    factor    in    hypostatic    congesiion 


should  not  be  lost  sight  of.  Distention 
of  the  stomach  embarrasses  the  heart's 
action  by  pressure  and  also  encroaches 
upon  the  lower  lobes  of  the  lungs,  pre- 
venting their  full  expansion.  It  should 
be  relieved  by  re-establishment  of  intes- 
tinal peristalsis  as  early  as  possible  after 
the  first  twenty-four  hours  following  the 
operation.  Following  Czerny's  sugges- 
tion, the  patient  should  be  urged  to  ex- 
pand the  lungs  fully,  even  though  the 
effort  is  painful,  to  further  aid  in  the 
prevention  of  hypostasis.  J.  L.  Eotli- 
rock  (St.  Paul  Medical  Journal,  Sep- 
tember, 1905). 

PUERPERAL     INFECTIONS,     TREATMENT 
OF,  BY  TURPENTINE. 

In  the  treatment  of  puerperal  infec- 
tions the  want  has  been  felt  for  an  anti- 
septic with  little  toxic  effect  on  the  hu- 
man organism.  The  writer  believes  that 
this  agent  has  been>  found  in  oil  of  tur- 
pentine, which  he  used  by  intrauterine 
and  hypodermic  injection  in  streptococ- 
cal infections.  Turpentine  has  been 
found  to  have  marked  antiseptic  and 
antiphlogistic  powers,  which  are  exer- 
cised especially  on  the  streptococcus.  If 
the  inflammation  is  local,  the  author 
employs  an  intrauterine  douche  of  15 
cubic  centimeters  each  of  turpentine  and 
alcohol,  mixed  with  a  liter  of  steri'e 
water.  If  burning  sensations  are  pro- 
duced in  the  vagina  and  vulva,  they  may 
be  avoided  by  a  simultaneous  vaginal 
lavage  with  sterile  water.  These  injec- 
tions should  be  made  twice  daily,  and 
continued  even  after  the  temperature 
has  reached  the  normal  point.  In  cases 
where  the  infection  has  spread  beyond 
the  uterine  cavity,  the  author  employs 
subcutaneous  injections.  A  mixture  of  1 
cubic  centimeter  each  of  turpentine  and 
alcohol  is  agitated  with  ?00  enbie  ccnti- 
meters  of  normal  saline  solution,  and  is 


RENAL  CALCULUS,  X-RAY  DIAGNOSIS. 


RHEUMATIC  POISON. 


517 


injected  into  the  cellular  tissue  of  the 
abdominal  wall.  This  treatment  is  to 
be  repeated  twice  daily.  M.  Fabre 
(Lyon  Medical,  August  6,  1905;  Amer- 
ican Medicine,  September  23,  1905). 

RENAL     CALCULUS,     X-RAY     DIAGNOSIS 
OF. 

The  x-rays  are  an  extremely  useful 
auxiliary  to  the  ordinary  methods  of 
diagnosis  in  renal  calculus,  and  this 
method  should  be  resorted  to  in  every 
case  of  suspected  stone,  and  no  operation 
should  be  decided  upon  until  the  case 
has  been  carefully  photographed.  The 
method  entails  a  great  responsibility 
and  should  in  every  case  be  carried  out 
with  the  greatest  possible  care,  for  the 
patient's  sake  as  well  as  for  the  opera- 
tor's reputation,  as  a  mistake  may  lead 
to  such  serious  consequences.  The  great 
increase  in  the  power  of  the  apparatus 
used,  and  the  increased  knowledge  of 
how  to  obtain  the  best  results,  will  soon 
enable  x-ray  specialists  to  exclude  all 
doubt  in  the  interpretation  of  a  nega- 
tive. 

In  cases  where  the  negative  shows  the 
shadow  of  a  stone  and  an  operation  is 
decided  upon,  the  patient  should  be  re- 
photographed  under  as  nearly  as  pos- 
sible similar  conditions  a  clay  or  so 
prior  to  the  operation.  The  writer  con- 
siders this  necessary,  because  in  one  case 
a  patient  was  photographed  and  a  diag- 
nosis of  renal  calculus  was  made.  The 
operation  took  place  some  time  after- 
ward, and  no  stone  was  found  in  the 
kidney.  Another  photograph  was  taken 
shortly  after  the  operation,  and  the 
stone  was  again  seen,  but  this  time  it 
was  in  the  ureter.  During  the  interval 
between  taking  the  photograph  and  per- 
forming the  operation  the  stone  had 
moved  downward.  The  writer  consid- 
ers that  every  case  should  be  taken  stere- 


oscopically  at  least  once.  Morton  Smart 
(British  Medical  Journal,  September 
16,  1905). 

RHEUMATIC  POISON. 

The  writer  states  that  his  experience 
shows  that  it  is  only  necessary  to  cut 
out  of  the  diet  red  meats,  such  as  beef 
and  mutton,  and  alcoholic  stimulants, 
and  reduce  to  a  minimum  all  articles 
containing  sugar.  All  other  foods  may 
be  taken,  and  the  best  results  come  from 
a  free  use  of  white  meats,  soups,  eggs, 
'fish,  cereals,  vegetables,  fresh  fruits, 
milk,  and  coffee.  As  soon  as  acute 
symptoms  have  subsided,  exercise  by 
walking  and  massage  is  very  necessary 
for  good  circulation  and  normal  cell 
action.  He  is  in  favor  of  the  cold 
sponge  bath  every  morning,  and  in  some 
cases  a  quick  hot  bath  before  retiring 
at  night.  Chronic  cases  also  do  well 
with  a  Turkish  bath  once  or  twice  a 
week.  Baths  of  mineral  water  have  no 
remedial  effect  in  rheumatism.  The  au- 
thor does  not  believe  that  external  ap- 
plications, such  as  ointments,  oils,  and 
liniments,  have  any  permanent  value. 
In  cases  in  which  the  muscles  around 
joints  are  inflamed,  sedative  ointments 
and  liniments  give  temporary  relief 
while  the  full  action  of  the  internal 
medicine  is  waited  for.  The  author  pro- 
tests against  the  use  of  colchicum,  sali- 
cylic acid,  salicin,  and  the  salicylates  in 
this  condition.  From  the  beginning  of 
the  treatment  he  used  an  alkaline  mix- 
ture to  stimulate  the  action  of  the  liver 
and  bowels,  which  contains  in  each  dose 
20  to  40  grains  of  sodium  hyposulphite. 
20  to  40  drops  of  glycerine,  and  100  to 
200  drops  of  cinnamon  water.  This 
makes  a  dose  of  2  to  4  drachms,  to  be 
taken  every  morning  before  any  food, 
and  at  night  if  required.  In  severe  cases 
a  larger  dose  may  be  given.    If  an  anal- 


518       SCIATA,  TREATMENT.  SHOCK,  CONDITION  OF  BLOOD-VESSELS  IN. 


gesic  is  required  one  should  be  given 
that  does  not  depress  the  heart.  When 
the  acute  symptoms  are  past,  tonics, 
such  as  iron,  quinine,  strychnine,  and 
arsenic,  should  be  given  in  gradually  in- 
creasing quantities  until  full  doses  are 
administered,  while  special  symptoms 
are  cared  for  as  in  any  chronic  disease. 
P.  LeEoy  Satterlee  (New  York  Medical 
Journal  and  Philadelphia  Medical  Jour- 
nal, September  30,  1905). 

SCIATICA,  TREATMENT  OF. 

Pain  in  the  course  of  the  sciatic  nerve 
is  common,  but  genuine  sciatic  neural- 
gia is  rare.  Most  of  the  cases  are  really 
perineuritis  or  interstitial  neuritis, 
while  others  are  symptomatic  of  inter- 
ference with  nutrition  by  some  extrinsic 
lesion.  The  causes  of  sciatica  are  ex- 
posure to  cold,  overfatigue  of  the  legs, 
and  pressure  on  the  nerve  from  habitual 
sitting  in  persons  whose  metabolic  proc- 
esses are  impaired  by  rheumatism,  gout, 
diabetes,  or  alcoholism,  injuries  from 
lifting  heavy  weights,  horseback  or  bi- 
cycle riding,  sewing-machine  work,  etc. 
Sciatic  pain  occurs  in  diseases  of  all 
neighboring  organs  that  are  associated 
with  compression  of  the  sciatic  nerve  or 
sacral  plexus.  Such  are  tumors  and  in- 
flammation in  the  pelvis,  or  of  the  spi- 
nal meninges,  vertebral  caries,  uterine 
disease,  pregnancy,  parturition,  malig- 
nant disease  of  rectum,  haemorrhoids, 
hardened  fasces,  sarcoma  of  femur,  etc. 
It  may  result  from  fracture  or  disloca- 
tion of  the  thighs.  It  is  rare  from  lead, 
mercury,  or  syphilis.  Anaemia,  chloro- 
sis, and  hysteria  have  little  influence  in 
producing  it.  It  may  develop  suddenly 
from  exposure,  or  slowly  when  sympto- 
matic of  oilier  diseases.  The  diagnosis 
is  based  on  pain  or  tenderness  over  the 
nerve  trunk,  which  radiates  to  the  foot 
or  toes,  and   diminution   or  loss  of  the 


Achilles  tendon  reflex.  When  degenera- 
tive, it  is  accompanied  by  paralysis, 
atrophy,  vasomotor   disturbances,  etc. 

In  the  treatment  of  sciatica  the  first 
thing  is  the  diagnosis  of  the  cause  and 
its  removal  when  possible.  In  acute 
cases  heat  by  the  hot  wet-pack,  com- 
bined with  rest  and  fixation  and  hot 
saline  enemata,  relieve  pain.  The  bow- 
els should  always  be  moved  by  enema, 
and  calomel  given  to  unload  the  bowel 
and  eliminate  poisons.  Morphine  or 
opium  suppositories  are  always  indi- 
cated to  obtain  sleep  at  night.  Massage, 
if  gentle,  is  useful.  Linear  cauteriza- 
tion is  of  value  in  relieving  pain,  as  is 
the  ice-bag  at  times.  The  continuous 
galvanic  current  in  either  direction  is 
useful  at  the  end  of  one  week.  It  is  more 
useful  in  mild,  subacute,  or  chronic 
cases.  Mild  cases  will  yield  to  hot  packs, 
massage,  and  rectal  irrigation.  In  sub- 
acute or  chronic  cases  a  modified  rest 
cure  is  essential.  Drugs  are  useless. 
Daily  massage  and  passive  movements, 
and  systematic  exercises  are  useful.  Hy- 
drotherapy, in  form  of  local  pack, 
Scotch  douche,  etc.,  is  most  valuable. 
Static  or  faradic  electricity  in  the  form 
of  the  brush  is  useful.  W.  M.  Leszyn- 
sky  (Medical  Eecord,  September  9, 
1905). 

SHOCK,  CONDITION  OF  THE  BLOOD- 
VESSELS DURING. 
The  author  maintains  that  it  is  a 
mistake  to  suppose  that  a  fall  of  blood- 
pressure  indicates  absolutely  that  the 
vessels  are  dilated.  On  the  contrary,  a 
contraction  of  an  individual  vessel  al- 
ways reduces  the  pressure  within  that 
vessel,  and  the  effect  on  other  parts  of 
the  vascular  system  is  not  invariably  the 
same.  Shock  is  of  nervous  origin.  An 
injury  to  a  nerve  causes  contraction  of 
the  arterioles  throughout  the  body.     If 


STOMACH  AND  HYDROCHLORIC  ACID.  STRICTURES  OF  RECTUM.        519 


the  irritation  is  sufficiently  severe  and 

persistent,  the  contraction  tends  to  in- 
crease and  extend  to  larger  vessels.  The 
blood  is  forced  into  the  central  warmer 
parts  of  the  body,  the  vessels  of  which 
probably  relax  on  account  of  the  phys- 
iologic necessity  for  the  conservation  of 
heat.  The  veins  of  the  internal  parts 
are  possibly  enlarged  more  than  the  ar- 
teries, and  there  is  an  increased  pressure 
in  the  portal  system,  but  there  is  no  loss 
of  tone  in  any  part  of  the  vascular  sys- 
tem. If  the  vessels  in  the  splanchnic  or 
other  large  area  lose  their  tone,  death 
must  follow,  as  if  from  haemorrhage. 
During  these  processes  the  blood  must 
be  subjected  to  pressure,  and  the  blood 
plasma  is  forced  out  of  the  vessels  into 
the  tissues,  thus  raising  the  specific 
gravity  of  the  blood. 

The  treatment  of  shock  must  be  di- 
rected toward  preventing  the  ill-effects 
of  the  local  irritation,  relaxing  the  ves- 
sels as  soon  as  possible,  and  keeping  up 
the  blood-pressure  in  the  superficial  ves- 
sels until  physiologic  relaxation  occurs. 
Nerve  blocking  by  cocaine,  the  admin- 
istration of  morphine,  and  perfect  anaes- 
thesia are  important  measures  in  com- 
bating the  first  indication.  Warmth, 
nitroglycerine,  and  alcohol  are  useful  in 
dilating  the  vessels,  as  are  also  friction 
and  the  use  of  rubefacients.  In  order  to 
keep  up  pressure  in  the  vessels,  hamior- 
rhage  must  be  avoided.  The  injection 
of  saline  fluids  is  of  temporary  assist- 
ance, as  the  fluid  is  soon  expelled  into 
the  tissues.  Pressure  on  the  abdomen, 
bandaging  the  limbs,  the  use  of  adre- 
nalin, ergot,  and  strychnine  are  bene- 
ficial for  a  time;  but  they  increase  the 
work  of  the  heart  to  an  enormous  ex- 
tent, and  may  contribute  to  death  from 
heart  failure.  J.  D.  Malcolm  (Lancet, 
August  26,  1905). 


STOMACH,   HYDROCHLORIC  ACID   IN  DIS- 
EASES OF  THE. 

The  writer  gave  2V  minims  of  HC1 
in  90  cubic  centimeters  of  water,  two  or 
three  times,  at  fifteen-minute  intervals, 
after    an    Ewald    test   breakfast.      One 
hour  after  the  meal  was  given  the  gas- 
trie   contents   were  withdrawn   and   the 
acidity   tested.      Four  tests  were  made. 
The  total  acidity  was  always  increased, 
and  in  three  of  the  four  tests,  free  HC1 
Mas  present  in  appreciable  amounts.    In 
one  test  it  was  absent.     From  15  to  25 
minims  of  HC1  were  given  in  99  cubic 
centimeters  of  water  three  times  within 
an  hour  after  the  ingestion  of  a  large 
meat  sandwich,  and  300  cubic  centime- 
ters of  water.     Nine  tests  were  made. 
In  from  sixty  to  seventy  minutes  after 
the  meal  was  given,  the  total  acidity  of 
the  gastric  contents  was  always  found 
increased,  but  free  HC1  was  never  pres- 
ent.     The   author   also   found  that  the 
long-continued  use  of  large  doses    (45 
drops,   three   times   daily),   of   HC1   di- 
minished the  total  acidity.     He  believes 
that  the  HC1  has  a  depressing  influence 
on    the    gastric    acidity    which    is    not 
generally  recognized.     Peptic  digestion, 
however,   is   accelerated   by  the   use   of 
HC1,    although    in    certain    conditions 
large  doses  in  some  manner  retard  pep- 
tic digestion.    He  is  of  the  opinion  that 
while  large  doses  of  HC1  alleviate  cer- 
tain symptoms,  they  never  improve  any 
function  of  the  stomach.     P.  F.  Chase 
(Boston  Medical  and  Surgical  Journal, 
September  7.  1905). 

STRICTURES  OF  THE  RECTUM,  NON- 
MALIGNANT:  TREATMENT. 
In  the  treatment  of  rectal  strictures 
situated  in  the  distal  portion  of  the 
bowel,  the  writer  advises  painstaking 
prophylaxis,  recognizing  that  many  cases 
of  so-called  diarrhoea  and  dysentery  are, 


520 


SUPRARENAL  HEMORRHAGE  OF  THE  NEW-BORN. 


iu  reality,  cases  of  chronic  proctitis, 
which,  if  neglected,  may  go  on  to  the 
formation  of  strictures.  To  say  this,  is 
to  insist  upon  a  more  careful  investiga- 
tion of  these  affections.  The  treatments 
consist  in  rest,  diet,  keeping  the  upper 
bowel  emptied,  cleansing  solutions  and 
applications,  healing  applications  and 
packs. 

A  stricture  of  moderate  caliber  may 
be  cured  by  dilation  with  bougies;  by 
the  elastic  pressure  of  a  rubber  bag,  dis- 
tended by  air  and  made  to  distend  in  a 
uniform  manner  by  a  silk  covering 
(Sweetnam's  plan)  ;  and  by  digital  dis- 
tention and  massage.  If  a  contracting 
bowel  is  watched  and  treated,  the  pa- 
tient may  go  on  for  a  long  time,  for 
years  even,  in  great  comfort,  even  though 
the  disease  is  not  cured  and  the  parts 
are,  both  to  the  eye  and  touch,  far  from 
normal,  and  this  is  often  better  than 
surgical  interference. 

Eesection  of  the  bowel  may  be  prac- 
ticed even  when  the  disease  extends 
over  an  area  as  long  as  20  centimeters. 
A  posterior  incision  with  the  removal  of 
the  coccyx,  and  sometimes  of  the  last 
sacral  vertebras,  with  the  preservation 
of  the  anal  sphincters  and  ampulla  when 
possible,  and  an  end-to-end  anastomosis 
of  the  bowel, 'is  the  best  procedure.  The 
writer  has  not  had  experience  with 
Hochenegg's   invagination   method. 

It  is  sometimes  worth  while  in  the 
attempt  to  save  the  bowel  when  the  local 
process  persists  in  advancing,  to  make 
an  artificial  anus  completely  diverting 
the  faecal  current.  The  boAvel  may  then 
heal  and  the  extensive  surrounding  in- 
flammation undergo  resolution,  when 
after  some  months  or  a  year  or  more, 
and  generally  after  a  successful  resec- 
fion,  the  artificial  anus  may  be  closed. 
In    a    high    grade   of   tuberculous    or 


syphilitic  stricture,  when  an  extensive 
area  is  involved,  it  is  often  best  tt>  make 
an  artificial  anus  and  extirpate  the  dis- 
eased bowel.  The  writer  prefers  to  do 
this  by  amputating  the  bowel  above  first, 
and  ligating  such  hemorrhoidal  vessels 
of  the  lower  end  as  are  within  reach, 
and  then  to  complete  the  extirpation 
from  below  by  an  incision  from  sacrum 
to  anus.  Advanced  tuberculosis  always 
demands  extirpation,  and  syphilis  calls, 
of  course,  for  persistent  specific  treat- 
ments in  addition  to  whatever  local 
means  may  be  employed.  Howard'  A. 
Kelly  (American  Medicine,  September 
16,  1905). 

SUPRARENAL  HEMORRHAGE  OF  THE 
NEW-BORN. 

The  writer  states  that  common  patho- 
logical changes  found  in  the  suprarenals 
are    hemorrhage,    which    converts    the 
medulla  of  the  organ  into  a  pulpy  mass, 
and  embolism  of  the  suprarenal  artery, 
whereby  the   entire  organ  is   destroyed. 
Occasionally,  one  or  both  organs  will  be 
converted  into  the  large  bluish  tumors, 
whose  contents  are  fluid  blood.     This  is 
especially    common    in    the   newly-born, 
and  many  believe  that  the  motions  nec- 
essary for  artificial  respiration  are  the 
real  cause.     In   a  number  of  cases  ob- 
served by  the  author,  however,  artificial 
respiration  was  not  resorted  to,  and  it 
is  likely  that  severe  labor,  particularly  if 
the  child  is  in  the  breech  position,  will 
furnish  the  necessary  trauma  to  rupture 
the   friable   suprarenal   tissue   and   thus 
give  rise  to  a  hematoma.    If  both  organs 
arc  affected  the  symptoms  are  those  of 
Addison's  disease,  and  death  rapidly  sets 
in.       S.     Oberndorfer     (Wiener     klin.- 
therap.   Wocheuschrift.  June   IS,   1905; 
Medical  News,  September  23,  1905). 


SURGICAL  CASES. 


THROMBOSIS  OF  EXTERNAL  ILIAC  VEIN. 


521 


SURGICAL   CASES,   TREATMENT   OF. 

Propter  pre-operative  and  post-opera- 
tive care  of  surgical  cases  is  not  second- 
ary even  to  the  technique  of  the  op- 
eration itself.  The  value  of  habitua- 
tion of  the  patient  to  the  bed,  giving 
a  restricted  non-putrefactive  dietary, 
the  alimentary  canal  emptied,  and  put 
in  good .  condition,  the  eliminative  or- 
gans inspected,  and  normal  action  if 
possible  secured,  and  lowered  states  of 
resistance  as  far  as  practicable  reme- 
dies, is  inestimable.  Shock  may  be  at 
times  averted  and  well  treated  by  arti- 
ficial heat  and  stimulants,  of  which  the 
chief  are  the  physiological  saline  solu- 
tion and  adrenalin.  The  stomach 
should  be  emptied  and  kept  so  for  the 
alleviation  of  vomiting.  The  devotion 
of  special  care  to  the  cleansing  of  the 
site  of  incision  or  mucous  membrane  is 
important.  After  the  operation,  con- 
serving the  energy  of  the  patient  in 
every  possible  way  and  avoiding  need- 
less purgation  and  unnecessary  annoy- 
ances of  all  sorts  are  self-evident  pro- 
cedures, as  are  the  prevention  of  tym- 
pany by  proper  dietetic  measures  and  the 
avoidance  of  opiates.  The  value  of 
physiological  therapeutics  in  the  man- 
agement of  the  convalescent  need  not 
be  insisted  upon  by  the  writer.  J.  E. 
Cannaday  (New  York  Medical  Journal 
and  Philadelphia  Medical  Journal,  Au- 
gust 26,  1005). 

TABES   DORSALIS,   MERCURY   IN. 

The  preferable  treatment  is  that  by 
injection  of  the  soluble  salts,  given 
daily,  twice  or  thrice  a  week.  The  in- 
jections should  he  intramuscular,  given 
slowly  and  followed  by  massage.  The 
puncture  should  ho  at  least  an  inch  and 
a  quarfer  deep.  The  choice  of  the  Ball 
depends  upon  the  case  to  bo  treated. 
The  biniodido,  the  benzoate.  and  the  bi- 


chloride are  more  active,  but  less  well 
borne  than  the  cacodylate  or  the  hermo- 
phenylate  when  given  in  the  same  dose, 
in  younger  patients  whose  condition  is 
good,  the  more  active  salts  may  be  used 
in  large  doses.  The  dose,  however, 
should  be  calculated  for  each  patient  ac- 
cording to  the  effect  produced;  when 
the  insoluble  salts  are  given  the  injec- 
tion should  be  in  one  large  dose  per 
week,  while  the  less  irritating  prepara- 
tions are  better  given  in  repeated  smaller 
dosage.  The  treatment  is  given  in  series 
of,  in  case  of  the  insoluble  salts,  six  to 
twelve  injections;  in  case  of  the  soluble 
salts,  six  to  forty.  These  series  are  given 
at  intervals  of  proper  duration.  The 
number  of  series  in  a  "treatment"  varies 
from  two  to  four,  as  also  does  the  num- 
ber of  "treatments"  in  a  year.  The  pa- 
tient should  be  given  all  the  mercury 
that  he  will  tolerate  without  exhibiting 
toxic  symptoms,  and  proper  diet,  hy- 
giene, and  mode  of  life  should  be  pre- 
scribed. Maurice  Faure  (Journal  de 
Medecine  de  Paris,  Xo.  11,  p.  113, 
1005;  American  Journal  of  Medical 
Sciences.   October.   1005). 

THROMBOSIS  OF  THE  EXTERNAL  ILIAC 
VEIN  AFTER  APPENDICECTOMY, 
CAUSE    OF. 

The  author  discusses  the  question 
why,  as  is  generally  known  among  prac- 
tical surgeons,  thrombosis  of  the  exter- 
nal iliac  vein  occasionally  occurs  after 
an  apparently  aseptic  operation  for  the 
removal  of  the  appendix.  The  explana- 
tions that  have  hi 'en  given  of  this  an- 
noying, and,  it  may  be.  life-threatening 
result  are  regarded  as  unsatisfactory  by 
the  author,  whose  personal  experience  of 
three  recent  instances  of  this  kind  have 
led  him  in  the  conclusion  that  the 
thrombosis  is  first  developed,  not  in  the 
enseal  roots  of  the  portal  vein,  but  in  the 


522 


TUBERCULOUS  CERVICAL  LYMPH  GLANDS,  SURGICAL  TREATMENT. 


epigastric  vessels  m  the  anterior  ab- 
dominal wall,  after  simultaneous  liga- 
ture of  the  arterial  and  venous  trunks 
on  the  right  side  practiced  for  the  arrest 
of  bleeding  in  the  course  of  the  opera- 
tion. In  the  majority  of  such  cases,  it 
is  held,  the  consequent  thrombosis  is 
overlooked,  as  it  is  slight  and  limited 
to  the  right  side,  but  occasionally  it  ex- 
tends to  the  epigastric  veins  on  the  left 
side  and  onward  to  the  left  external  iliac 
vein.  If  this  be  the  correct  explanation 
the  surgeon,  in  opening  the  abdominal 
cavity,  should  carefully  endeavor  to 
avoid  exposing  the  epigastric  vessels. 
The  external  wound  of  a  vertical  one 
should  be  made  well  outside  the  sheath 
of  the  rectus  and  not  be  directed  inward 
at  its  lower  part,  and  if  made  parallel  to 
Poupart's  ligament  should  not  extend 
too  far  inward.  If  any  of  the  epigastric 
vessels  be  wounded  only  the  bleeding 
branch  should  be  ligatured  and  not  a 
thick  cord  of  both  arterial  and  venous 
trunks.  Witzel  ( Centralblatt  fur  Chi- 
rurgie,  Nu.  28,  1905;  British  Medical 
Journal,   September  30,   1905). 

TUBERCULOUS     CERVICAL     LYMPH 
GLANDS,       SURGICAL       TREATMENT 
OF. 
Although  recovery  from  tuberculosis, 
wherever    situated,    occurs    not    rarely, 
such  a  result,  of  course,  is  not  always  to 
be  expected.     When  the   disease  is  not 
accessible    to    surgical    intervention    the 
best  results  will  be  obtained  from  an  in- 
telligent combination  of  fresh  air.  a  gen- 
erous diet,  and  a  proper  adjustment  of 
rest  and  exercise.     On  the  other  hand. 
surgical   measures   should    be  instituted 
when  the  disease  is  within  reach.    These 
remark-  are  applicable  especially  to  tu- 
-    of   the    lymphatic   glands   in 
the  neck.    Apart  from  the  local  disturb- 
ance, there  is  here  also  the  danger  of  the 


conveyance  of  the  disease  to  remote 
parts  through  the  blood-stream.  Ad- 
mirable results  have  been  reported  from 
various  sources  from  extirpation  of  such 
tuberculous  glands,  the  prognosis  being- 
more  favorable  in  children  than  in 
adults.  To  the  statistics  already  pub- 
lished may  be  added  those  recently  pre- 
sented by  Dr.  Charles  N.  Dowd  (Annals 
of  Surgery,  July,  1905),  who  records 
the  results  of  operation  by  thorough  re- 
moval of  the  affected  glands  with  a  min- 
imum disturbance  of  the  surrounding 
tissue  in  100  cases,  principally  in  chil- 
dren. In  his  opinion,  tuberculosis  of 
the  cervical  lymph  nodes  in  the  large 
majority  of  cases  is  due  apparently  to 
infection  introduced  by  way  of  the 
fauces,  the  pharynx,  or  the  nasal  mu- 
cous membrane — in  86  per  cent,  of  the 
cases  under  his  own  observation.  Statis- 
tics show  that  extension  to  the  lungs 
and  other  internal  organs  takes  place 
in  from  one-quarter  to  one-half  of  the 
cases  in  which  removal  of  the  nodes  is 
not  undertaken.  Apart  from  the  ten- 
dency to  infect  other  structures,  the  dis- 
ease is  tedious  and  a  source  of  great  dis- 
comfort and  disability,  and  it  leaves  be- 
hind it  disfiguring  scars. 

Thorough  removal  of  the  diseased 
nodes  by  operation  has  yielded  better 
results  than  any  other  treatment  that 
has  been  thus  far  employed.  In  favor- 
able cases  the  operation  is  entirely  safe, 
leaving  a  scar  that  is  scarcely  visible. 
The  patient  will  be  "confined  to  bed  prob- 
ably for  two  or  three  days  and  will  be 
required  to  wear  a  bandage  or  dressing 
for  from  one  and  a  half  to  three  weeks. 
There  is  freedom  from  recurrence  in 
about  75  per  cent,  and  ultimate  recov- 
ery in  about  90  per  cent,  of  the  cases. 
In  less  favorable  cases,  also,  the  opera- 
tion is  safe,  while  the  disfigurement 
from    scars   is   less   than   that   resulting 


TUBERCULOUS  ULCERATION  OF  ASCENDING  COLON.     UTERUS,  TUMORS.      523 


from  discharging  sinuses.  There  is 
freedom  from  recurrence  in  from  50  to 
55  per  cent.,  and  ultimate  cure  in  from 
70  to  75  per  cent,  of  cases.  The  pref- 
erable incisions  are  transverse,  either  in 
the  creases  of  the  neck  or  parallel  to 
them ;  they  should  avoid  the  facial 
nerve.  A  vertical  incision  behind  the 
hair  line  is  occasionally  helpful.  Ex- 
tensive incisions  are  necessary  in  ad- 
vanced cases.  Every  precaution  should 
be  taken  to  preserve  the  normal  struc- 
tures of  the  neck.  It  is  not  feasible  to 
divide  the  cases  into  groups  of  those 
suitable  and  others  unsuitable  for  op- 
eration. Every  patient  with  tubercu- 
lous cervical  lymph  nodes  should  be  op- 
erated on  unless  the  operation  is  posi- 
tively contraindicated.  Editorial  (Jour- 
nal of  the  American  Medical  Associa- 
tion, September  30,  1905). 


TYPHOID    FEVER,    PERITONITIS    IN. 

The  writer  states  unhesitatingly  that 
by  far  the  most  important  sign  of  the 
onset  of  acute  peritonitis  in  a  case  of 
enteric  fever  is  a  sudden  marked  altera- 
tion in  the  general  aspect  of  the  patient, 
the  appearance  either  of  the  typical 
Hippocratic  facics.  or  a  close  approxi- 
mation to  it.  Xext  in  importance  he 
places  the  presence  of  rigidity  of  the 
abdominal  vail,  with  the  associated 
abolition  of  movement  of  the  abdominal 
wall  on  deep  inspiration.  Third  comes 
the  gradual  increase  of  the  pulse-rate, 
particularly  if  with  the  onset  of  symp- 
toms there  has  been  a  sudden  rise  fol- 
lowed by  a  slight  fall,  and  this  again 
succeeded  by  a  gradual  progressive  in- 
crease in  the  rate.  Farquhar  Macrae 
(Glasgow  Medical  Journal,  October, 
1905). 


TUBERCULOUS  ULCERATION  OF  THE 
ASCENDING  COLON  SIMULATING 
APPENDICITIS. 

A  growth  in  the  caecum  may  be  asso- 
ciated with  attacks  like  appendicitis. 
These  attacks  may  be  due  to  obstruction 
or  to  inflammation  of  the  parts  around 
and  this  may  go  on  to  the  formation  of 
an  abscess  which  may  exactly  simulate 
one  due  to  appendicitis. 

A  growth  in  any  part  of  the  large  in- 
testine beyond  the  cecum  may  become 
blocked,  and  if  there  is  a.  competent  ileo- 
cecal valve,  the  caecum  is  the  first  part 
to  feel  the  stress  of  the  obstruction,  and 
at  first  all  the  pain  is  referred  to  this 
region.  It  is  only  as  the  attack  passes 
off  that  the  falling  distension  enables 
the  lump  elsewhere  1m  be  Pelt.  Primary 
malignant  disease  of  the  appendix  may 
be  the  cause  of  the  symptoms.  C!.  Grey 
Turner   (Lined.   September  16,    L905). 


UTERUS,    FIBROID    TUMORS    OF    THE. 

The  routine  treatment  for  fibroids  of 
the  uterus,  presenting  symptoms,  in 
women  under  45  years  of  age,  should 
be  supravaginal  hysterectomy,  except  as 
hereinafter  stated.  The  exception  to 
this  rule  should  be  (a)  in  subperitoneal 
tumors  either  pedunculated  or  not,  in 
which  only  one  or  more  distinct  devel- 
opments exist  which  do  not  materially 
increase  the  size  of  the  uterus  proper 
and  the  area  of  its  endometrium,  when 
myomectomies  may  be  resorted  to;  (b) 
in  fibroids  which  present  excessive  haem- 
orrhagic  tendencies,  in  which  the  haemo- 
globin is  reduced  below  25  per  cent.,  or 
in  which  serious  vascular  cardiac  or  kid- 
ney complications  exisl  which  greatly 
increase  the  risk  of  the  operation,  when 
a  preliminary  operation  of  vagina]  liga- 
tion of  the  uterine  arteries  should  be  re- 
BOrted   to;    (<■)   in  cases  where  a   radical 


524 


VARICOSE  ULCERS. 


VERTIGO  OF  AURAL  CAUSATION. 


operation  will  not  be  accepted,  a  curette- 
ment  and  vaginal  ligation  of  the  uterine 
arteries  may  be  resorted  to,  or,  if  no 
operation  at  all  will  be  accepted,  general 
tonics,  ergotine  in  tonic  doses,  and  gal- 
vanism scientifically  applied  may  be  de- 
pended upon  to  relieve  the  patient  mate- 
rially, and  occasionally  tide  them  over 
the  menopause  to  a  complete  sympto- 
matic cure. 

The  treatment  for  large,  complicated 
tumors  without  regard  to  age,  or  large 
apparently  uncomplicated  tumors  in 
which  symptoms  of  haemorrhage  or  pres- 
sure exist,  should  be  supravaginal  hys- 
terectomy. 

Tumors  of  medium  size  apparently 
uncomplicated  in  women  over  45  years 
of  age,  may  be  managed  by  one  of  the 
less  radical  forms  of  treatment  as :  (a) 
when  the  tumors  are  of  the  symmetrical 
development  type,  enlarging  uniformly 
the  uterus,  and  the  principal  symptom 
is  an  exaggerated  menstrual  flow,  the 
cases  may  almost  invariably  be  relieved 
by  galvanism  and  tided  over  the  meno- 
pause; or  (b)  if  the  growth  is  of  the 
irregular  type  which  has  distorted  more 
or  less  the  uterine  cavity,  the  case  should 
be  submitted  to  dilatation,  finger  ex- 
ploration, curettement,  and,  if  consider- 
able flowing  is  a  symptom,  vaginal  liga- 
tion of  the  uterine  arteries,  with  the 
idea  of  obtaining  a  symptomatic  cure 
over  the  menopause. 

The  extremely  small  class  of  tumors 
coming  under  the  head  of  "inoperable" 
cases  must  be  managed  on  general  prin- 
ciples— rest  in  bed,  general  tonics, 
treatment  of  the  cardiovascular  and 
kidney  complications  when  they  exist, 
curetting  and  irrigating  for  septic  endo- 
metritis, electricity  for  pain  and  haem- 
orrhage, ligation  of  the  uterine  blood- 


supply  if  practicable  for  intractable 
haemorrhage,  and  vaginal  incision  of 
impacted  cysts  or  pus  accumulations. 
F.  H.  Martin  (Chicago  Medical  Ke- 
corder,  September  15,  1905). 

VARICOSE   ULCERS. 

The  ambulant  treatment  of  leg  ulcers 
is  advised  by  the  writer,  because  the 
patients,  who  usually  belong  to  the  lower 
classes,  will  not  lie  abed  or  enter  a  hos- 
pital while  the  ulcer  is  of  a  size  to  be 
easily  curable.  He  uses  a  modification 
of  Jessner's  method,  which  consists  of 
cleansing  the  ulcer  and  its  neighborhood 
with  benzine,  dusting  it  with  an  anti- 
septic powder,  and  covering  it  with  oiled 
silk.  A  roller  bandage  of  cotton  20  cen- 
timeters wide  is  then  applied  over  the 
whole  lower  third  of  the  leg,  including 
the  ankle  and  the  ulcer.  Over  this  an 
elastic  bandage  is  carefully  applied.  If 
applied  with  sufficient  firmness  a  new 
dressing  need  not  be  applied  often er 
than  once  a  week.  With  this  treatment 
an  ulcer  the  size  of  a  dollar  should  heal 
in  about  six  weeks.  P.  Loele  (Therapie 
der  Gegenwart,  Bd.  xlvi,  Nu.  4;  Jour- 
nal of  the  American  Medical  Associa- 
tion, August  26,  1905). 

VERTIGO  OF  AURAL  CAUSATION. 

In  view  of  the  existing  knowledge  of 
normal  conditions  in  the  semicircular 
canals,  vertigo  of  aural  causation  may 
be  regarded  as  primarily  a  pressure 
symptom.  Pressure  may  be  exerted  on 
the  labyrinth  by  forces  operating  from 
without,  as  the  result  of  changes  in  the 
middle-ear  transmitting  apparatus.  It 
may  be  produced  from  within  by  inva- 
sion of  the  intracapsular  space  as  in  the 
case  of  haemorrhage  into  the  labyrinth. 


WOUNDS,  INFLUENCE  OF  PNEUMOCOCCI  ON  HEALING.     BOOK  REVIEWS.      525 
The  effect  upon  the  semicircular  canals      WOUNDS,  INFLUENCE  OF  PNEUMOCOCCI 


ON  THE   HEALING   OF. 


of  intralahyrinthine  pressure  thus  pro- 
duced will  depend  as  to  its  intensity  and  The  pneumococci,  if  alone,  cause  lit- 
duration   upon   the   locality   and   extent  tle  inflammatory  reaction  in  the  healing 
of  the  hemorrhage  invasion.     The  re-  of   wounds-      Possib1^   in   surSical   dis" 
current   vertigos    are    the    result    either  ('a?es  caused  b>'  Pneumococci,  some  pro- 
,                          .   ,     ,  ,      .   ,.  .               ,  tective  substance  is  formed  that  amelio- 
of  an  excessive  liitralabynnthine  vessel  ,                                                              .. 
......                            .                      .  rates   the   symptoms,    as   occurs    m    The 

dilation  from  suspense  ot  vasomotor  m-  ■  ■       .                        .         T      ,, 

.  crisis   ol   a  pneumonia.     In   the  treat- 

hibition  of  reflex  origin,  either  alone  or  ,     .                                 i      1 1  1            i 

°    '  ment  oi  a  pus  case,  care  should  be  used 

coupled   with   a   persistent   intralabyrin-  to  prev(?nt  a  ]mxC(l  infoction>  as  healirjg 

thine  pressure  of  either  extrinsic  or  in-  ig  mllch  more  ^  to  be  rapi(1  aU(1  smooth 

trinsic    origin.      C.    J.    Blake    (Boston  if  oniy  one  variety  of  bacteria  is  present. 

Medical  and   Surgical  Journal,   October  J.  Wirt  Robinson  (Medical  Record,  Sep- 

5,  1905).  tember  16,  1005). 


5ool<  Reviews. 


A  Treatise  ox  Diagnostic  Methods  of  Examination.  By  Prof.  H.  Sahli.  Authorized 
Translation  from  the  Fourth  Revised  and  Enlarged  German  Edition.  Edited  -with  Addi- 
tions by  Francis  P.  Kinnieutt  and  Nathaniel  Bowditch  Potter.  Philadelphia  and  London: 
W.  B.  Saunders  &  Co.,  1905.  Octavo  of  1008  pages.  Illustrated.  Cloth,  $6.50  net; 
Half  Morocco,  $7.50. 

This  work  of  Professor  Sahli  was  first  published  in  1894  and  followed  by  three  other 
editions,  this  being  the  fourth.  Not  only  are  all  methods  of  examination  for  the  purposes 
of  clinical  investigation  exhaustively  considered,  but  explanations  of  the  clinical  phenomena 
are  discussed  from  the  physiologic  as  well  as  the  pathologic  point  of  view  with  (so  the 
editors  say)  a  thoroughness  which  has  not  been  attempted  in  any  other  work  of  similar 
scope  as  yet  appearing.  A  brief  review  is  added  of  the  investigations  of  American  and 
English  observers  on  the  clinical  estimation  of  blood-pressure,  with  descriptions  of  some 
instruments  for  this  purpose  by  Theodore  C.  Janeway.  Several  prominent  teachers  and 
clinicians  have  added  notes  to  special  chapters  of  the  book,  which  arc  indicated  by  their 
initials.  Among  these  are  Joseph  Collins,  Charles  Nonas,  H.  C.  Jackson,  Arnold  Knapp,  and 
\V.  Sohier  Bryant.  In  the  preface  of  the  fourth  edition  the  author  states  he  has  laid  equal 
stress  on  all  the  various  branches  of  internal  medicine.  In  the  dill'erent  sections  he  acknowl- 
edges changes  and  additions  through  a  review  of  the  work  done  by  Jaquet,  Volhard,  Reissner, 
Hehner-Malay,.  Mett,  Nirenstein,  SchifF,  etc.  A  number  of  new  methods  and  tests  are 
added,  among  which  are  those  of  Seliwanow,  Bial,  Klemperer,  and  others.  It  is  impossible 
to  present  all  the  additions  and  modifications  which  the  preface  of  the  fourth  edition  sets 
forth,  but  these  amount  to  a  very  considerable  number  and  mostly  of  much  importance.  A 
very  large  number  of  additions  are  made  to  the  section  on  Examination  of  the  Nervous 
System,  and  with  some  important  discussions  and  explanations  of  vexed  questions.  Itfever 
theless,  the  size  of  the  book  has  not  been  greatly  enlarged,  because  some  older  met  hods,  not 
having  stood  the  test  of  time,  are  omitted.  Many  of  the  more  original  observations  and 
suggestions  in  this  book  have  never  been  published  elsewhere,  and  many  of  the  theories 
advanced  are  the  author's  own.  Altogether,  the  book  will  be  found  of  great  value  to 
clinicians,  and  especially  to  those  who  desire  to  become  thorough  and  complete  in  researches 
in  all  departments  of  internal  medicine.  The  illustrations  are  numerous  and  excellent,  and 
many  of  these  are  quoted  from  American  observers.  Some  of  the  diagrams  are  in  three 
colors,  but  are  not  excessively  elaborate,  al  leas!  not  enough  to  prove  confusing.  There 
are  a  few  handsome  colored  plates,  notabh  two  giving  seventeen  views  of  the  fundus  of  the 
eye,  one  of  Koplik's  spots  and  several  of  blood  cells.     On   the   whole,  the  illustrations  are 


526  BOOK  REVIEWS. 

beautiful  and  admirably  selected.  The  index  occupies  forty  pages  and  seems  most  compre- 
hensive. Indeed,  the  book  will  be  greatly  welcomed,  notwithstanding  the  fact  that  we  are 
accustomed  to  admirable  home-grown  books  on  similar  lines,  notably  the  masterly  work 
of  Simon  on  Clinical  Laboratory  Methods  and  that  on  Diagnosis  by  Musser. — J.  M.  T. 

A  Text-Book  of  the  Practice  of  Medicine.  By  James  M.  Anders,  M.D.  Seventh 
Edition,  Revised  and  Enlarged.  Octavo  of  1297  pages.  Fully  Illustrated.  Philadelphia 
and  London:  W.  B.  Saunders  &  Co.,  1905.  Cloth,  5.50,  net;  Sheep  or  Half  Morocco, 
$6.50,   net. 

Dr.  Anders  has  presented  us  with  so  many  valuable  editions  of  his  work  on  the 
Practice  of  Medicine  that  the  appearance  of  this,  the  seventh,  edition  is  an  event  we  have 
a  right  to  expect.  There  is  little  to  be  said  upon  the  book  as  a  whole,  so  much  having 
already  appeared,  and  all  pointing  to  the  wisdom  and  thoroughness  of  the  author  that  we 
can  do  little  more  than'  speak  of  the  special  features  of  the  seventh  edition.  The  well 
known  diagnostic  tables  are  retained  and  amplified,  because,  as  the  author  states,  of  many 
assurances  from  students  and  practitioners  of  their  extreme  helpfulness.  The  new  subjects 
introduced  are  Rocky  Mountain  Fever,  Examination  of  Patients  for  Diagnosis  of  Diseases 
of  the  Stomach,  Splanchnoptosis,  Cammidge*s  Tests  for  Glycerose  in  the  Urine,  and  Myasthenia 
Gravis.  Paragraphs  on  the  following  subjects  are  also  added:  Pseudotuberculosis,  Benign 
Cirrhosis  of  the  Stomach,  Intestinal  Lithiasis,  Intestinal  Calculi,  Red  Light  in  Variola, 
Emulsion-Albuminuria,  Sequela  of  Valvular  Lesions,  and  Adams-Stokes  Syndrome.  The 
subjects  of  Paratyphoid  Fevers,  Beriberi,  and  Trypanosomiasis  have  been  rewritten.  Atten- 
tion is  drawn  to  tropical  diseases  now  appearing  in  temperate  latitudes.  The  section  on 
Diseases  of  the  Nervous  System  has  been  revised  by  Dr.  Joseph  Sailer,  and,  as  before,  he 
acknowledges  the  assistance  of  Drs.  L.  Napoleon  Boston  and  R.  H.  Spangler.  The  book  will 
continue  to  maintain  a  high  position  in  the  esteem  of  all  students  of  medicine. — J.  M.  T. 

Health  and  Disease  in  Relation  to  Marriage  and  the  Married  State.  A  Manual 
Contributed  to  by  G.  Abelsdorff,  L.  BlumreicK,  R.  Eberstadt,  A.  Eulenburg,  C.  A.  Ewald, 
P.  Fiirbringer,  M.  Gruber,  W.  Havelburg,  A.  Hofl'a,  R.  Kossmann,  F.  Kraus,  R.  Ledermann, 
A.  Leppmann,  E.  v.  Leyden,  E.  Mendel,  A.  Moll,  A.  Neisser,  J.  Orth,  S.  Placzek',  C.  Posner, 
P.  F.  Richter,  H.  Rosin,  W.  Wolff.  Edited  by  Prof.  Dr.  H.  Senator  and  Dr.  Med.  S. 
Kaminer.  Only  Authorized  Translation  from  the  German  to  the  English  by  J.  Dulberg, 
M.D.    Rebman  Company,  New  York  and  London,  1905.     Two  Volumes. 

This  masterly  work  on  a  very  important  subject  now  appears  in  English.  A  full  review 
of  the  German  edition  appeared  in  the  Monthly  Cyclopaedia  about  five  months  ago.  As 
was  then  said  by  the  reviewer,  this'  work  contains  a  series  of  essays  of  great  value  ordinarily 
omitted  in  medical  works,  but  which,  nevertheless,  requires  presentation  to  the  profession, 
and  also  to  the  laity.  Indeed,  it  would  be  of  great  utility  if  some  one  would  prepare  a 
resume  of  the  practical  points  contained  in  the  monographs  in  such  form  that  they  could 
be  understood  and  utilized  by  the  laity.  In  its  present  massive  form  it  serves  as  a  valuable 
reference  book,  but  is  not  in  such  shape  as  to  be  consulted  by  the  very  ones  who  need  it  most. — 
J.  M.  T. 

The    Eye,   Mind,   Energy,   and   Matter.     By   Chalmers  Prentice,  M.D.     Published   by   the 

Author.    Chicago,  1905. 

Dr.   Prentice   has  evolved  a  work  which  gives  his  own  individual  views  on  the  power  of 
the  mind   as  a  curative  agency.     He  also  advances  his  opinions  on   the  elucidation  of  the 
phenomena   of   diseases,   especially    of    those   of    the    eye.     His   concept   is    a   triple    alliance 
between  physical  culture,  faith  cure,  and  the  conservation  of  energy. — J.  M.  T. 
Carronic  Acid  in  Medicine.    By  Achilles  Rose.    Funk  &  Wagnalls.    Price,  $1.     1905. 

Dr.  Rose  contributes  an  interesting  little  book  under  the  above  title  on  the  use  of 
carbonic  acid  baths.  He  has  availed  himself  of  the  publications  of  Winternitz,  Fellner. 
Homberger,  and  others,  giving  scientific  explanations  of  a  number  of  fctets  thus  far  only  known 
empirically.  His  views  oil  physiology  and  chemistry  of  respiration  are  from  llammarstein. 
The  author  expresses  his  indebtedness  to  Dr.  E.  C.  Dent,  of  Manhattan  State  Hospital,  Ward's 


BOOKS  AND  MONOGRAPHS  RECEIVED.  527 

Island,  who  encouraged  the  introduction  of  carbonic  acid  baths  there.  The  book  contains 
a  series  of  chapters,  beginning  with  one  on  physiology  and  chemistry  of  respiration  and 
passing  on  through  the  history  of  the  use  of  the  remedy,  dealing  at  length  with  the  thera- 
peutic effects  of  carbonic  acid  gas  in  various  conditions  and  maladies.  In  Chapter  IX  he 
teaches  us  that  rectal  fistula?  can  be  cured  by  means  of  carbonic  acid  applications.  Altogether. 
the  book  serves  a  good  purpose  in  making  clear  a  rational  method  valued  by  the  ancients  — 
J.  M.   T. 

Superstition    ix    Medicine.     By   Prof.   Hugo   Magnus.     Authorized   Translation  from   the 
German.     Edited  by  Dr.  Julius  L.  Salinger,  Late  Assistant  Professor  of  Clinical  Medicine, 
Jefferson  Medical  College;    Physician  to  the  Philadelphia  General  Hospital,  etc.     Funk  & 
Wagnalls  Company,  New  York  and  London,  1905.     12mo.  Cloth.     214  pages.     Price,  $1. 
This  subject  is  treated  in  a  scholarly  manner  in  an  interesting  little  volume.     The  scope 
of  tlic   work  can   be  appreciated  best  by   reference  to   the   seven   chapter  headings.     In  the 
first  chapter  medical  superstition  is  defined  as  follows:     "Belief  that  the  normal  as  well   as 
the   pathological    manifestations   of    organic   life   may   be   explained   and   eventually   treated 
without  consideration  of  their  physical  nature  by  means  of  supernatural  agencies."     In  the 
second  chapter  is  considered"  theism  in  its  relation  to  medicine  and  in  its  struggle  with  the 
physico-mechanical  theory  of  life.     In  the  third  is  shown  how  religion  has  been  the  support 
of  medical  superstition,  while  in  the  fourth  chapter  is  described  the  influence  of  philosophy 
upon  the  form  and  origin  of  medical  superstition.    The  fifth  deals  with  the  relation  of  natural 
science  to  medical  superstition.     The  sixth  chapter  tells  how  medicine  itself  exerted  an  influ- 
ence upon  the  development  of  superstition.     The  seventh  chapter  has  been  written  by   the 
translator;    in  it  is  described  the  relation  between  medical  superstition  and  insanity.     The 
book  is  very  interesting  as  well  as  instructive. — H.  C.  C. 


IJooks  and  /Vlonographs  Received. 


The  editor  begs  to  acknowledge,  with  thanks,  the  receipt  of  the  following  books  and 
monographs:    - 

"The  National  Standard  Dispensatory."  Containing  the  Natural  History,  Chemistry, 
Pharmacy,  Actions  and  LTses  of  .Medicines,  including  those  recognized  by  the  Pharmaco- 
poeias of  the  United  States,  Great  Britain  and  Germany,  with  numerous  references  and 
other  Foreign  Pharmacopoeias.  In  accordance  with  the  United  States  Pharmacopoeia,  eigiith 
decennial  revision  of  1005  by  authorization  of  the  Convention.  By  Hobart  Amory 
Hare,  15. Sc,  M.D.,  Professor  of  Therapeutics  in  the  Jefferson  Medical  College,  Philadel- 
phia, Member  of  the  Committee  of  Revision  of  the  U.  S.  P.;  Charles  Caspari,  Jr.,  Ph.G., 
Phar.D.,  Professor  of  Pharmacy  in  the  Maryland  College  of  Pharmacy,  Baltimore,  Member 
of  the  Committee  of  Revision  of  the  U.  S.  P.,  and  Henry  H.  Rushy,  M.D.,  Professor  of 
Botany  and  Materia  Medica  in  the  College  of  the  City  of  New  York,  Member  of  the 
Committee  of  Revision  of  the  U.  S.  P.  Imperial  octavo,  2858  pages,  47S  engravings. 
Cloth,  $7.25.  net;    leather,  $8,  net.     Thumb-index,  50  cents  extra.     Lea  Brothers  &   Co., 

Publishers,  Philadelphia  and  New  York,  1905. "Practical  Massage  in  Twenty  Lessons." 

By  Bartvig  Nissen,  [nstructor  and  Lecturer  in  Massage  and  Gymnastics  at  Harvard 
University  Summer  School:  Director  of  Physical  Training,  Brookline  Public  Schools; 
Former  Acting  Director  of  Physical  Training,  Boston  Public  Schools;  Former  Instructor 
of  Physical  Training  at  Johns  Hopkins  University  and  Welleslej  College;  Former 
Director  of  the  Swedish  Health  Institute,  Washington,  D.  C,  etc.,  etc.  Author  of 
"Swedish  Movemehl  and  Massage  Treatment,"  "A,  B,  C  of  Swedish  Educational  Gym- 
nastics," "Rational  Home  Gymnastics,"  etc.  With  forty-six  Original  Illustrations.  L68 
pages.     12mo.     Price,   Extra   Cloth,  $1,  net.     F.   A.   Davis  Company.   Publishers,   1914-16 

Cherry  Street,  Philadelphia. "Transactions  of  the  Twentj  seventh   Animal   Meeting  of 

the  American  Laryngological  Association,"  held  al    Atlantic  City,  V  J.,  dune  1,  2  and  3. 
1905.— — "Transactions  of  the  American  Otological   Society.  Thirty-eighth  Annual   Met 
ing,"  Boston,  Mass.,  May  !>  and  lo,  1905,     Volume  IX,  Pail  I.        "Cystoscopy  and  Renal 


528 


BOOKS  AND  MONOGRAPHS  RECEIVED. 


Lavage."     By   F.    M.   Johnson,   Boston,   Mass,    1905. "An   Inspection    of   the    Eastern 

Pennsylvania  State  Penitentiary  with  Reference  to  Tuberculosis."    By  Guy  Hinsdale.  Hot 

Springs,  Va.,   1905. "Some  Results  of  Abdominal   Operations."     By  G.  E.  Shoemaker, 

Philadelphia,  1905. "Some  'Liver'  Cases."     By  J.  H.  Carstens,  Detroit,  Mich.,  1904. 

"Paraplegia  from  Fracture  of  the  First.  Second  and  Third  Dorsal  Vertebrae;  Seven  Other 
Fractures;     Laminectomy;   Recovery  with  Ability   to   Walk  with  Assistance."     By  Guy 

Hinsdale,   Hot   Springs,   Va.,   1905. "Report   of    Working  Party   No.   2,   Yellow   Fever 

Institute."      May,    1904.      United    States    Public    Health    and    Marine    Hospital    Service, 

Washington,  D.   C,   1905. "Tobacco   Investigations   in  Ohio."     By   G.   T.   McNess   and 

G.  B.  Massey,  United  States  Department   of  Agriculture,  Washington,  D.   C,   1905. 

"Forest  Reserves  in  Idaho,"    United  States  Department  of  Agriculture,  Washington,  D.  C. 

1905. "Trade  with  Noncontiguous  Possessions  in  Farm  and  Forest  Products,  1902-1904." 

United  States  Department  of  Agriculture,  Washington,  D.  C,  1905. "The  Commercial 

Cotton  Crop  of  1903-4."     By  J.  L.  Watkins,  United  States  Department   of  Agriculture, 

Washington,  D.  C,  1905. "Game  Laws  for  1905."    By  T.  S.  Palmer,  H.  Oldys  and  R.  W. 

Williams,   Jr.,   United   States  Department   of  Agriculture,   Washington,   D.  C,   1905. 

"Manurial  Requirements  of  the  Portsmouth  Sandy  Loam  of  the  Darlington  Area,  South 
Carolina."    United  States  Department  of  Agriculture,  Washing-ton,  D.  C,  1905. 


EDITORIAL    STAFF. 
Sajous's  Analytical  Cyclopaedia  of  Practical  Medicine. 


J.  GEORGE  ADAMI,  M.D„ 

MONTREAL,  P.  Q. 

LEWIS  H.  ADLER,  M.D., 

PHILADELPHIA. 

JAMES  M.  ANDERS,  M.D.,  LL.D., 

PHILADELPHIA.. 

THOMAS  G.  ASHTON,  M.D., 

PHILADELPHIA. 

A.  D.  BLACKADER,  M.D., 

MONTREAL,  P.  ft. 

E.  D.  BONDURANT,  M.D., 

MOBILE,  ALA. 

DAVID  BOVAIRD,  M.D., 

NEW  YOKK  CITY. 

WILLIAM  BROWNING,  M.D., 

BROOKLYN,  W.  T. 

WILLIAM  T.  BULL,  M.D., 

NEW  YORK  CITT. 

CHARLES  W.  BURR,  M.D., 

PHILADELPHIA. 

HENRY  T.  BYFORD,  M.D., 

CHICAGO,  ILL. 

HENRY  W.  CATTELL,  M.D., 

PHILADELPHIA. 

WILLIAM  B.  COLEY,  M.D., 

NEW  YOKK  CITT. 

FLOYD  M.  CRANDALL,  M.D., 

NEW  YORK  CITT. 

ANDREW  F.  CURRIER,  M.D., 

NEW  TORK  CITT. 

ERNEST  W.  CUSHING,  M.D., 

BOSTON,  MAS8. 

GWILYM  Q.  DAVIS,  M.D., 

PHILADELPHIA. 

N.  8.  DAVIS,  M.D., 

CHICAGO.  ILL 

AUGUSTUS  A.  ESHNER,  M.D., 

PHILADELPHIA. 

8IMON  FLEXNER.  M.D., 

PHILADELPHIA. 

LEONARD  FREEMAN.  M.D., 

DENVER.  COL. 

8.  O.  GANT.  M.D., 

NEW  YORK  CITT. 

J.  MoFADDEN  GASTON,  SB.,  M.D., 

ATLANTA.  GA. 

J.  McFADDEN  GASTON,  Jr.,  M.D.. 

ATLANTA,  OA. 

E.   B.  GLEASON,  M.D.. 

PHILADELPHIA. 

■GBERT  H.  URANDIN,  M.D., 
■av  r»M  hit. 


ASSOCIATE.    EDITORS. 

J.  P.  CROZER  GRIFFITH,  M.D., 

PHILADELPHIA. 

C.  M.  HAY,  M.D., 

PHILADELPHIA. 

FREDERICK  P.  HENRY,  M.D., 

PHILADELPHIA. 

L.  EMMETT  HOLT,  M.D., 

NEW  YORK  CITY. 

EDWARD  JACKSON,  M.D., 

DENVER,  COL. 

W.  W.  KEEN,  M.D., 

PHILADELPHIA. 

EDWARD  L.  KEYES,  Jr.,  M.D., 

NEW  YORK  CITY. 

ELWOOD  R.  KIRBY,  M.D., 

PHILADELPHIA. 

L.  E.  La  FETRA,  M.D., 

NEW  YORK  CITT. 

ERNEST  LAPLACE,  M.D.,  LL.D., 

PHILADELPHIA. 

R.  LEPINE,  M.D., 

LTONS,  FRANCE. 

F.  LEVISON,  M.D., 

COPENHAGEN,  DENMARK. 

A.  LUTAUD,  M.D., 

PARIS,  PRANCE. 

G.  FRANK  LYDSTON,  M.D., 

CHICAGO,  ILL. 

F.  W.  MARLOW,  M.D., 

SYRACUSE,  N.  Y. 

SIMON  MARX.  M.D., 

NEW  YOKK  CITY. 

ALEXANDER  McPHEDRAN.  M.D., 

TORONTO,  ONT. 

E.  E.  MONTGOMERY,  M.D., 

PHILADELPHIA. 

HOLGER  MYGIND,  M.D., 

COPENHAGEN,  DENMARK. 

W.  P.  NORTHRUP,  M.D.. 

NEW  YORK  CITT. 

RUPERT  NORTON,  M.D., 

WASHINGTON,  D.  0. 

H.  OBERSTEINER.  M.D.. 

VIENNA,  AUSTRIA. 

CHARLES  A.  OLIVER,  M.D., 

PHILADELPHIA. 

WILLIAM  OSLER.  M.D., 

BALTIMORE,  MD. 

LEWIS  S.  I'lLCIIEK,  M.D., 

BROOKLTN,  N.  T. 

WILLIAM  CAMPBELL  l'OSEY,  M.D., 

PHILADELPHIA. 


W.  B.  PRITCHARD.  M.D., 

NEW  YORK  CITY. 

JAMES  J.  PUTNAM,  M.D., 

BOSTON. 

B.  ALEXANDER  RANDALL.  M.D., 

PHILADELPHIA. 

CLARENCE  C.  RICE,  M.D., 

NEW  YORK  CITT. 

ALFRED  RUBINO,  M.D., 

NAPLES,  ITALY. 

REGINALD  H.  SAYRE,  M.D., 

NEW  YORK  CITY. 

JACOB  E.  SCHADLE,  M.D., 

ST.  PADL,  MINN. 

JOHN  B.  SHOBER,  M.D., 

PHILADELPHIA. 

J.  SOLIS-COHEN,  M.D., 

PHILADELPHIA. 

SOLOMON  SOLIS-COHEN,  M.D., 

PHILADELPHIA. 

H.  W.  STELWAGON,  MD., 

PHILADELPHIA. 

D.  D.  STEWART,  M.D., 

PHILADELPHIA. 

LEWIS  A.  STIMSON,  M.D., 

NEW  YORK  CITY. 

J.  EDWARD  STUBBERT,  M.D., 

LIBERTY,  N.  Y. 

A.  E.  TAYLOR,  M.D., 

SAN  FRANCISCO,  CAL. 

J.  MADISON  TAYLOR,  M.D., 
PHILADELPHIA. 

M.  B.  TINKER.  M.D., 

PHILADELPHIA. 

CHARLES  8.  TURNBULL,  M.D.. 

PHILADELPHIA. 

HERMAN  F.  VICKERY.  M.D„ 

BOSTON,   MASS. 

F.  E.  WAXIIAM,  M.D., 

DENVER,    COL. 

J.  WILLIAM  WHITE,  M.D., 
PHILADELPHIA. 

JAMES  C.  WILSON.  M.D., 

PHILADELPHIA. 

C.  SUMNER  WITHERSTINE.  M.D„ 

"PHILADELPHIA. 

ALFRED  C.  WOOI),.M.D, 

PHILADELPHIA. 

WALTER  WYMAN,  M.D„ 

WASHINGTON.  D.  a 


THE    MONTHLY   CYCLOPEDIA 

OF 

PRACTICAL   MEDICINE 


(Published  the  Last  of  Each  Month) 


Vol.  XVIII. 
Old  Series. 


PHILADELPHIA,  DECEMBER,  1905. 


Vol.  VIII,  No.  12. 
New  Series. 


TABLE  OF  CONTENTS. 


FiGE 

EDITORIALS 

ELECTBO-THEBAPEUTIC8. 

John  H.  W.  Rhein 529 

CLINICAL     FACT8     EELATING      TO 

SUPERHEATED     MILE.      Louis 

Fischer 534 

HINTS  FOE  THE  INTEBFBITATION 

OF      URINALYSES.      Nathaniel 

Gilder«leeve._ 537 

LES80N8     IF     PHY8I0L0GT     FBCM 

8URGEKY.     J.  Madison  Taylor...  545 

CYCLOPEDIA   OF    CURKENT 
LITERATUR 

ABDOMEN,    HEW  METHOD   OF    EX- 

FLOEINO  THE.  A.  H.  Ferguson.  549 

AN.CMI  A,  DIAGNOSIS  AND  TREAT- 
MENT OF.     Harlow  Brooks 550 

ABTHMA,  THE    FOOD    FACTOE   IH. 

Francis   Hare - 550 

ATONY     OF     THE     EECTUM     AND 

COLON.    F.  B.  Turck 551 

BEBIBEBI.    H.  Wright,  C.  Hose,  F.  W. 

Mott 552 

BLOOD     COAGULABILITY.         A.    E. 

Wright  and  W.  E.  Paramore 552 

OATABACT,       IMMATURE.        A.    E. 

Bulson,  Jr 553 

CELLULAR  ELEMENTS  OF  COLOS- 
TRUM AND  HUMAN  MILE. 
Wallich  and  Levaditi 554 

OHOLECY8TITI8.     R.  W.  Hardon 554 

COLITIS,     MEMBRANOUS.       W.     II. 

White 554 

DB9ENEEATI0N     OF    THE    HEAET. 

John  Hay 554 


PAGE 

DIGITALIS  TEEATMENT,  BEMAIES 

ON.     Fritz  Schwyzer 556 

ETHYL  CHLORIDE.     W.  J    McCardie.  557 

FLOATING    KIDNEY;     SURGICAL 

TEEATMENT.     J.  Hutchinson 557 

FEACTUEE    OF    THE    SPINE.     II.   L. 

Burrell 55S 

GONORRHCEA,     LACTIC     ACID     IN. 

Swithin  Chandler 55S 

GYNAECOLOGY,  CONSEBVATIf  M  IN. 

D.  H.  Craig 55S 

HEADACHE      IN     CHILDHOOD. 

Cattaneo 559 

HYPEETEOPHIED  PBOSTATB, 
CHOICE  OF  METHOD  IN  OPER- 
ATING UPON  THE.  Willy 
Meyer... 560 

INTRAPERITONEAL       TUBIBCULO- 

8IS.     F.  F.  Lawrence 561 

INTUSSUSCEPTION     IN      INFANCY 

AND  CHILDHOOD.     J.  H.  Hess..  562 

LABYNGEAL  AND  PULMONABY 
TUBEBCUL08I8,  BEST  IN.  W. 
P.  Porcher 562 

LEUCOCYTES,  EXAMINATION  OF, 
A8  DIAGNOSTIC  AID.  T.  R. 
Brown 562 

MASTOIDITIS,  ACUTE,  INDICA- 
TIONS FOB  OPERATING  IN. 
P.  D.  Kerrison 563 

MYOPIA,   CAU8E  OF  PROGRESSIVE. 

G.  Seggel 563 

NASO -PHABYNGEAL       ADENOIDS. 

J.  A.  Stucky 564 

OBESITY,     TEEATMENT      OF.       II . 

Labbe  and  L.  Furet 565 

PAROTITIS,   8ECONDAEY.     R.  T.  II. 

Bucknall 565 


PEBICABDITIS  COMPLICATING 

ACUTE    LOBAE    PNEUMONIA. 

J.  A.  Chatard 566 

PHLEB0SCLEB08IS.       C.    F.    Martin 

and  J.  C.  Meakins 566 

PLEURISY      AND       TUBERCULOSIS. 

Silvio  von  Ruck 567 

POTASSIUM    PERMANGANATE     £B 

A  HEMOSTATIC.     Torner 567 

PE08TATE,     CARCINOMA    OF    THE. 

H.H.Young 56S 

3CABLET  FEVEE,  INFECTION  WITH, 

THROUGH      OPEN      WOUND8. 

Charles  Haemann 568 

SC0FOLAMINE-M0EPHINE  ANES- 
THESIA.    Ries 569 

SLEEPLESSNESS     AND     PAIN.       L. 

Brunton 570 

SPINE,   TUBERCULAR    CONDITIONS 

OF  THE.     DeForest  Willard 570 

SUEGBEY     DUEING     THE     BU8B0- 

JAPANESB       NAVAL       WAE. 

Surgeon-General  Suzuki 571 

SYPHILIS   THE  FEVEE  OF  LATE. 

(VISCEEAL).     Arthur  Birt 572 

TABES,      EABLY      DIAGNOSIS     OF. 

Severino 572 

TUBEE0ULO8I8.     PULMONABY, 

AFTER  -  TREAT  MI  NT     OF.      J. 

A.  Wilder '72 

VOMITING  OF    PREGNANCY.     J.  W. 

Williams 573 

X-EAY  IN    MALIGNANT    DISEASE 

W.  B.  Coley 574 

BOOK  BEVIEWS 574 

BOOKS  AND  MONOGBAFH8  RE- 
CEIVED     576 

STAFF  LIST 678 


Editorials. 


I)i:i'.\i:tmi:.\t   in  charge  of 
.1.    \1  UDISON  TAYLOR,  A.M.,   M.D. 


ELECTRO-THERAPEUTICS. 

The  older  works  on  electro-therapeutics,  with  a  few  exceptions,  give  to  the 
reader,  on  the  whole,  a  more  hopeful  view  of  the  value  of  electricity  in  the  treat- 
ment of  diseased  conditions  than    is   warranted.      The   genera]    practitioner   could 

(529) 


530  ELECTRO-THERAPEUTICS. 

readily  receive  the  impression  from  a  perusal  of  these  works  that  electricity  is 
almost  a  panacea  for  all  ills.  Its  application  in  many  nervous  conditions  as  well 
as  diseases  of  the  internal  organs  is  described,  in  which  no  orthodox  therapeutist 
would  recommend  its  use. 

There  are  many  who  are  enthusiastic  advocates  of  electro-therapeutics,  and 
there  are  many,  on  the  other  hand,  who  have  absolutely  no  faith  in  its  efficacy. 
There  is,  however,  a  common-sense  and  practical  position  to  be  taken,  and  the  true 
value  of  this  therapeutic  measure  should  be  recognized,  as  it  is  of  great  use  in  the 
diagnosis  and  treatment  of  certain  nervous  diseases.  If  the  general  practitioner 
makes  himself  familiar  with  these  conditions,  he  will  find  it  an  important  aid  to 
other  therapeutic  measures. 

Excluding  the  x-ray,  the  forms  of  electricity  which  are  of  practical  importance 
in  the  treatment  and  diagnosis  of  diseases  are,  (1)  the  faradic,  or  induced  current; 
(2)  the  galvanic,  or  direct  current;  (3)  the  static,  or  frictional  current;  (4)  the 
sinusoidal  current,  and  (5)  the  high-frequency  current.  The  difference  in  the 
effects  of  these  currents  is  largely  one  of  degree,  with  the  exception  of  the  galvanic 
current,  which  has  certain  specific  qualities. 

The  galvanic  current  applied  to  the  skin  produces  (1)  local  congestion;  (2) 
stimulates  muscular  contractions;  (3)  applied  over  a  gland  causes  increased  secre- 
tion; (4)  has  an  electrotonic  action;  (5)  produces  a  chemic  and  electrolytic  effect; 
(6)  influences  osmosis,  and,  finally  (7)  is  of  value  as  a  means  of  suggestion. 

The  faradic  current  does  little  more  than  act  as  an  irritant,  causing  involun- 
tary contraction  of  healthy  muscles  and  excitation  of  sensory  nerves.  Its  irritative 
action  produces  also  some  vasomotor  dilatation. 

When  the  static  current  is  applied  to  a  motor  point  muscular  contractions 
ensue.  It  also  is  of  value  as  a  peripheral  counter-irritant,  and  it  produces  a  pow- 
erful psychic  effect. 

The  sinusoidal  current  has  the  same  physiologic  qualities  as  the  faradic  cur- 
rent, but  has  the  advantage  of  producing  little  or  no  pain. 

The  high-frequency  current,  according  to  Apostoli,  affects  powerfully  the  nutri- 
tion of  the  organism.  Rheumatic  states,  according  to  the  same  authority,  are 
benefited  by  its  use.  Apostoli  is  very  enthusiastic  about  the  value  of  this  form  of 
current,  but  an  experience,  though  limited,  in  the  use  of  these  currents  has  made 
the  present  writer  less  so. 

To  understand  the  proper  application  of  electricity  in  the  treatment  of  disease 
it  is  necessary  to  be  familiar  not  only  with  elect rophysics,  but  also  electrophysiology. 
The  technique  of  the  application  of  electricity  requires  much  practice.  One  must 
be  familiar  with  the  resistance  of  the  body,  and  the  resistance  offered  by  electrodes, 
as  well  as  the  proper  methods  to  reduce  this  resistance  to  a  minimum.     It  is  neces- 


ELECTRO-THERAPEUTICS.  531 

sary  to  know  that  the  skin  should  be  thoroughly  moistened,  and  the  electrodes  satu- 
rated with  water;  that  the  electrodes  should  be  held  in  close  contact  with  the  skin, 
and  that  applying  the  electrodes  to  a  bony  point  causes  unnecessary  pain. 

The  electro-therapeutist  must  be  familiar  with  the  motor  points  of  the  body, 
that  is,  that  portion  of  the  muscle  where  the  nerve  enters.  He  should  know  that 
when  the  galvanic  current  is  applied  to  the  body  there  are  different  effects  at  the 
negative  and  positive  poles.  He  should  know  that  at  the  point  where  the  negative 
pole  touches  the  skin,  if  the  current  is  sufficiently  powerful,  there  is  liquefaction, 
and  that  at  the  positive  pole  there  is  coagulation  of  the  tissues. 

The  effect  of  electricity  upon  the  brain  is  not  great  or  important.  When 
applied  to  the  skull  there  is  dizziness,  nausea,  pallor,  and,  if  the  current  be  suffi- 
ciently strong,  there  is  sometimes  fainting.  When  efforts  are  made  to  affect  the 
spinal  cord  with  electricity  the  results  are  always  doubtful. 

The  effect  of  electricity  upon  the  peripheral  nerves  is  readily  demonstrated. 
The  special  senses  can  be  stimulated  with  great  facility.  Application  of  the  galvanic 
current  to  the  olfactory  nerve  is  followed  by  the  recognition  of  an  odor.  Stimula- 
tion of  the  gustatory  nerve  produces  a  metallic  taste.  Stimulation  of  the  optic 
nerve  produces  flashes  of  light.  The  auditory  nerve,  also,  is  susceptible  to  stimu- 
lation by  the  galvanic  current,  that  is,  CaCIC  produces  a  sense  of  sound,  which  is 
increased  by  AnOC.     CaOC  or  AnCIC  produces  no  reaction. 

Electricity  is  of  much  value  as  an  aid  in  the  diagnosis  of  certain  forms  of 
nervous  disease.  In  order  to  employ  this  diagnostic  measure  it  is  necessary  to  have 
a  clear  and  definite  idea  of  the  reaction  of  degeneration.  The  DeR  (reaction  of 
degeneration)  occurs  in  muscles  which  are  cut  off  in  any  way  from  their  connections 
with  the  ganglion  cells  in  the  anterior  horns  of  the  spinal  cord,  and  may  be  present 
in  diseases  of  the  anterior  horns,  diseases  of  the  spinal  roots,  and  diseases  of  the 
nerve  trunks  themselves.  DeR  means  that  CaCIC  is  less  than  AnCIC,  generally 
speaking,  but  if  a  muscle  responds  to  galvanic  stimulation  in  a  sluggish,  wa\elike 
manner  this  itself  is  pathognomonic  of  the  reaction  of  degeneration.  Del?  may  be 
present  also  in  the  cranial  nerve  palsies,  when  the  palsy  is  due  to  either  a  nuclear 
or  a  peripheral  disease.  It  is  found  in  isolated  muscles  in  progressive  muscular 
atrophy  of  spinal  origin.  In  lead  palsy  DeE  is  found  in  the  paralyzed  muscles, 
and  may  also  he  found  at  times  in  the  muscles  which  show  no  paralysis. 

The  use  of  electricity  is  of  some  prognostic  value.  If,  in  peripheral  palsy,  the 
Deli  appears  shortly  after  the  paralysis,  the  prognosis  is  rendered  more  grave.  On 
the  other  hand,  if  the  faradic  excitability  persists  in  spile  of  a  lowered  galvanic 
excitability,  the  prognosis  is  more  favorable. 

In  the  opinion  of  the  writer  the  therapeutic  value  of  electricity  is  somewhat 
restricted.     Every  general  practitioner  should  be  familiar,  however,  with  the  indi- 


532  ELECTRO-THERAPEUTICS. 

cations  for  its  application,  as  in  those  diseased  conditions  which  call  for  its  use  it 
is  of  great  value,  and  in  most  instances  it  cannot  be  replaced  by  any  other  thera- 
peutic measure. 

The  galvanic  current  is  an  essential  factor  in  the  treatment  of  palsies  of  pe- 
ripheral origin.  In  the  treatment  of  these  diseases  one  should  be  familiar  with  the 
proper  technique  for  the  application  of  the  current.  For  example,  in  the  early 
stages  of  a  traumatic  neuritic  the  indifferent  or  negative  electrode  should  be  placed 
between  the  scapulas  or  over  the  sacrum,  and  a  small  electrode  attached  to  the 
positive  pole  of  the  galvanic  battery  should  be  applied  to  that  part  of  the  nerve 
which  is  diseased.  The  current  should  be  small  in  amount,  usually  about  4  to  6 
milliamperes  being  sufficient,  and  should  be  applied  for  five  minutes. 

A  knowledge  of  the  localization  of  nerves  is  necessary,  and  also  a  familiarity 
with  what  is  called  the  motor  points  of  the  muscles — that  portion  of  the  muscle 
where  the  nerve  enters  it. 

Later,  after  the  acute  inflammation  has  subsided  in  cases  of  neuritis,  and  in 
which  the  muscles  have  undergone  DeE,  the  best  results  are  obtained  from  an  inter- 
rupted current,  applying  that  pole  to  the  muscles  which,  with  an  interrupted  cur- 
rent, gives  the  best  contractions.  When  DeR,  is  present  the  anode  over  the  muscle 
produces  this  result. 

Spasmodic  conditions  of  the  muscles,  such  as  spasmodic  wry-neck,  call  for  the 
application  of  electricity,  but  the  results  are  not  always  satisfactory. 

The  value  of  electricity  in  the  treatment  of  progressive  muscular  dystrophies 
is  not  very  great.  It  has  certainly  no  curative  action,  and  if  it  has  any  effect  at  all 
it  serves  but  to  delay  the  progress  of  the  disease. 

In  the  treatment  of  palsies  of  spinal  or  cerebral  origin  electricity  plays  a 
minor  part,  with  the  exception  of  acute  poliomyelitis.  In  this  disease,  however, 
together  with  massage,  it  constitutes  the  principal  and  most  important  feature  of 
the  treatment. 

In  apoplexy,  thrombosis,  embolism,  and  brain  softening  electricity  is  of  no 
value;  nor  is  it  to  be  used  in  myelitis  or  systemic  spinal  diseases.  In  locomotor 
ataxia  the  sinusoidal  current  has  been  recommended  by  some  writers,  but  a  fairly 
extensive  experience  with  this  treatment  in  the  hands  of  the  writer  has  been  dis- 
couraging. The  galvanic  current,  however,  sometimes  helps  the  lancinating  pains 
of  this  disease,  and  temporarily  relieves  the  incontinence  of  urine  if  applied  locally. 

Sciatica,  especially  the  subacute  forms,  is  greatly  helped  by  the  application 
of  a  stabile  or  labile  galvanic  current,  the  anode  being  stroked  over  the  painful 
nerve,  while  the  cathode  is  placed  over  the  sacrum. 

The  pains  of  trifacial  neuralgia  are  often  relieved  temporarily,  and  sometimes 
permanently,  by  the  skillful  application  of  the  stabile  or  labile  galvanic  current  in 


ELECTRO-THERAPEUTICS.  533 

small  doses,  the  anode,  as  a  rule,  being  placed  peripherally,  and  the  cathode  at  some 
indifferent  spot.  Sometimes,  for  empirical  reasons,  the  reverse  current  seems  more 
effective. 

The  galvanic  current  is  highly  recommended  by  some  authorities  for  the  treat- 
ment of  exophthalmic  goiter.  It  seems,  in  some  cases,  to  lower  rapidity  of  the 
heart's  action,  temporarily,  and  on  the  whole,  should  be  used  in  every  case.  The 
anode  is  placed  at  the  nape  of  the  neck,  and  the  cathode  stroked  slowly  up  and 
down  the  inner  border  of  the  sternocleido-mastoid  muscle,  the  object  being  to  stim- 
ulate the  pneumogastric  nerve,  and  thus  slow  the  heart's  action.  The  anode  is 
afterward  placed  over  the  base  of  the  heart,  and  the  cathode  at  the  nape  of  the 
neck.  I  have  seen,  by  this  means,  the  pulse-rate  lowered  10  or  20  beats  per  minute. 
But,  in  some  cases,  the  'current  does  not  seem  to  act  well,  and  the  pulse-rate  is 
increased. 

In  the  treatment  of  chronic  joint  diseases,  especially  rheumatoid  arthritis,  the 
results  are  unusually  happy,  in  fact,  associated  with  massage,  daily  galvanism,  ex- 
tending over  a  prolonged  period  of  months,  it  seems  to  exert  a  curative  action  upon 
the  latter  disease. 

Electricity  should  be  used  with  caution  in  the  treatment  of  psychic  disorders. 
It  has  the  disadvantage  of  possibly  suggesting  to  the  disordered  mind  new  delusions. 
However,  in  mild  cases  of  melancholia,  without  delusions,  the  static  breeze  seems 
to  have  a  beneficial  J3sychic  influence,  probably  largely,  if  not  entirely,  by  means 
of  suggestion. 

In  hysterics  and  neurasthenics,  as  an  adjunct  to  massage,  the  slowly  interrupted 
faradic  current  applied  to  the  motor  points  of  all  the  muscles,  for  from  half  to  one 
hour,  is  useful.  The  "dry  brush"'  is  of  value  hi  treating  hysteric  sensory  disturb- 
ances, and  also  those  sensory  manifestations  which  are  so  frequent  in  the  neuras- 
thenic. Hypochondriac  neurasthenics  are  often  helped  by  the  application  of  the 
static  breeze,  and  the  tired  headache  of  the  overworked  brain  is  undoubtedly  relieved 
by  this  measure. 

The  treatment  of  diseases  of  the  thoracic  ami  abdominal  organs  does  not  often 
require  the  use  of  electricity.  Gastric  dilatation  or  atony,  or  atonic  constipation, 
indicate,  sometimes,  the  application  of  the  faradic  or  galvanic  currents,  and  these 
measures  are  often  useful,  when  skillfully  employed.  But  in  the  treatment  of  other 
diseases  of  the  internal  organs  so  many  measures  are  of  so  much  more  value  than 
electricity  that  no  one  should  feel  called  upon  to  employ  it. 

While  this  isnot  Ihesuni  total  of  all  our  information  aboui  electro-therapeutics, 
it  perhaps  covers  the  important  knowledge  that  we  have  on  the  subject.  With  few 
exceptions,  no  disease,  not  mentioned  above,  can  lie  vitally  influenced  by  the  appli- 
cation of  any  form  of  electricity  described  in  the  foregoing  paragraphs. 

John   II.  W.  Rhein.* 


'Neurologist  to  the  Howard  ami  St.  Agnes  Hospitals,  Philadelphia. 


534  CLINICAL  FACTS  RELATING  TO  SFPERHEATED  MILK. 


CLINICAL  FACTS   RELATING   TO    SUPERHEATED  MILK. 

We  are  indebted  to  Soxhlet  for  devising  means  of  procuring  germ-free  milk. 
This  noted  chemist  believed  that  to  kill  the  germs  in  milk  should  be  our  sole  object 
in  its  preparation,  regardless  of  the  after-effects.  The  profession  all  over  the  world 
took  this  hint  kindly  and  there  are  sterilizers  in  use  wherever  civilization  is  found. 

Sterilization  aims  chiefly  to  destroy  pathogenic  bacteria,  such  as  typhoid  or 
diphtheria  bacilli,  thus  preventing  the  introduction  of  living  disease  germs  into 
the  body.  The  main  argument  in  favor  of  complete  sterilization  is  the  necessity  to 
destroy  tubercle  bacilli  and  prevent  the  transmission  of  tuberculosis. 

If  milk  contains  pathogenic  bacteria  for  any  length  of  time,  the  toxins  generated 
by  these  bacteria  will  not  be  destroyed,  even  though  the  milk  be  subjected  to  a 
temperature  much  higher  than  that  of  the  boiling  point.  The  toxins  of  some 
pathogenic  bacteria  can  withstand  a  temperature  of  300°  F.,  according  to  Prof. 
Victor  Vaughn. 

The  mistake  made  in  the  teaching  of  Soxhlet's  principle  is  that  it  disseminates 
the  impression  that  if  milk  is  sterilized  for  from  thirty  to  forty-five  minutes  the 
same  is  a  wholesome  article  for  baby-feeding,  bcause  the  living  germs  were  killed  by 
continued  steaming;    ergo,  the  milk  is  suitable  for  infant-feeding. 

This  is  not  true  because,  in  the  first  place,  even  prolonged  boiling  does  not  kill 
the  spores  of  all  bacteria;  and  in  the  second  place,  the  chemical  poisons  produced 
by  certain  germs  are  not  altered  by  the  temperature  of  boiling  milk.  These  toxins 
remain  in  solution  and  are  poisons  which,  when  continuously  given,  must  hurt  the 
infant.  I  have  always  associated  the  continuous  feeding  of  milk  containing  toxins 
in  solution  as  one  of  the  causes  of  scorbutus  and  perhaps  the  main  cause. 

Immunity  from  infectious  diseases  has  frequently  been  found  in  the  nursling, 
due  no  doubt  to  the  presence  of  a  large  quantity  of  serum,  which  holds  anti-bodies 
in  the  human  milk. 

There  is  no  question  in  my  mind  that  the  serum  albumin  and  lactalbumin 
present  in  cows'  milk  contains  immunizing  and  protective  substances  similar  to 
those  found  in  human  milk,  which  are  destroyed  when  milk  is  subjected  to  the 
process  of  sterilization;  and  which  protective  substances  are  not  altered  or  modified 
when  milk  is  heated  to  a  temperature  ranging  between  100°  F.  (my  plan)  or  to 
that  of  140°  F.  (Babcock  and  Russell's  plan),  for  the  reason  previously  stated. 

The  physiologic  requirements  are  that  all  the  constituents  of  the  milk  must  be 
digested  before  they  can  be  absorbed  into  the  system.  Therefore,  there  is  distinct 
loss  of  utility  in  boiled  milk  because  the  living  cells  of  fresh  milk"  do  not  enter  into 
the  circulation  direct  as  they  would  do  in  fresh  unboiled  milk. 


CLINICAL  FACTS  RELATING  TO  SUPERHEATED  MILK.  535 

In  practice  it  will  have  been  noticed  by  most  medical  practitioners  that  there 
is  a  very  distinctly  appreciable  lowered  vitality  in  infants  who  are  fed  on  boiled 
milk.  The  process  of  absorption  is  more  delayed,  and  the  quantity  of  milk  required 
is  distinctly  larger  for  the  same  amount  of  growth  and  nourishment  of  the  child 
than  is  the  case  when  fresh  milk  is  used.    • 

Milk  consists  of  a  number  of  fat  cells  suspended  in  serum.  These  cells  form 
the  cream.  The  serum  consists  of  water  in  which  is  dissolved  milk-sugar  and  serum 
albumin,  with  various  salts,  including  iron,  and  chief  factor  of  all,  casein.  The 
cells  with  the  exception  of  the  fat-corpuscles  are  all  living  cells,  and  they  retain 
their  vitality  for  a  considerable  time  after  the  milk  is  drawn  from  the  mammary 
glands. 

There  is  reason  for  supposing  that  when  fresh  milk  is  ingested,  the  living  cells 
are  at  once  absorbed  without  any  process  of  digestion,  and  enter  the  blood  stream 
and  are  utilized  in  building  up  the  tissues.  The  casein  of  the  milk  is  ingested  in 
the  usual  way  of  other  albuminoids  by  the  gastric  juice  and  absorbed  as  peptone. 
There  is  also  absorption  of  serum  albumin  by  osmosis.  The  chemical  result  of 
boiling  milk  is  to  kill  all  the  living  cells  and  to  coagulate  all  the  constituents. 
Notably  herein  we  have  coagulated  albuminate  of  fluorin  and  iron. 

Butyric  acid  is  frequently  found  instead  of  lactic  acid  after  submitting  milk  to 
the  process  of  sterilization.  The  first  evil  result  noticed  while  using  sterilized 
milk  is  that  children  so  fed  are  constipated.  It  is  noteworthy  that  prolonged  use 
of  sterilized  milk  results  in  rachitis.  For  this  reason  the  symptom  of  constipation 
has  been  so  intimately  associated  with  the  resultant  rickets  that  many  clinical  ob- 
servers believe  constipation  to  be  in  many  instances  a  forerunner  of  rickets.  There 
are  many  cases  of  scurvy  that  can  be  traced  to  a  long-continued  use  of  sterilized 
milk,  and  when  such  scorbutic  symptoms  manifest  themselves,  a  radical  change, 
such  as  the  feeding  of  raw  milk,  will  modify  such  a  condition  very  rapidly. 

What  has  just  been  said  concerning  the  use  of  raw  milk  in  the  treatment  of 
scorbutus  applies  equally  well  to  the  benefit  which  will  be  noted  when  we  attempt 
to  relieve  a  constipated  condition  during  sterilized  milk-feeding  and  prescribe  raw 
milk. 

Let  me  explain  what  raw  milk  is.  Eaw  milk  is  natural  milk.  Because  a  woman 
nurses  her  baby  with  milk  without  subjecting  it  to  chemical  changes,  hence  it  is  nat- 
ural milk,  i.e.,  milk  served  in  its  natural  state.  If  we  imitate  Nature  and  take 
woman  as  an  example,  then  cows'  milk,  if  procured  under  hygienic  conditions,  with 
strict  sanitary  supervision,  may  be  fed  to  children  without  subjecting  the  milk  to 
the  process  of  sterilization.  Certain  reasons  can  be  given  as  to  why  a  woman's 
breast-milk  is,  and  should  be,  neither  boiled,  sterilized,  or  pasteurized.  For  this 
reason  the  albumin,  fat,  salt,  and  sugar  are  fed  in  a  very  assimilable  form. 


536  CLINICAL  FACTS  RELATING  TO  SUPERHEATED  MILK. 

When  milk  is  sterilized  or  boiled  there  is  a  coagulation  of  the  living  sub- 
stances, such  as  the  albuminate  of  iron  and  phosphorus,  which  are  derived  from 
tissues  containing  them,  and  hence  they  are  present  in  a  devitalized  form  as  proteids. 

Infants  require  phosphatic  and  ferric  proteids  in  a  living  form.  These  are 
present  in  raw  milk  only.  When  we  prescribe  codliver-oil  as  a  restorative  in  rickets, 
we  do  so  in  order  to  feed  "a  live  food"  to  overcome  the  harm  that  has  been  caused 
by  giving  a  devitalized  or  dead  food.  Such  deadness  or  devitalization  is  produced 
by  feeding  sterilized  milk  or  boiled  milk  for  any  length  of  time. 

Exceptional  instances  may  be  quoted  where  milk  must  be  steamed  or  pasteurized 
to  a  temperature  capable  of  destroying  the  tubercle  bacillus.  This  can  be  accom- 
plished, according  to  Eussell  and  Babcock,  by  subjecting  milk  to  a  temperature  of 
140°  F.  This  should  be  borne  in  mind  if  the  source  of  the  milk  is  unknown  or  the 
age  of  the  milk  cannot  be  ascertained.  When,  however,  we  have  municipal  control 
and  the  sanitary  supervision  of  milk  dairies,  and  we  are  conversant  with  the  methods 
used  in  the  dairy,  then  my  advice  has  always  been  to  warm  the  milk  to  blood  heat 
(temperature,  100°  F.)  for  five  minutes  and  feed  in  this  manner  the  required  quan- 
tity at  stated  intervals. 

A  careful  inquiry  into  the  results  of  sterilization  will  show  that : — ■ 

First. — The  coagulation  of  the  milk  albumin  by  sterilization  or  boiling  may 
render  the  milk  more  difficult  of  digestion. 

Second. — Sterilization  or  boiling  interferes  with  the  coagulability  of  milk  by 
rennet,  and  presumably,  therefore,  with  its  digestibility  by  the  gastric  juices. 

Third. — Free  fat,  as  found  in  sterilized  or  boiled  milk,  is  probably  not  readily 
assimilated  in  infant  food.  The  fat,  not  free,  being  inclosed  in  a  less  easily  destruc- 
tible envelope,  is  probably  slow  of  digestion. 

The  following  table  of  C.  H.  Stewart1  shows  the  percentage  of  soluble  albumin 
in  milk  at  various  temperatures: — 

Soluble  Suhlhle 

Time  nf  Heating  Albumin  in  Albumin  in 

Fresh  Mill;.         Heated  Mil.. 

\ 

Per  Cent.  Per  Cent 

]()  minutes  at  60°  C.  I  1 40     P.) 0.423  0.418 

30   minutes  at  60°   C.  (140°    P.) 0.435  0.427 

10  minutes  at  65°  C.  (140°  P.) 0.395  0.362 

30  minutes  at  65°  C.  (1  19     F.) '. 0.395  0.333 

10  minutes  at  70°   ( !.  (158°  F.) 0.422  0.209 

30  minutes  at  70 '  C.  I  158°   F.) 0.421  0.253 

10   minutes  at  75"   <  .  (167      F.) '•  •  •    <»--s,)  0.070 

30  minutes  at  75°  ('.  (167°  P.) 0.380  0.050 

10  minutes  at  so    c.  ( 176°   P.i ' 0.375  none 

30  minutes  a1  80    C.  (176°   F.) <):!':*  none 

■Taken  from  "Infant  Feeding  in  Health  and  Disease,"  third  edition,  Louis  Fischer.  F.  A. 
Duvis  Co.,  publishers,  Philadelphia. 


HINTS  FOR  THE  INTERPRETATION  OF  URINALYSES.  537 

A  study  of  the  above  table  will  soon  convince  the  student  that  there  is  a 
decided  loss  of  albumin  which  is  the  proteid  and  really  the  backbone  of  milk.  The 
loss  of  albumin  occurs  least  in  pasteurized  milk  and  most  in  milk  subjected  to  a 
temperature  required  to  sterilize  according  to  Soxhlet's  method.  When  we  consider 
the  treatment  advocated  to  relieve  scurvy  brought  on  by  a  continuous  feeding  of 
"dead  milk"  caused  by  high  temperature  sterilization,  then  the  indication  is  to  stop 
sterilization  and  feed  a  milk  containing  a  "live  factor,''  which  is  warmed  raw  milk. 

In  attempting  to  relieve  obstinate  constipation  by  continuous  sterilized  milk- 
feeding,  nothing  will  replace  the  sudden  change  of  feeding  with  milk  subjected  to 
less  heat.  This  method  has  been  used  and  advocated  by  me  for  many  years,  and  is 
simply  imitating  Nature. 

Louis  Fischer,  M.D.,* 

New  York  City. 


HINTS  FOR  THE  INTERPRETATION  OF  URINALYSES. 

The  editor,  some  time  ago,  requested  me  to  write  an  article  on  the  interpre- 
tation of  an  analysis  of  the  urine.  I  confess  the  subject  is  approached  with  some 
degree  of  hesitation;  when  one  takes  into  consideration  the  vast  amount  of  litera- 
ture on  the  subject  to  be  found  in  the  medical  and  chemical  journals,  works  on 
urinalysis  and  clinical  diagnosis,  to  say  nothing  of  the  fact  that  most  text-books 
on  medicine  and  many  of  the  specialties  contain  more  or  less  on  the  significance  of 
urinary  abnormalities,  the  field  appears  to  be  so  thoroughly  covered  that  an  article 
of  this  kind  is  not  justifiable.  However,  one  who  studies  the  subject  will  be  con- 
fronted by  a  mass  of  literature  on  the  significance  of  certain  variations  from  normal 
in  the  composition  of  the  urine,  much  of  which  is  contradictory,  showing  that,  in 
spite  of  the  great  amount  of  research  on  the  subject,  the  true  significance  of  many 
abnormalities  is  not  yet  known;  again,  in  many  of  our  works  on  urinalysis  much  is 
said  about  the  various  methods  employed,  with  a  discussion  of  their  relative  merits. 
and  very  little  on  the  interpretation  of  an  analysis  niter  ii   is  made. 

The  busy  practitioner  manifestly  cannoi  keep  up  fco  date  in  all  branches  of  med- 
icine, and  we  find  that  clinical  diagnosis,  while  one  of  the  most  important,  is  still 
one  of  the  most  frequently  neglected  subjects,  and  it  is  this  class  of  practitioners  to 
whom  this  is  offered. 

An  analysis  of  urine  should  he  based  on  a  twenty-four  hours'  excretion;  the 
urine  should  he  collected  in  a  sterile  bottle,  passed  directly  into  the  receptacle  when 
possible;  when  not.  the  vessel  used  should  he  thoroughly  washed  out  with  boiling 
water  each  time  it   is  to  he  u^fd.  and  precautions  employed  against  the  entrance  of 

•Visiting  Physician  i<>  the  Willard   Parker  and  Riverside  Hospitals. 


538  HINTS  FOR  THE  INTERPRETATION  OF  URINALYSES. 

more  extraneous  micro-organisms  than  is  absolutely  unavoidable;  when  these  pre- 
cautions are  carried  out  I  have  found  the  use  of  preservatives  in  the  majority  of 
cases  unnecessary,  and  to  be  avoided  if  possible,  as  those  capable  of  preserving 
the  urine,  unless  used  intelligently,  at  times  greatly  interfere  with  the  estimation 
of  certain  urinary  constituents.  The  sample  submitted  for  analysis  should  be  taken 
from  the  total  quantity  after  thorough  agitation  of  the  receptacle  to  insure  an 
average  sample;  it  is  not  infrequently  of  advantage  to  collect  the  urine  passed  at 
various  intervals  in  separate  bottles  and  submit  the  whole  for  analysis.  This  pro- 
cedure I  have  seen  in  several  instances  aid  greatly  in  determining  the  exact  nature 
of  intermittent  and  obscure  cases  of  albuminuria.  When  an  analysis  is  negative,  in 
a  case  in  which  the  diagnosis  is  difficult,  several  analyses  should  be  made;  too  much 
dependence  is  frequently,  in  these  cases,  placed  on  the  results  of  one  analysis,  and 
many  discrepancies  between  the  urinary  conditions,  physical  and  post-mortem  find- 
ings, are  in  all  probability  due  to  the  fact  that  enough  analyses  have  not  been  made. 
If  these  precautions  are  carried  out,  and  not  too  much  taken  for  granted  from  one 
negative  or  even  positive  analysis,  many  physicians  who  now  say  that  they  do  not 
place  much  dependence  on  a  urinary  analysis  would  change  their  views.  I  have 
seen  many  times  in  private  and  hospital  laboratories  samples  of  urine  for  analysis 
standing  around  in  a  variety  of  receptacles,  waiting  their  turn,  manifestly  in  various 
stages  of  decomposition;  how  one  can  expect  to  obtain  information  of  value  from 
such  specimens  is  more  than  I  can  conceive. 

In  interpreting  a  urinalysis  we  must  take  into  consideration  the  normal  urine, 
the  physical  characteristics,  amount,  and  relation  of  the  various  constituents;  any 
abnormalities  in  the  relation  of  the  normal,  and  the  presence  and  amount  of  abnor- 
mal substances;  also  the  condition,  habits,  etc.,  of  the  patient;  the  character  and 
amount  of  food  ingested ;  and  last,  but  by  no  means  least,  the  drugs  which  are  being 
employed.  The  normal  amount  and  composition  of  the  urine  of  a  healthy  individual 
varies  markedly,  depending  on  the  relation  between  the  imbibition  and  abstraction 
of  fluid  in  the  body,  but  that  of  a  healthy  adult  may  be  put  down  as  from  1200  to 
1500  cubic  centimeters,  and  will  contain  approximately  GO  grams  of  solids,  of  which 
25  grams  will  be  inorganic  and  35  grams  organic  constituents. 

The  inorganic  substances  are  sodium,  potassium,  ammonium,  calcium,  mag- 
nesium, and  iron,  combined  principally  with  the  following  acids:  hydrochloric, 
sulphuric,  nitric,  phosphoric,  and  oxalic.  The  organic  constituents  are:  urea,  uric 
acid,  creatinin,  hippuric  acid,  with  small  amounts  of  other  organic  compounds, 
among  which  are  traces  of  acetic,  formic,  butyric,  and  lactic  acids,  oxaluric  acid, 
traces  of  carbohydrates,  proteids,  acetone,  pigments,  etc. 

Abnormal  constituents  are  acetone,  in  more  than  traces,  diacetic  acid,  oxybutyric 
acid,  volatile  fatty  acids  in  large  amounts,  lactic  acid  in  more  than  a  trace,  fats, 


HINTS  FOR  THE  INTERPRETATION  OF  URINALYSES.  539 

leucin,  tyrosin,  alkapton,  albuminous  substances,  .blood  and  certain  of  its  deriva- 
tives, bile  pigments  and  acids,  urobilin  in  large  amounts,  indoxyl,  phenol,  and  skatol 
in  large  quantities,  cholesterin,  lecithin,  etc.,  including  compounds  derived  from,  and 
produced  by  the  ingestion  and  action  of  certain  drugs.  The  quantity  eliminated 
in  twenty-four  hours  is  normally  subject  to  considerable  variation. 

Polyuria  is  observed  in  diabetes  mellitus  and  diabetes  insipidus,  and  during 
the  resorption  of  large  pericardial,  pleural,  peritoneal,  and  subcutaneous  effusions, 
in  chronic  diffuse  nephritis,  and  following  strong  psychical  disturbances.  One  form 
of  polyuria  ("epicritic  polyuria")  occurs  during  convalescence  from  acute  febrile 
diseases,  and  is  looked  upon  as  a  favorable  sign;  a  polyuria  of  this  kind  indicates 
the  elimination  of  waste  products  which  have  accumulated  in  the  system  during  the 
course  of  the  disease.  It  must  be  borne  in  mind  that  a  polyuria  may  appear  after 
the  subsidence  of  the  fever,  be  followed  by  a  marked  oliguria,  and  in  some  cases  the 
termination  will  be  fatal. 

Polyuria  may  occur  in  multiple  myelomate  of  the  bones,  in  functional  and 
organic  nervous  diseases;  it  frequently  occurs  as  a  transitory  and  permanent  symp- 
tom in  hysteria,  neurasthenia,  migraine,  chorea,  and  epilepsy.  Large  quantities 
of  a  very  pale  urine  are  secreted  after  severe  and  profound  hysterical  attacks. 
Paroxysmal  polyuria  is  usually  associated  with  functional,  and  continuous  with 
organic,  nervous  diseases,  as  in  certain  cases  of  abscess,  cerebro-spinal  and  spinal 
meningitis,  the  first  stage  of  general  paresis,  tumors  of  medulla,  cerebellum,  and 
spinal  cord,  injuries  of  the  central  nervous  system,  Basedow's  disease,  etc. 

Oliguria  is  seen  in  many  conditions  associated  with  a  lowered  blood-pressure, 
as  in  cardiac  diseases  with  failing  compensation,  in  acute  febrile  diseases,  acute 
nephritis  and  chronic  parenchymatous  nephritis,  diarrhceal  diseases,  following 
haemorrhage,  in  puerperal  eclampsia,  hysteria,  etc.  Obstruction  to  the  flow  of  blood 
in  vena  cava  or  liver,  increasing  venous  or  decreasing  arterial  pressure  in  the  kidneys, 
causes  a  diminution  in  the  amount,  as  in  atrophic  cirrhosis,  acute  yellow  atrophy, 
thrombosis  of  the  vena  cava  and  renal  vein,  or  pressure  exerted  upon  them  by  tumors, 
ascitic  fluid,  etc.  Shock  following  the  use  of  anassthetics  frequently  results  in  an 
oliguria,  or  even  anuria. 

From  the  color,  which  varies  normally  from  a  pale  to  a  reddish  yellow,  very 
little  information  can,  as  a  rule,  be  obtained.  Pale  urines  either  have  an  ex- 
cess of  water  or  a  small  percentage  of  pigment,  which  may  be  normal,  but  may 
occur  in  diabetes,  chronic  interstitial  nephritis,  hysteria,  and  various  anaemias; 
and  further,  during  convalescence  from  febrile  diseases.  Dark  colored  urines  are 
either  concentrated  or  febrile  urines  with  an  excess  of  pigment,  or  may  be  due  to 
the  presence  of  certain  drugs,  as  phenol  and  its  derivatives. 

The  most  important  pathological    pigments   are   those   due   to   blond-coloring 


540  HINTS  FOR  THE  INTERPRETATION  OF  URINALYSES. 

matters,  the  color  varying  from  a  bright  red  to  a  black,  the  shade  depending  on 
the  quantity  of  blood-coloring  matter  present,  and  the  changes  the  blood  may  have 
undergone  either  before  or  after  voided,  and  also  as  to  whether  the  pigment  is  in 
solution  or  contained  in  the  erythrocytes;  and  those  due  to  the  presence  of  biliary 
coloring  substances,  the  color  varying  from  a  greenish-yellow  to  a  greenish-brown. 
In  chyluria  we  have  a  milky  color. 

The  odor  is  usually  of  little  significance.  Some  lay  stress  on  the  odor  of 
acetone  in  diabetes,  but  one  is  not  justified  in  determining  the  presence  of  this  sub- 
stance by  the  sense  of  smell.  An  ammoniacal  odor  in  freshly  voided  urine  is  im- 
portant, as  it  indicates  a  cystitis.  After  the  ingestion  of  certain  food-stuffs  the 
urine  will  have  a  characteristic  odor  which  is  of  no  significance  clinically. 

The  reaction  of  normal  urine  is  slightly  acid;  pathologically,  a  strongly  acid 
urine  may  be  seen  after  poisoning  with  one  of  the  organic  acids;  and  a  marked 
acidity  is  found  in  acute  febrile  diseases,  phthisis,  diabetes,  and  leukasmia.  Strongly 
alkaline  urine  may  be  due  to  the  ingestion  of  alkalies,  or  to  the  production  of  am- 
monia by  bacterial  action  in  the  bladder. 

The  specific  gravity  varies  normally  from  1012  to  1022.  A  low  specific 
gravity  indicates  either  an  excess  of  water  or  a  low  amount  of  solids.  Pathologically 
we  find  the  specific  gravity  low  in  diabetes  insipidis,  hysteria,  and  in  chronic  inter- 
stitial nephritis.  A  high  specific  gravity  is  found  in  febrile  urines,  concentrated 
urines,  and  in  diabetes  mellitus. 

The  chlorides  are  present  in  larger  amount  than  all  other  inorganic  salts  com- 
bined, the  normal  amount  being  from  10  to  15  grams  in  twenty-four  hours,  depend- 
ing directly  on  the  amount  and  character  of  the  food.  The  chlorine  is  greatly  re- 
duced in  starvation,  sometimes  almost  completely  disappearing.  An  example  of 
this  is  found  in  conditions  causing  stenosis  of  the  pyloris,  such  as  gastric  carcinoma ; 
in  these  cases  the  chlorides  are  of  some  importance,  the  amount  present  being  an 
index  to  the  amount  of  food  absorbed.  The  excretion  of  chlorides  is  reduced  in 
most  acute  febrile  diseases,  as  scarlatina,  roseola,  variola,  typhoid  fever,  and  pneu- 
monia; also,  in  acute  yellow  atrophy  of  the  liver,  in  acute  and  chronic  renal  dis- 
eases, associated  with  albuminuria;  in  chronic  hypersecretion  with  gastric  dilata- 
tion, a  decrease  which  may,  in  certain  cases  of  hyperaciditis,  with  gastric  ulcer,  go 
on  to  almost  total  absence  is  frequently  observed.  A  total  absence  has  been  noted 
in  pemphigus  foliaceous.  In  anaemic  conditions,  rachitis,  melancholia,  and  idiocy 
a  marked  decrease  is  observed,  and  to  a  less  extent  in  dementia  and  chorea. 

The  chlorides  are  found  in  increased  amount  in  all  conditions  when  retention 
has  previously  occurred,  such  as  acute  febrile  diseases,  and  during  absorption  of 
exudates  and  transudates,  with  an  increased  diuresis.  A  marked -increase  is  found 
in  many  cases  of  diabetes  insipidus.    In  epilepsy,  the  polyuria  following  the  attacks 


HINTS  FOR  THE  INTERPRETATION  OF  URINALYSES.  541 

is  associated  with  an  increase  of  chlorides.  Certain  drugs,  as  some  diuretics,  and 
some  potassium  salts  produce  an  increase;  chloroform  administered  internally  or 
as  an  anaesthetic  is  in  part  eliminated  in  the  form  of  a  chloride.  Salicylates,  it  is 
claimed,  cause  a  temporary  diminution.  In  many  eases  the  estimation  of  chlorides 
is  of  little  or  no  diagnostic  value.  In  acute  febrile  diseases  the  decrease  of  chlorides 
appears  to  be  in  direct  relation  to  the  intensity  of  the  disease,  and  when  there  is  an 
almost  total  absence,  0.05  to  0.1  gram  in  twenty-four  hours,  the  case  is  usually 
one  of  extreme  gravity.  The  elimination  of  chlorine  also  gives  us  a  fair  index  of 
the  digestive  powers  of  an  individual;  this  is  of  importance  in  most  chronic  dis- 
eases. 

The  Phosphates. — A  diminution  is  observed  in  most  acute  febrile  diseases,  the 
degree  of  diminution,  as  that  of  the  chlorides,  being  an  index  to  the  severity  of  the 
disease;  and  in  chronic  diseases  in  which  there  is  a  decreased  metabolism.  It  is 
claimed  that  in  typhoid  fever  with  intense  nervous  manifestations,  an  increased 
elimination  during  the  fastigium  is  looked  upon  as  an  unfavorable  symptom,  while 
an  increase  during  defervescence  is  favorable.  A  similar  decrease  in  phosphates 
has  been  observed  in  pulmonary  tuberculosis  associated  with  marked  pyrexia.  Of 
importance  is  the  decreased  excretion  of  phosphates,  associated  with  acute  and,  to  a 
certain  extent,  chronic  nephritis,  amyloid  kidney,  and  the  anaemias.  A  diminished 
excretion  is  seen  in  osteomalacia  and  certain  other  destructive  diseases  of  the  bones, 
although  at  times  an  increase  of  the  earthy  phosphates  is  found.  During  profound 
hysterical  attacks  there  is  a  diminution  in  the  phosphates,  frequently  in  proportion 
to  the  intensity  of  the  attack.  Low  phosphates  are  noted  in  chronic  lead  poisoning. 
Addison's  disease,  acute  yellow  atrophy,  and  in  certain  cases  of  hepatic  cirrho- 
sis; in  gout,  the  phosphates  decrease  before  the  onset  of  an  acute  attack,  then  rise, 
following  the  uric  acid  excretion  closely.  An  increased  elimination  of  phosphates 
occurs  in  diabetes  mellitus;  here  we  must  take  into  consideration  the  large  proteid 
intakes  of  the  patient,  a  peculiar  relation  frequently  exists  between  the  elimination 
of  phosphates  and  glucose  in  this  disease,  the  amount  of  the  formei  rising  and  fall- 
ing in  inverse  ratio  to  the  latter.  An  increased  elimination  of  phosphates  has  been 
described  under  the  name  of  phosphatic  diabetes  and  phosphaturia ;  patient-;  suf- 
fering from  this  condition  are  usually  subjects  of  nervous  disorders,  and  frequently 
of  sexual  neurasthenia — the  true  cause  and  significance  of  this  condition  is  as  yel 
unknown. 

An  increased  deposit  of  phosphates  is  found  in  the  aril £  patients  suffering 

from  acute  or  chronic  inflammations  of  the  genito-urinary  tract,  bul  it'  the  amount 
of  phosphates  be  determined  they  will  lie  found  within  the  norma]  limits. 

Bromides,  cocaine,  and  quinine  cause  a  decrease  in  the  aniounl  of  phosphates; 
the  cerebral  excitants  cause  a  relative  decrease,  while  the  cerebral  depressants  produce 
an  opposite  effect. 


542  HINTS  FOR  THE  INTERPRETATION  OF  URINALYSES. 

The  Sulphates  exist  in  the  urine  as  preformed  and  conjugate  sulphates.  The 
elimination  of  sulphates  depends,  to  a  great  extent,  upon  the  degree  of  albuminous 
decomposition  taking  place  in  the  tissues,  hence,  to  a  certain  extent  on  the  quantity 
of  proteid  material  ingested;  the  degree  of  intestinal  putrefaction  accordingly 
plays  a  part.  An  increased  elimination  is  observed  in  acute  febrile  diseases,  followed 
by  a  decrease  during  convalescence;  in  leukaemia,  diabetes  mellitus,  diabetes  in- 
sipidus, visceral  carcinoma,  in  certain  diseases  of  the  nervous  system,  and  in  some 
skin  diseases,  as  eczema,  an  increased  elimination  is  noted,  while  in  chronic  renal 
diseases  they  are  as  a  rule  decreased. 

The  estimation  of  the  conjugate  sulphates,  and  the  relation  existing  between 
them  and  the  preformed,  are  usually  of  more  importance  than  that  of  the  total 
sulphates;  in  both  cases,  however,  the  information  obtained  from  their  estimation 
is  usually  disappointing.  The  conjugate  sulphates  are  increased  in  all  cases  of  intes- 
tinal putrefaction  and  in  many  cases  of  gastric  disturbances  and  in  obstruction  of 
the  bile  ducts;  while  in  non-obstructive  jaundice  they  are  frequently  decreased.  An 
increase  has  been  noted  in  cases  of  hepatic  cirrhosis  and  carcinoma.  The  conjugate 
sulphates  are  increased  by  the  use  of  drugs  containing  the  aromatic  group,  and  in 
phosphorus  poisoning;  while  the  ingestion  of  the  terpines  and  camphor  causes  a 
diminution.  The  total  sulphates  are  increased  by  morphine,  the  salicylates,  and 
certain  antipyretics;   alcohol  causes  a  slight  diminution  in  the  excretion. 

In  health  the  ratio  between  the  sulphates  and  total  nitrogen  is  surprisingly 
constant;  this  relation  is  disturbed  in  many  morbid  conditions,  but  it  is  disappoint- 
ing to  note  that  our  knowledge  of  the  significance  of  this  disturbed  relation  is 
extremely  limited,  and  it  is  therefore  of  comparatively  little  value  in  diagnosis. 

Of  the  clinical  significance  of  so-called  neutral  sulphur,  which  constitutes  about 
15  per  cent,  of  the  total  sulphur  in  the  urine,  very  little  is  known ;  an  increase  is 
observed  in  biliary  obstruction ;  the  greatest  increase  is  noted  in  the  condition  called 
cystinuria. 

Oxalic  Acid. — The  oxalic  acid  in  the  urine  is  derived  from  two  sources:  the 
greater  portion  from  the  food  ingested;  the  remainder  is  formed  by  some  rather 
obscure  metabolic  process  in  the  tissues.  When  an  excess  of.  oxalates  'is  found  in 
the  urine,  the  diet  of  the  patient  should  be  closely  inquired  into  before  concluding 
that  an  abnormal  oxaluria  exists. 

An  increased  elimination  of  oxalates  is  noted  in  certain  gastro-intestinal  and 
nervous  disorders,  in  some  cases  of  diabetes,  obesity,  and  in  many  cases  of  jaundice. 
The  so-called  oxalic  acid  diathesis,  the  symptoms  of  which  it  has  been  claimed  are 
due  to  the  presence  of  oxalates  in  the  tissues,  is  to-day  looked  upon  by  the  majority 
of  writers  from  a  different  standpoint,  namely,  that  the  excess  of  oxalate  is  due  to 


HINTS  FOR  THE  INTERPRETATION  OF  URINALYSES.  543 

a  faulty  metabolism,  a  disturbance  of  function,  and  to  which  the  symptoms  are 
due,  the  oxalates  being  a  manifestation  of  the  condition  rather  than  the  cause. 

The  Ammonia. — There  is  a  fairly  constant  ratio  existing  between  the  total 
nitrogen  and  the  ammonia  nitrogen  in  a  person  living  under  normal  conditions. 
The  ammonia  nitrogen  factor  is  greatly  increased  in  acute  gastro-enteritis,  and  as  a 
rule  in  hepatic  diseases,  phosphorus  poisoning,  acute  infectious  fevers,  and  fre- 
quently in  diabetes,  but  there  is  a  question  as  to  whether  it  is  of  much  diagnostic 
value. 

Urea  is  undoubtedly  the  most  important  of  the  nitrogenous  urinary  constit- 
uents, notwithstanding  the  statement  of  a  few  writers  who  have  taken  the  stand 
that  the  estimation  of  urea  is  of  comparatively  little  importance.  The  amount 
excreted  in  twenty-four  hours  under  normal  conditions  is  about  30  grams,  mani- 
festly depending  to  a  great  extent  on  the  character  and  amount  of  food  ingested. 
Urea  is  increased  in  acute  febrile  diseases,  many  cases  of  diabetes,  pneumonia,  and 
phosphorus  poisoning.  A  moderate  increase  has  been  observed  in  leukaemia,  scurvy, 
chorea  minor,  and  paralysis;  certain  drugs,  as  coffee,  caffeine,  morphine,  codeine, 
ammonium  chloride,  increase  the  amount  of  urea.  A  marked  diminution  is  found 
in  many  hepatic  diseases,  as  acute  yellow  atrophy,  carcinoma,  Weyl's  disease,  and 
cirrhosis;   also  in  starvation  and  some  renal  diseases. 

In  acute  nephritis  there  is  usually  a  diminished  amount,  due  to  a  retention  of 
urea  in  the  tissues.  In  the  early  stages  of  chronic  parenchymatous  nephritis  the 
urea  may  or  may  not  be  lessened ;  in  the  later  stages  the  urea  is  greatly  diminished 
in  amount. 

Simon  says:  "Whenever  there  is  disease  affecting  that  portion  of  the  renal 
parenchyma  which  is  concerned  especially  in  the  elimination  of  urea,  a  diminished 
amount  will,  of  course,  be  met  with,  and  carefully  conducted  observations  upon  the 
excretion  of  the  various  urinary  constituents  are  here  of  considerable  value  from 
a  diagnostic  as  well  as  a  therapeutic  standpoint.  As  the  glomeruli  of  the  kidneys 
are  mainly  concerned  in  the  elimination  of  water  and  salts  from  the  blood,  and  as 
the  striated  epithelium  of  the  convoluted  tubules  appears  to  provide  for  the  excretion 
of  urea,  the  elimination  of  a  fair  amount  of  the  bitter  with  a  diminished  elimination 
of  salts,  the  phosphates  being  of  special  interest,  as  they  are  derived  to  a  large  extent 
from  albuminous  material,  would  point  more  particularly  to  glomerular  disease. 
On  the  other  hand,  a  fair  excretion  of  phosphates  and  a  diminished  excretion  of 
urea  would  be  indicative  of  tubular  disease.  Whenever  glomeruli  and  tubuli  con- 
torti  are  equally  diseased,  an  insufficient  elimination  of  both  phosphates  and  urea  will 
be  observed." 

A  diminished  excretion  of  urea  is  noted  in  many  cases  of  melancholia  and 
general  paresis,  after  epileptic,  cataleptic,  and  hysterical  convulsions;    the  dimin- 


544  HINTS  FOR  THE  INTERPRETATION  OF  URINALYSES. 

ished  excretion  noted  in  Addison's  disease  is  by  some  authors  attributed  to  nervous 
disturbances.  A  decrease  is  found  in  chronic  anaemias,  chronic  rheumatism,  osteo- 
malacia, and  certain  skin  diseases,  and  in  chronic  lead  poisoning. 

Uric  acid,  depending  to  a  great  extent  on  diet,  exercise,  etc.,  is  normally  elimi- 
nated daily  in  amounts  varying  from  0.5  to  1.5  grams.  An  increase  is  found  during 
the  acute  symptoms  in  gout;  after  the  symptoms  subside  the  elimination  will 
quickly  drop,  frequently  so  low  that  tests  will  reveal  but  a  faint  trace,  and  will 
remain  low  until  the  acute  stage  again  becomes  manifest,  when  it  will  steadily 
rise.  The  greatest  increase  is  found  in  leukaemia ;  a  considerable  increase  is  noted 
in  the  diseases  associated  with  a  marked  leucocytosis,  as  erysipelas  and  pneumonia ; 
in  other  febrile  diseases  an  increase  is  less  marked.  In  acute  articular  rheumatim 
it  is  increased  during  the  febrile  period,  as  the  temperature  falls,  and  during  con- 
valescence the  elimination  decreases  and  falls  to,  or  even  below,  normal.  It  is 
usually  diminished  in  diabetes ;  in  some  cases  we  will  find,  with  a  diminution  in  the 
amount  of  sugar,  an  increase  in  the  elimination  of  uric  acid.  In  the  ordinary  form 
of  anaemia  and  chlorosis  the  amount  is  quite  constantly  diminished.  A  decrease  is 
also  noted  in  chronic  interstitial  nephritis,  and  chronic  lead  poisoning. 

The  Xanthin  or  Putin  Bases  have,  in  the  past  ten  years,  been  the  subject  of  a 
great  deal  of  discussion;  normally,  they  are  present  in  very  small  amounts;  patho- 
logically, they  may  be  said  to  increase  or  decrease  with  the  uric  acid;  this  while 
the  rule  is  not  invariably  the  case.  Our  knowledge  of  the  value  of  the  estimation 
of  these  bodies  for  diagnostic  purposes  is  as  yet  extremely  limited. 

Hippuric  acid  is  found  in  normal  urine  in  small  amounts,  0.1  to  1  gram  being 
excreted  in  twenty-four  hours.  It  is  increased  by  the  use  of  certain  drug.-,  notably 
the  benzoates.  It  is  diminished  or  totally  disappears  in  acute  and  chronic  nephritis, 
and  in  amyloid  diseases  of  the  kidney.  It  is  frequently  greatly  increased  in  acute 
febrile  diseases,  hepatic  diseases,  diabetes  mellitus,  chorea,  etc. 

Kreatinin  is  a  normal  constituent  of  the  urine,  and  while  a  great  deal  has  been 
said  regarding  its  pathological  significance,  we  must  admit  that  very  little  of  value 
has  been  demonstrated. 

The  total  nitrogen  excretion  has  within  the  past  few  years  become  what  bids 
fair  to  be  an  important  factor  in  urinary  diagnosis,  but  at  present  the  practitioner 
gains  from  it  but  few  facts  of  diagnostic  value.  An  increase  in  the  excretion,  i.e., 
a  diminution  of  the  nitrogen  contained  in  the  organism,  is  seen  in  diseases  accom- 
panied by  marked  malnutrition,  and  is  noted  in  sepsis  and  other  forms  of  infection, 
including  many  of  the  infectious  diseases;  an  important  factor  in  the  increase  being 
the  action  of  bacteria  or  their  toxic  products  in  the  breaking  down  of  proteid.  A 
similar  condition  is  seen  in  patients  suffering  from  carcinoma  and  other  malignant 
growths,  pernicious  anamiia,  chronic  infectious  diseases,  including  tuberculosis,  in 


LESSONS  IN  PHYSIOLOGY  FROM  SURGERY.  545 

the  leukaemias,  phosphorus  poisoning,  exophthalmic  goiter.  An  increase  is  noted 
in  nephritis  with  a  high  degree  of  albuminuria,  this  manifestly  being  due  to  the 
nitrogen  content  of  the  albumin  ;  large  quantities  are  excreted  during  the  resorp- 
tion of  an  exudate. 

A  diminution  is  noted  in  convalescents,  owing  to  the  fact  that  the  nitrogen  of 
the  food  is  being  used  for  tissue  repair. 

In  nephritis,  especially  in  the  last  stages  of  the  chronic  diffuse  form,  a  con- 
siderable decrease  in  elimination  occurs;  frequently  a  marked  increase  will  be 
found  in  the  nitrogen  of  the  faoces  in  these  cases. 

Nathaniel  Gildeksleeve.* 

(To  be  concluded  in  next  issue.) 


LESSONS  IN  PHYSIOLOGY  FROM  SURGERY. 

No  reasonable  dissent  can  be  made  from  the  assumption  that  the  medical 
profession  most  needs  light  on  the  subject  of  physiology.  Clinicians  are  perpetually 
confronted  with  the  phrase,  in  numberless  variants,  in  text-books  and  other  litera- 
ture, "on  this  fundamental  question  we  know  practically  nothing/'  or  "if  we  could 
know  accurately  the  action  of  such  and  such  a  group  of  phenomena  we  could  explain 
the  rationale  of  those  under  discussion"  or  "until  we  have  information  on  the 
physiology  of  so  and  so,  we  can  only  conjecture,"  etc. 

Yet,  notwithstanding  the  mass  of  data  collected  by  those  exceedingly  per- 
sistent, acutely  observant,  highly  specialized  workers  in  lines  of  pure  physiology, 
there  remains  conspicuous  gaps  in  our  knowledge  of  subjects  whereon  we  must  have 
information,  otherwise  we  cannot  comprehend  many  of  our  most  important  clinical 
problems.  When  we  are  supplied  with  practical  manuals  on  "Clinical  Physiology," 
divested  of  the  confusing  conjectural  data  which,  mar  the  best  text-hooks  and  mono- 
graphs on  physiology,  providing  elucidation  of  much  now  unknown,  the  general 
practitioner  can  proceed  to  reason  upon  the  phenomena  of  his  cases  and  apply  the 
logic  of  cause  to  effect,  to  outline,  and  apply  indications  for  treatment,  to  estimate 
relative  etiology  and  forecast  results. 

At  present  he  must  be  content  to  accept  the  reasoning  of  master  minds  ai 
second-hand,  and  these  are  only  too  often  nullified  by  contrary  opinions,  positive 
or  tentative  data  which  are  often  either  actually  conflicting  or  apparently  so  because 
of  diversities  in  the  points  of  view.  At  all  events  lie  is  cripplied  in  his  best  en- 
deavors to  obey  the  mandates  freely  expressed  by  "authorities"  to  avoid  empiricism  ; 
to  act  on  "rational"  or  "physiologic"  lines. 


First  Assistant  in  Bacteriology,  Hygiene  Department,  University  of  Pennsylvania. 


546  LESSONS  IN  PHYSIOLOGY  FROM  SURGERY. 

Worst  of  all,  our  undergraduates,  certainly  in  some  schools,  are  taking  less  and 
less  interest  in  physiology  except  to  "pass."  They  freely  assert  that  they  do  not  see 
much  utility  in  the  subject  of  physiology,  nor  are  they  to  be  altogether  blamed,  as 
the  subject  is  now  taught.  It  may  be  well  taught,  somewhere,  but  it  is  not  usually 
presented  in  such  guise  as  to  furnish  the  aid  it  must  of  necessity  do,  if  we  are  to 
unravel  successfully  the  mysteries  of  human  ailments.  These  mysteries  are,  many 
of  them,  just  as  profound  as  a  century  or  two  ago,  and  others  are  opening  up  vistas 
just  as  discouraging  as  ever,  especially  as  we  know  enough  to  realize  our  need  to 
know  with  exactitude  so  much  more. 

The  reason  for  much  of  this  difficulty  lies  in  the  fact  that  few,  almost  none,  of 
our  professors  of  physiology,  are  trained  clinicians.  They  are,  as  a  rule,  biologists, 
and  achieve  an  M.D.  only  for  the  purpose  of  satisfying  technical  demands.  Nor 
will  this  deficit  be  met  till  the  practical  branches  are  presented  only  by  clinicians 
who  are  also  trained  physiologists.  It  is  only  too  plain  that  many  of  our 
clinical  teachers  are  unfamiliar  with  the  elemental  principles  of  modern  physiology. 
Hence  it  follows  that  the  public  perceives  that  the  most  obvious  tangible  advances 
in  our  professional  knowledge  are  accomplished  by  the  surgeons.  Not  only  are 
their  problems  more  concrete  and  definite,  but  they  have  been  studied  with  a  mixture 
of  sound  common  sense,  practical  experience,  logical  steps  compounded  of  carefully 
compared  and  sifted  empirical  findings,  but  they  adopt  judiciously,  in  addition  to 
their  anatomical  mechanics,  whatever  of  bio-chemistry,  physics,  pathology,  and 
therapeutics  the  whole  realm  of  scientific  medicine  is  able  to  afford  them. 

Clinicians  have  made  many  contributions  to  physiology  which,  as  S.  J.  Meltzer 
says,  physiologists  are  over-slow  to  avail  themselves.  Again,  in  the  debatable  ground 
between  normal  and  morbid  functional  phenomena,  "physiology  has  set  up  some 
laws,  but  if  conditions  appear  which  do  not  fit  in  with  these  laws,  physiology  declines 
to  deal  with  them;  it  refers  you  to  medicine." 

"The  laws  which  physiology  establishes  must  be  capable  of  covering  the  func- 
tional phenomena  in  all  conditions  of  life,  normal  and  morbid.  Nature  makes 
daily  thousands  of  experiments  upon  man  and  beast,  and  physiology  refuses  to 
utilize  them  for  its  own  elucidation." 

Furthermore,  the  research  workers  in  medicine  receive  their  training  in  a 
science  made  up  largely  of  morphology,  hence  their  contributions  to  medical  science 
are  essentially  of  a  morphologic  character.  What  we  need  most  is  a  study  of  phys- 
iology under  morbid  conditions.  "Diseases  which  are  exclusively  due  to  palpable 
anatomic  changes  are  quite  well  understood.  Their  harmful  effects  are,  for  the 
most  part  of  a  mechanical  nature.  In  proportion  as  they  are  understood,  these 
forms  of  disease  become  amenable  to  efficient  treatment;  it  is  mechanical,  it  is 
surgery."     (S.  J.  Meltzer.) 


LESSONS  IN  PHYSIOLOGY  FROM  SURGERY.  547 

It  is  only  fair  to  surgeons  to  call  attention  to  the  contributions  they  have  al- 
ready made  to  a  knowledge  of  pure  function  along  with  an  enormous  aggregation 
of  isolated  facts  of  peculiarities,  deviations,  adaptations.  The  surgeon,  more  than 
any  one,  enjoys  opportunities  of  noting  the  actions  and  appearances  of  living  tis- 
sues beneath  their  enveloping  structures.  This  privilege  is  peculiarly  valuable 
when  the  brain,  blood-vessels,  or  viscera  are  laid  bare.  Much  could  be  learned  by 
those  physiologists  who  would  carefully  scrutinize  the  writings  of  acutely  observing 
surgeons,  and  correlate  the  facts  and  conclusions;  but  obviously  no  adequate  use 
has  yet  been  made  of  the  recorded  material.  It  is  the  purpose  of  this  brief  com- 
munication to  ask  attention  to  a  vast  realm  of  possibilities  afforded  by  what  already 
exists,  and  to  emphatically  petition  that  a  systematic  use  shall  be  made  of  these 
daily  recurring  opportunities. 

Specialization  has  become  so  highly  differentiated,  the  literature  of  medicine 
has  grown  so  great,  writing  on  the  practical  branches  is  limited  to  such  well-defined 
fields  that  relatively  little  use  is  made  of  many  collateral  and  even  direct  means  of 
learning  life's  secrets.  Secrets  these  vital  processes  are;  physiology  at  present  is  in 
places  provokingly  inadequate.  We  do  not  begin  to  know  as  yet  many  of  those  facts 
which  are  most  essential  to  an  understanding  of  normal  physiology,  and  our  data  on 
morbid  physiology  is  still  chiefly  inferential.  Many  of  the  most  important  working 
axioms  of  clinical  physiology  are  the  products  of  intelligent  deduction  from  phe- 
nomena occurring  in  sick  people.  To  be  sure,  priceless  data  have  come  to  us  through 
experimentation  on  the  lower  animals,  but  none  of  these  is  comparable  to  obser- 
vations made  on  man  for  the  purposes  of  elucidating  problems  in  clinical    medicine. 

It  is  not  permissible  to  actually  experiment  on  human  beings,  at  least  in  such 
a  way  as  shall  involve  exposing  the  subject  to  pain  and  peril  of  serious  injury. 
Nevertheless  it  is  only  through,  and  by,  observations  on  the  workings  of  the  human 
mechanism  that  we  can  learn  the  normal  actions  and  the  delicate  degrees  or  variants 
from  the  strictly  normal  so  essential  in  achieving  knowledge  of  means  to  control, 
to  check  or  repair,  the  effects  of  morbific  damaging  agencies. 

Since  we  are  inhibited  from  utilizing  the  bodies  of  human  beings  in  pursuing 
those  researches  which,  by  common  consent,  are  absolutely  essential  to  a  right  under- 
standing of  the  processes,  sequences,  and  signficance  of  cellular  activities  and  their 
variants,  we  must  seize  upon  whatever  occasions  offer.  Among  the  richest  are  the 
manipulations  of  the  surgeon,  particularly  when  the  knife  has  opened  the  enveloping 
structures  and  permitted  a  view  of  actions  of  those  structures  which  are  thus  exposed 
to  eye  or  touch. 

Nor  does  the  matter  end  here.  The  phenomena  of  readjustment  present  end- 
less important  facts  other  than  the  mere  accomplishment  of  the  surgical  purpose. 
It  is  a  research  in  itself,  worthy  of  a  large  monograph  or  perhaps  a  treatise,  to 


548  LESSONS  IN  PHYSIOLOGY  FROM  SURGERY. 

note  and  compare  the  findings  in  patients  some  years  after  they  have  suffered  sur- 
gical loss,  in  part  or  the  whole,  of  vital  organs. 

Surgery  has  attained  such  perfection  in  methods  and  results,  that  the  tempta- 
tion is  great  to  remove  tissue,  even  organs,  with  perfect  safety  as  to  immediate 
results.  We  ought  to  know  what  effects  are  induced  years  hence,  on  structure, 
function,  circulation,  condition  of  the  vessels,  etc.  The  apparent  gain  may  be 
outweighed  later  by  greater  ultimate  harm.  However,  this  brief  communication 
can  do  no  more  than  call  attention  to  the  vitally  important  subject;  to  beg  that 
surgeons  shall  recognize  that  in  the  course  of  their  daily  work  it  is  within  their 
power  to  gather,  observe,  and  record  phenomena  which,  when  judiciously  collated 
and  interpreted,  will  constitute  a  fund  of  information  which  may  place  them  at 
the  head  of  the  contributors  to  the  secrets  of  life,  to  arm  the  conservators  of  health 
so  efficiently  that  a  large  gain  shall  be  made  in  our  control  over  those  destructive 
influences  which  perpetually  assail  us. 

Not  being  myself  a  surgeon  I  can  only  indicate  a  few  of  the  departments  of 
medical  knowledge  which  have  already  been  conspicuously  illumined  by  the  re- 
searches of  surgeons,  having  in  mind  especially  the  physiologic  facts  presented. 

Brain:  motor  functions,  circulation,  absence  of  motor  phenomena  in  the 
so-called  intellectual  areas. 

Spinal  cord:  many  opinions  regarded  as  settled  changed  radically,  e.g.,  the 
entire  cord  severed  completely  can  yet  be  repaired  (F.  T.  Stewart),  infantile  and 
other  palsies  relieved  by  nerve  grafting,  hence  restoring  connection  with  unimpaired 
motor  centers;   organs  can  be  transplanted:    kidneys,  thyroid,  spleen,  etc. 

Lymphatic  channels  and  their  connections:  facts  have  been  elicited  which  could 
be  learned  in  no  other  way,  most  important  as  throwing  light  on  infections  and 
repair. 

The  great  organs — stomach  :  it  has  been  shown  that  the  removal  of  the  stomach 
induces  relatively  little  disturbance,  also  portions  of  the  intestines,  especially  the 
lower  part  may  be  excised  and  little  derangement  of  nutrition  follow.  Surgeons 
enunciate  the  principle,  practically  the  axiom,  that  when  in  doubt  as  to  a  disorder 
promising  to  be  more  than  trivial,  a  functional  disturbance,  at  once  exploratory 
incision  is  demanded  in  (1)  the  stomach,  duodenum,  etc.,  (2)  gall-bladder,  (3) 
appendix  vermiformis.  The  functions  of  the  gall-bladder  are  made  more  clear  by 
the  surgeons  than  by  all  the  physiologists;  the  amount  of  bile  secreted,  etc.  Gall- 
stones unsuspected  are  commonly  found  in  the  gall-bladder;  the  presence  of  these 
goes  far  toward  causing  cancer  of  the  liver.  Cancers  in  the  liver  or  stomach  are 
largely  due  to  the  effects  of  gastric  ulcers.  The  pancreas  and  its  infections  are 
shown  by  surgeons  to  be  often  secondary  to  inflammations  of  the  gall-bladder. 


ABDOMEN,  NEW  METHOD  OE  EXPLORING  THE. 


549 


The  kidneys  can  be  removed,  opened,  and  transplanted,  all  which  opens  up  vast 
physiologic  problems. 

The  heart  can  be  handled,  operated  on,  massaged  to  restore  its  beat  in  such  a 
fashion  as  would  have  been  denied  as  possible  by  the  physiologists  of  a  short  time  ago. 

A.  Charrin  (Sem.  Med.  xxv,  Feb.  8,  1905)  has  reviewed  the  information 
learned  of  late  in  regard  to  the  functions  of  the  omentum,  spleen,  ovaries,  and  other 
organs  by  surgeons,  pointing  out  that  their  removal  is  by  no  means  such  a  simple, 
harmless  matter  as  lias  hitherto  been  supposed.  The  cutting  off  of  the  secretions 
of  certain  of  the  great  organs  may,  and  undoubtedly  does,  produce  profound  alter- 
ations in  the  metabolic  status. 

.).   Madison   Taylor.* 


Cyclopaedia  of  Current  literature. 


ABDOMEN,     NEW    METHOD    OF    EXPLOR- 
ING  THE. 

The  value  of  the  various  methods  now 
in  use  of  exploring  the  abdomen  are 
pointed  out  by  the  writer,  and  attention 
is  called  to  a  new  one  devised  by  him- 
self. Through  the  incision  for  exposing 
the  gall-bladder  and  ducts  it  is  his  prac- 
tice to  see  and  feel  all  he  can  within  a 
reasonable  radius.  It  is  not  uncommon 
that  appendicectoiny  can  be  performed 
through  this  incision  without  even  ex- 
lending  it  downward.  In  one  instance 
he  removed  a  stone  in  the  right  kidney 
through  this  incision.  On  the  other 
hand,  the  bile  ducts  may  be  explored 
through  the  incision  usually  made  to 
reach  the  kidney.  This  is  done  by  mak- 
ing an  incision  through  the  peritoneum 
in  front  of  the  kidney,  reaching  inward 
to  the  gall-bladder,  discovering  gall- 
stones, and  removing  them  through  a 
buttonhole  incision  made  over  the  fun- 
dus of  the  gall-bladder  as  it  is  held  by 
the  exploring  hand  against  the  anterior 
abdominal  wall.     lie  has  also  removed 


the  appendix  through  the  lumbar  incis- 
ion for  kidney  work.  Through  an  en- 
larged gridiron  incision  for  appendi- 
citis he  has  often  removed  small  fibroids, 
shortened  ovarian  ligaments,  bisected 
ovaries,  and  he  has  performed  anterior 
transplantation  of  the  round  ligaments, 
salpingostomy,  and  hystero-salpingos- 
tomy  before  or  after  removing  the  ap- 
pendix. In  cases  presenting  the  clinical 
evidences  of  both  appendicitis  and  gall- 
stones, he  makes  a  "compromise  incis- 
ion" through  the  right  rectus  muscle 
opposite  the  umbilicus,  of  sufficient 
length  to  admit  the  hand,  which  easily 
reaches  the  gall-bladder  and  appendix 
respectively,  and,  if  need  he.  the  other 
organs  within  1  lie  abdomen. 

In  certain  cases  an  examination  of 
the  abdominal  organs  would  he  highly 
satisfactory,  although  often  the  operator 
does  not  feel  justified  in  opening  through 
the  abdominal  wall  for  that  purpose. 
The  problem  is  solved  in  passing  the  hand 
and  entire  forearm  into  the  abdominal 
cavity  through  the  vagina.     In  order  to 


•Physician  to  llio  Philadelphia   Hospital,  etc. 


550     ANAEMIA,  DIAGNOSIS  AND  TREATMENT. 


ASTHMA,  FOOD  FACTOR   IN. 


furnish  enough  space  for  this  purpose, 
it  is  imperative  to  cut  through  the  mu- 
cous membrane  of  the  vagina  its  whole 
length  on  each  side  postero-laterally. 
The  mucous  membrane  being  severed;, 
the  other  structures  stretch  at  once.  The 
bare  arm  being  smeared  over  with  sterile 
vaseline,  glides  in  with  ease.  A  number 
of  instances  are  cited  in  which  this 
method  of  examination  proved  exceed- 
ingly useful.  A.  H.  Ferguson  (New 
York  Medical  Journal  and  Philadelphia 
Medical  Journal,  November  4,  1905). 

ANiEMIA,    DIAGNOSIS    AND    TREATMENT 
OF. 

Anaemia  is  defined  by  the  writer  as  a 
condition  of  the  blood  characterized  by 
deficiency  in  the  total  or  relative  amount 
of  haemoglobin,  or  it  may  be  a  condition 
of  the  body  resulting  from  an  insufficient 
absorption  from  the  blood  of  nourish- 
ment for  the  proper  support  and  oxy- 
genation of.  the  body  tissues.  Accepting 
this  imperfect  definition  as  a  basis,  it 
appears  that  there  are  cases  in  which  no 
discoverable  defect  in  the  blood  can  be 
found,  but  in  which  the  disease  seems  to 
be  localized  in  the  inability  of  the  tissues 
to  properly  absorb  the  substances  con- 
tained in  the  blood.  Of  course  this 
definition  is  subject  to  the  greatest  mod- 
ification and  correction,  for,  as  yet,  but 
very  little  is  known  of  the  obviously  im- 
portant chemistry  of  the  blood,  and  what 
may  now  be  considered  a  normal  blood 
may  be  deficient  in  the  most  important 
of  chemical  requisites.  Study  of  the 
blood  and  of  the  patient  cannot  fail, 
however,  to  demonstrate  in  a  large  num- 
ber of  cases  the  inadequacy  of  the  usual 
condition,  of  deficiency  in  corpuscular 
elements  and  haemoglobin  only.  There 
can  be  no  question  but  that  certain  in- 
dividuals roqnire  less  corpuscles  and  less 
haemoglobin    than    others    of    the    same 


body  weight,  just  as  some  persons  thrive 
best  on  what  would  be  a  very  insufficient 
diet  for  others.  The  important  point 
which  the  writer  wishes  to  make  here  is 
that  we  must  not  judge  entirely  of  the 
presence  or  absence  of  anaemia  by  the 
volume  and  condition  of  the  blood  alone, 
but  also  by  the  function  of  the  tissues 
which  are  dependent  on  the  blood  for 
their  well-being.  Thus  85  per  cent,  of 
haemoglobin,  with  4,000,000  red  corpus- 
cles, may  be  normal  for  one  individual 
in  apparently  perfect  health,  and  yet 
another  person  of  the  same  body  weight 
with  this  condition  may  suffer  to  a  con- 
siderable degree  from  anaemia.  Harlow 
Brooks  (Medical  News,  October  21, 
1905). 

ASTHMA,  THE  FOOD  FACTOR  IN. 

Hyperpyraemia,  that  is,  accumulation 
of  unoxidized  carbonaceous  material  in 
the  blood  beyond  the  capacity  of  the 
physiological  decarbonizing  processes,  is 
an  essential  factor  in  some  cases  of 
asthma ;  and  in  such  the  recurrent  asth- 
matic paroxysms  may  be  regarded  as 
ultraphysiological,  that  is,  pathological 
reinforcements  of  inadequate  physiolog- 
ical decarbonization.  But  even  so,  hy- 
perpyraemia is  only  one  of  many  factors 
in  asthma.  For  example,  the  asthmatic 
paroxysm  depends  upon  the  vasomotor 
response  to  hyperpyraemia;  and  this  re- 
sponsiveness of  the  vasomotor  system 
may  be  vastly  increased  by  numerous 
factors.  When  this  is  so,  the  vasomotor 
responsiveness  (irritability)  becomes  a 
much  more  important  factor  in  deter- 
mining .paroxysms,  and  consequently 
calls  more  urgently  for  therapeutic  at- 
tack than  the  food  factor.  And  there 
are  many  other  factors  to  be  considered. 
Hence  it  must  not  be  inferred  that 
asthma  can  always  be  successfully 
treated  by  diet  of  any  kind.     Neverthe- 


ATONY  OF  THE  RECTUM  AND  COLON. 


551 


less,  the  food  factor  is  usually,  if  not 
always,  present,  and  its  due  recognition 
will  often  make  the  difference  between 
successful  and  unsuccessful  therapeutics. 
For  those  who  are  inclined  to  make  a 
trial  of  the  treatment  by  restriction  of 
the  carbonaceous  intake,  the  author 
would  suggest  that  commencement  be 
made  with  asthmatics  with  a  tendency 
to  corpulency.  Indeed  in  such  success 
is  much  more  easily  and  rapidly  at- 
tained. Francis  Hare  (JSTew  York  Med- 
ical Journal  and  Philadelphia  Medical 
Journal,  September  23,  1905). 

ATONY   OF   THE   RECTUM   AND    COLON. 

Atony  of  the  intestine  is  a  failure  of 
the  normal  function  of  the  muscle  coat. 
The  principal  cause  of  normal  peristalsis 
is  the  distention  produced  by  the  bowel 
content,  whether  that  be  fasces,  or  un- 
digested food,  water,  gas,  or  air.  Ex- 
cessive or  prolonged  distention  will  re- 
sult in  exhaustion  or  fatigue  of  the  mus- 
cle coat  of  the  muscle  wall.  In  experi- 
ments on  dogs,  prolonged  and  intermit- 
tent distention  of  the  intestine  with  air 
results  in  the  production  of  a  toxin  of 
fatigue,  which  produces  atony  and  dila- 
tation. Antitoxins  generated  by  fatigue 
toxins  are  obtained  which  neutralize  the 
action  of  the  fatigue  toxins,  which  nor- 
mally occurs  during  the  period  of  rest. 
Toxins  of  fatigue  are  not  dialyzable, 
and  remain  where  formed.  Rubbing, 
massage,  or  gentle  exercise  hastens  the 
union  of  the  antitoxin  with  the  toxin, 
resulting  in  recovery  from  fatigue. 

The  site  of  atony  of  hollow  viscera  is 
usually  found  in  those  organs  used  ns 
reservoirs,  such  as  stomach,  colon,  etc., 
because  fatigue  more  readily  occurs 
where  the  work  is  more  apt  to  be  in  dis- 
proportionate excess  to  the  rest  period. 
The  abdominal  circulation  is  an  impor- 
tant factor  in  relation  to  atony  of  the 


intestine.  Venous  blood  predisposes  to 
fatigue.  The  indications  for  treatment 
of  atony  are  therefore :  (a)  The  restora- 
tion of  the  chronic  fatigue  atony;  (b) 
restoration  of  the  congested  vessels. 
Diagnosis,  in  connection  with  history 
and  symptoms,  can  be  made  accurate  by 
examination  of  faeces  observed  during 
colonic  lavage,  and  the  reaction  of  the 
colon  to  distention. 

Drugs  are  useless  as  a  cure;  they  aid 
certain  symptoms,  but  ultimately  in- 
crease the  fatigue  of  the  colon.  Surgery 
does  not  correct  the  atony  of  the  wall, 
though  obstructions  by  tumors,  etc., 
must  be  removed  surgically.  Treatment 
by  general  gymnastics  is  only  indirectly 
helpful.  They  may  lengthen  the  ab- 
dominal muscle,  but  do  not  increase 
peristalsis,  or  correct  the  atony  of  the 
intestinal  wall.  All  methods  of  treat- 
ment usually  resolve  themselves  into 
some  form  of  mechanical  treatment.  In 
dietetics,  coarse-grained  food;  cathar- 
tics producing  excessive  fluids.  Drink- 
ing large  quantities  of  water;  gymnas- 
tics ;   exercises. 

Enemas  of  water  are  useful  for  the 
purpose  of  cleansing  out  the  colon,  as 
they  excite  peristalsis  by  distending  the 
colon,  but  do  not  correct  the  atony,  on 
account  of  the  resulting  fatigue.  They 
rather  tend  to  create  the  enema  habit, 
and  increase  the  atony.  Colonic  lavage 
with  temperature,  as  described  by  the 
author,  is  useful.  Injection  of  air  di- 
rectly is  helpful,  but  in  atonic  colicky 
condition  retention  of  air  follows,  and 
may  result  in  increased  fatigue  or  atony. 
This  is,  however,  a  useful  method  it' 
the  air  is  removed  through  the  tube  by 
pressure  and  massage  upon  the  abdo- 
men. By  confining  the  air  in  the  bag. 
and  the  rubber  bag  in  the  bowel,  the  de- 
gree of  exercise  by  distention  is  under 
the  direct  control  of  the  operator.     In- 


552 


BERIBERI. 


BLOOD  COAGULABILITY. 


termitteiit  distention  of  the  bags  in  the 
rectum  or  colon  for  a  short  period  gives 
sufficient  exercise  and  massage  of  the 
muscle  wall  to  gradually  restore  the 
atony  and  fatigue  of  the  muscle  to  a  con- 
dition of  normal  peristalsis.  If  the 
colon  is  partly  distended  with  air,  then 
the  rubber  bag  inserted  into  the  rectum 
or  sigmoid,  with  intermittent  compres- 
sion of  the  Politzer  bag,  causes  vibration 
of  the  air  in  the  entire  colon  to  the  rec- 
tum. The  massage  effect  gives  a  valu- 
able mode  of  treating  various  patholog- 
ical conditions  of  the  rectal  mucosa — 
haemorrhoids,  ulcers,  proctitis,  etc.  It 
is  useful  in  prolapse  of  the  bowel ;  asso- 
ciated pathological  condition  of  the  pel- 
vic viscera ;  in  certain  diseases  of  the 
uterus  and  appendages,  in  the  female; 
and  prostate,  in  the  male.  The  results 
have  shown  the  restoration  to  be  perma- 
nent. F.  B.  Turck  (Medical  Eecord, 
October  7,  1905). 

BERIBERI. 

Beriberi  is  an  acute  or  subacute  in- 
fectious disease  of  short  incubation  pe- 
riod, due  to  a  specific  micro-organism 
not  yet  isolated.  This  specific  organism 
is  not  one  whose  special  habitat  is  a  par- 
ticular food,  such  as  rice  or  fish,  but 
one  that  may  nevertheless  be  ingested 
with  any  food  or  drink  accidentally 
contaminated.  This  organism,  having 
gained  entrance  to  the  alimentary  canal. 
multiplies  in  the  contents  and  mucosa 
of  the  stomach  and  small  gut.  but  chiefly 
in  the  contents  and  mucosa  of  the  py- 
lorus and  duodenum.  It  there  elabo- 
rates an  extracellular  toxin,  which,  being 
immediately  absorbed,  poisons  the  pe- 
ripheral terminations  of,  first,  the  vagi 
to  the  stomach  and  heart,  and  then  other 
efferent,  afferent,  and  autonomic  neu- 
rones to  different  extents  and  degrees. 
giving  rise  in  groups  of  symptoms  which 


may  be  broadly  classified  as  acute  perni- 
cious, acute,  and  subacute  beriberi. 
These  cases  run  a  definite  course  of 
about  five  or  six  weeks,  and  on  the  elim- 
ination of  the  causal  organism  and  its 
toxin  the  poisoned  neurones  recover  and 
the  patient  recovers,  or  the  poisoned  neu- 
rones only  partially  recover,  and  there 
develops  in  those  of  them  which  mi- 
grate centralward.  For  this  persistent 
atrophy,  and  the  various  paralyses, 
atrophic  disturbances,  and  oedema  which 
result,  the  author  proposes  the  term 
"beriberi  residual  paralysis." 

The  factor  of  diet  cannot  be  ignored 
in  beriberi.  Grave  suspicion  is  attached 
to  the  practically  constant  presence  in 
mouldy  rice  of  a  certain  small  weevil 
(calandra  olyzge).  The  incidence  of 
beriberi  is  distinctly  heavier  in  those 
tropical  or  subtropical  countries  which 
import  rice  than  in  those  which  supply 
sufficient  on  the  spot  to  meet  all  local 
demands.  Naturally  in  the  former  the 
opportunity  for  degeneration  in  trans- 
port is  greater.  Fungoid  or  moldlike 
growths,  similar  to  those  of  rice,  have 
been  observed  on  maize  and  dried  fish — 
so  that  these  articles  of  diet  could  also 
carry  the  disease.  H.  Wright,  C.  Hose, 
V.  W.  Mott  (British  Medical' Journal, 
October  28,  1905). 

BLOOD    COAGULABILITY. 

By  testing  the  coagulation  time  of  the 
blood,  the  authors  have  determined  the 
effect  produced  by  various  calcium  salts 
and  cows'  milk.  Their  investigations 
show  that  the  coagulability  of  the  blood 
is  increased  by  the  ingestion  of  milk, 
and  this  effect  is  associated  with  the 
presence  of  large  quantities  of  calcium 
and  magnesium  salts  in  the  blood.  It 
follows  that  milk  is  much  more  than  a 
food-stuff,  it  being  "also  a  medicinal 
agent,  and  as  such  may  be  either  preju- 


CATARACT,  [MMATUB.E. 


553 


dicial  or  beneficial.  For  instance,  milk 
may  be  given  with  advantage  in  cases  of 
haemorrhage,  aneurism,  physiological  al- 
buminuria, and  the  oedema  of  Bright's 
disease.  But  every  adult  patient  placed 
on  a  dietary  of  milk  is  thereby  brought 
into  a  condition  which  predisposes  to 
thrombosis.  Typhoid  fever  is  an  exam- 
ple of  a  disease  in  which  milk  diet  is 
commonly  prescribed,  and  in  which 
thrombosis  frequently  occurs. 

A  rapid  increase  of  blood  coagulabil- 
ity such  as  is  desired  for  the  arrest  of 
actual  or  serious  haemorrhage  can.  un- 
less a  person  whose  power  of  absorbing- 
calcium  salts  is  deficient  is  dealt  with, 
be  achieved  by  the  administration  of 
a  single  GO-grain  dose  of  either  cal- 
cium lactate  or  calcium  chloride.  Suc- 
cess in  maintaining  the  blood  coagu- 
lability at  a  high  level  involves  adjusting 
successive  doses  of  calcium  salts  in  such 
a  manner  as  to  avoid  introducing  into 
the  blood  such  excess  of  these  salts  as 
would  effect  a  retardation  of  the  coagu- 
lation time.  Where  calcium  salts  are 
not  absorbed  when  given  by  the  mouth 
they  may  be  given  hypodermically.  For 
such  use  the  maximum  concentration  of 
the  salt  should  be  a  1  in  20  solution.  It 
is  possible  to  decalcify  the  blood  and 
diminish  blood  coagulability  by  the  ad- 
ministration of  citric  acid.  But  such 
decalcification  is  followed  after  a  time 
by  an  increase  in  (lie  calcium  sail-  of  the 
blood.  A.  F.  Wright  and  W.  F.  Para- 
more  (Lancet,  October  14,  1905). 

CATARACT.   IMMATURE. 

The  principal  objection  to  the  extrac- 
tion of  immature  cataracl  lias  been  that, 

in  1 1  io  attempt  to  remove  a  leu-  qoI  en- 
tirely opaque  more  or  less  of  the  cortex 
remain-,  which  adheres  io  the  capsule 
and  is  difficult,  if  not  impossible,  to  re- 
move   without    subjecting    the    eye    to 


trauma,  which  later  gives  rise  to  inflam- 
matory reaction  and  jeopardizes  the 
function  of  the  eye.  and  if  allowed  to 
remain  will  either  produce  secondary 
cataract,  with  attending  impairment  of 
vision,  or  inflammatory  reaction,  with 
danger  of  damage  to  the  function  of  the 
eye.  or  both.  In  considering  the  advis- 
ability of  attempting  extraction  the  fac- 
tors to  be  considered  are :  the  state  of 
vision  in  the  fellow  eye;  how  rapidly 
the  cataract  is  progressing;  how  seri- 
ously the  patient  will  be  inconvenienced 
if  he  waits  for  maturity;  what  contra- 
indications are  there  to  the  extraction, 
even  though  immature.  Xo  extraction 
of  an  unripe  cataract  is  warranted  when 
the  fellow  eye  has  vision  sutficient  for 
the  patient's  needs.  It  is  particularly 
contraindicated  in  a  lens  swollen  by  im- 
bibition, attended  with  shallow  anterior 
chamber  and  sluggish  pupil  from  an  ir- 
ritated iris.  Successful  results  from  the 
extraction  of  unripe  cataract  must  come 
from  the  adoption  of  methods  which 
make  it  possible  to  remove,  at  the  time 
of  operation,  practically  all  the  cortex, 
with  a  minimum  amount  of  trauma  and 
subsequent  inflammatory  reaction,  and 
the  employment  of  treatment  to  limit 
reaction  and  promote  resorption  of  any 
retained  cortical  substance.  The  opera- 
tive essentials  to  bring  about  the  result 
are:  a  large  corneal  section,  not  less 
than  two-fifths  of  the  corneal  circum- 
ference: an  iridectomy  with  a  fairly 
large  coloboma  extending  to  the  ciliary 
border:  a  large  opening  in  the  capsule 
by  two  incisions  at  right  angles  to  each 
other:  gentle  irrigation  of  the  anterior 
chamber  with  a  sterile  normal  salt  solu- 
tion :  the  early  and  free  use  »>f  atropine 
and  the  use  nf  dionin  after  the  corneal 
wound  has  closed.  A.  E.  Bulson.  Jr., 
(Journal  of  the  American  Medical  Asso- 

-ii,  September  83,  1905). 


554 


CELLULAR  ELEMENTS  OF  COLOSTRUM. 


COLITIS,  MEMBRANOUS. 


CELLULAR     ELEMENTS     OF     COLOSTRUM 
AND    HUMAN   MILK. 

The  authors  publish  the  results  of  a 
research  undertaken  to  determine  the 
actual  source  of  the  colostrum  corpus- 
cles present  in  human  milk,  whether 
from  leucocytes  or  from  epithelium. 
They  examined  milk  and  microscopic 
sections  of  breasts  in  various  stages  of 
activity,  and  performed  several  experi- 
ments on  animals.  As  a  result  they  are 
able  to  form  various  conclusions,  which 
lead  off  with  a  confirmation  of  the  fact 
already  known  that  various  cellular  ele- 
ments appear  in  the  milk,  differing  ac- 
cording to  ci  cumstances.  Leucocytes, 
especially  polymorphonuclears,  appear 
when  lactation  is  stopped,  probably  ex- 
ercising a  resorptive  function.  Colos- 
trum corpuscles  are  especially  notice- 
able where  lactation  is  slowed  down, 
while  in  the  milk  of  a  fully-secreting 
breast  cellular  debris  in  the  form  of 
"crescent  bodies"  are  found.  Though, 
however,  the  presence  of  leucocytes  in 
human  milk  was  clearly  established,  ex- 
amination of  the  milk  alone  did  not 
suffice  to  determine  whether  colostrum 
corpuscles  are  derived  from  them  or 
from  epithelial  elements.  The  examina- 
tion of  sections  of  breasts  of  women 
dead  immediately  before  or  after  deliv- 
ery, and  of  newly-born  infants'  "breasts, 
was  accordingly  undertaken  with  the  re- 
sult that  on  the  one  hand  leucocytes 
were  observed  around  and  within  secret- 
ing acini,  apparently  converting  them- 
selves into  colostrum  corpuscles  by  the 
ingestion  of  droplets  of  milk,  while  on 
the  other  hand  there  was  a  close  identity 
of  form  between  colostrnm  corpuscles 
and  the  secreting  epithelial  cells.  Be- 
lieving, therefore,  that  the  leucocytic 
origin  of  the  colostrum  corpuscles  was 
proved  while  the  epithelial  origin  was 
also  probable,  the  authors  employed  an 


ingenious  experiment  in  order  to  exam- 
ine the  latter  point.  The  serum  of  ani- 
mals which  have  been  inoculated  with 
milk  has  been  shown  by  von  Dungern 
and  others  to  contain  a  substance  spe- 
cifically toxic  to  epithelium;  the  au- 
thors found  that  such  a  serum  invariably 
agglutinated  a  part  of  the  cellular  ele- 
ments of  the  colostrum,  while  a  normal 
serum  had  no  such  effect.  This  confirms 
the  supposition  that  the  colostrum  cor- 
puscles are  in  part  derived  from  epithe- 
lium. To  further  establish  the  origin  of 
the  other  part  from  leucocytes,  it  was 
shown  that  milk  injected  into  the  peri- 
toneal cavity  of  animals  was  taken  up 
by  peritoneal  macrophages,  forming  cells 
exactly  like  colostrum  corpuscles.  Wal- 
lich  and  Levaditi  (Annales  de  lTnstitnt 
Pasteur,  May,  1905;  British  Medical 
Journal,  September  30,  1905). 

CHOLECYSTITIS. 

Cholecystitis,  if  subacute  or  chronic, 
should  be  subjected  to  early  operation. 
Early  operation  reduces  the  operative 
mortality  rate.  The  cases  of  primary 
cancer  of  the  gall-bladder  and  ducts  will 
be  greatly  reduced  by  early  operation. 
If  a  probability  of  cholecystitis  exists, 
an  exploratory  incision  should  be  made, 
and  if  it  is  found,  the  operation  contin- 
ued. E.  W.  Hard  on  (American  Journal 
of  Surgery,  October,  1905). 

COLITIS,   MEMBRANOUS. 

The  writer  gives  an- account  of  60  con- 
secutive cases  of  membranous  colitis  seen 
by  him.  Various  names  have  been  given 
the  affection — the  most  accurate  is  muco- 
membranons  enterocolitis.  Inflamma- 
tion is  not  necessarily  present;  the  colon 
is  so  disordered  that  the  mucus  secreted 
by  it  is  passed  from  the  anus  in  the  form 
of  a  membrane.  The  disease  is  com- 
moner   among   the   upper   classes   than 


DEGENERATION  OF  THE  HEART. 


555 


among  the  poor.  Of  the  60  cases  51 
were  women  and  9  men.  The  disease 
rarely  comes  on  under  20  years  of  age., 
and  usually  first  shows  itself  between  the 
ages  of  20  and  30  years.  Only  infre- 
quently is  it  found  to  begin  over  the  age 
of  45  years.  Of  the  60  cases,  8  have  been 
known  to  be  fatal,  and  in  none  of  these 
was  death  due  to  colitis.  Of  the  re- 
mainder 21  recovered  and  6  improved 
greatly.  The  25  that  did  not  recover 
were  all  women,  they  suffering  much 
more  severely  from  the  disease  than 
men. 

The  chief  symptom  is  the  passage  of 
membrane;  if  the  mucus  is  passed  soon 
after  its  formation,  it  is  glairy  like  the 
white  of  an  egg.  Nearly  all  the  patients 
are  constipated,  but  diarrhoea  may  alter- 
nate with  the  constipation.  Patients  af- 
fected with  a  severe  degree  of  the  disease 
sometimes  pass  intestinal  sand.  This  is 
usually  of  a  red  color,  rather  duller  than 
the  common  deposit  of  uric  acid  in  the 
urine;  sometimes  it  is  white  or  light 
brown  with  dark  patches  intermingled. 
In  severe  cases  there  is  much  abdominal 
pain;  it  may  be  dull  and  constant,  or 
there  may  be  paroxysms  of  very  severe 
pain  in  the  center  of  the  abdomen,  caus- 
ing the  patient  to  writhe  in  agony.  The 
paroxysms  are  usually  relieved  bv  a  pas- 
sage of  the  bowels.  Usually  there  is 
some  abdominal  tenderness.  The  tongue 
is  usually  coated  with  a  white  fur,  and 
there  is  flatulence  and  anorexia.  En- 
teroptosis  is  frequently  associated  with 
mucous  colitis.  Affections  of  the  or- 
gans of  generation  are  common,  occur- 
ring in  21  out  of  the  51  female  patients. 
It  is  needless  to  state  that  the  majority 
of  patients  are  nervous,  neurasthenic, 
hypochondriacal,  hysterical  individuals. 
Many  authorities  regard  the  disease  as 
being  primarily  a  nervous  disorder  witli 
an  excessive  secretion  of  mucus  from  the 


colon.  Others,  among  them  the  author, 
consider  it  a  local  affection,  probably 
due  to  constipation. 

By  far  the  most  important  part  of 
the  treatment  is  to  keep  the  large  bowel 
empty;  in  many  cases  castor-oil  by 
mouth  will  cure  the  patient.  It  should 
be  given  early  in  the  morning  as  soon 
as  the  patient  wakes.  If  the  oil  causes 
nausea,  magnesium  sulphate  may  be 
given  instead,  or  calomel  over  night. 
Should  these  fail  the  large  intestine 
should  be. washed  out  with  plain  water 
at  a  temperature  of  100°  F.,  a  pint  or 
more  being  used  at  a  time.  Intestinal 
antiseptics  are  worse  than  useless.  If 
diarrhoea  is  present  it  should  never  be 
checked  by  astringents;  castor-oil  is  the 
best  treatment.  W.  H.  White  (Lancet, 
October  28,  1905). 

DEGENERATION  OF  THE  HEART. 

The  venous  pulse  is  of  the  ventricular 
type  in  the  majority  of  those  cases  of  so- 
called  "chronic  myocarditis"  in  which 
there  are  signs  of  cardiac  disability — 
namely,  palpitation,  dyspnoea,  irregular 
pulse,  and  diminution  of  the  area  of 
cardiac  response. 

This  abnormal  inception  of  the  car- 
diac rhythm,  as  demonstrated  by  the 
ventricular  type  of  the  venous  pulse,  can 
and  does  frequently  occur  irrespective  of 
myocardial  degeneration.  The  parox- 
ysmal tachycardia  met  with  in  a  boy 
aged  6y2  years  is  a  case  in  point,  where 
there  were  no  grounds  for  assuming  the 
existence  of  any  myocardial  degenera- 
tion. The  dilatation  of  the  heart,  the 
cardiac  distress,  the  irregular  action, 
and  the  diminished  area  of  cardiac  re- 
sponse were  all  secondary  to  the  onset  of 
the  tachycardia,  and  disappeared  almost 
as  suddenly  as  they  had  appeared  on  the 
heart  resuming  its  normal  modp  of  ac- 
tion. 


556 


DIGITALIS  TREATMENT,  REMARKS  ON. 


The  conditions  are  not  known  which 
alter  the  excitability  of  the  musculature 
of  the  auricular  canal  and  adjoining  por- 
tions of  the  ventricle.  It  is  probable 
that  changes  in  the  nutrition  of  the 
myocardium  act  in  this  manner.  The 
onset  of  marked  symptoms  is  largely  in- 
dependent of  the  myocardial  degenera- 
tion, but  is  synchronous  with  the  onset 
of  the  abnormal  inception  of  the  rhythm. 
rl  nis  rhythm,  with  its  consequences, 
sometimes  occurs  in  the  absence  of  any 
evidence  of  myocardial  degeneration. 
The  heart's  action  is  always  inefficient 
in  the  presence  of  the  ventricular 
rhythm,  whether  myocardial  changes  be 
present  or  not.  John  Hay  (British 
Medical  Journal,  October  21,  1905). 

DIGITALIS    TREATMENT,    REMARKS    ON. 

The  writer  states  that  for  many  years 
there  has  been  a  strong  desire  among 
physicians  to  have  the  active  principle  of 
digitalis  isolated  from  those  responsible 
for  the  poisonous  effect  of  the  drug.  A 
number  of  digitalis  alkaloids,  etc.,  have 
been  isolated.  Schmiedeberg  found  four 
main  principles:  digitonine,  or  soluble 
digitaline,  insoluble  digitaline,  digita- 
leine,  and  digitoxin.  His  crystallized 
digitoxin  is  soluble  only  in  chloroform 
and  alcohol;  it  irritates  the  stomach 
very  much,  and,  subcutaneously,  causes 
painful  infiltration  or  local  necrosis. 
The  glycoside  digitaline  erystallisee  of 
Nativelle  was  recommended  by  Potain 
and  Huchard.  The  latter  uses  it  when- 
ever he  prescribes  a  digitalis  preparation. 
The  writer  states  that  his  experience 
with  it  is  limited,  but  many  authors  be- 
lieve that  digitaline  Nativelle  is  not  the 
chief  principle  of  digitalis. 

We  must  have  the  active  principle  of 
digitalis  as  one,  chemical  body  which 
must  be  constant  in  composition  and  ef- 
fect.    It  must  contain  all  the  valuable 


properties  of  the  fresh  leaves.  We  need 
this  pure  principle  as  a  standard,  we 
must  be  able  to  note  our  experiences 
from  a  standard  measure  in  our  histories, 
even  if,  afterward,  we  can  treat  our  cases 
with  our  empirical  doses  of  the  powder. 
We  should  be  able  to  buy  digitalis  leaves 
of  a  known  strength,  after  samples  of 
the  powder  .have  been  analyzed  for  a  per- 
centage of  pure  principle.  The  pure  iso- 
lated principle  should  be  "injectable" 
and  non-irritating.  All  of  these  re- 
quirements seem  to  be  fulfilled  in  a  new 
product,  the  soluble  digitoxin,  published 
by  Dr.  M.  Cloetta,  professor  of  pharma- 
cology at  the  University  of  Zurich.  A 
number  of  authors  like  Naumyn  and 
Ivottmann  (Miinchener  mediciniscne 
Wochenschrift,  No.  31,  page  1413,  1904), 
Senator  and  Bibergiel  (Berliner  klin- 
ische  Wochenschrift,  No.  51,  1904),  and 
Klemperer  (Therapie  der  Gegenwart, 
1904)  make  favorable  reports  of  their 
experience  with  this  digitoxin.  Good 
results  were  obtained  by  the  writer  from 
extensive  tests.  It  was  tried  under  al- 
most any  condition  in  which  digitalis  is 
indicated :  in  all  sorts  of  muscular  in- 
sufficiencies of  the  heart,  in  chronic  val- 
vular troubles,  in  arteriosclerotic  heart 
disturbances,  and  in  nephritis;,  also  in 
acute  diseases  like  pneumonia,  typhoid 
fever,  etc.  The  desired  digitalis  effect 
was  obtained  several  times  by  injecting 
digitoxin  into  the  muscles  of  patients 
who  had  already  been  given  powdered 
digitalis,  or  fluid  extracts  per  os,  with- 
out any  other  result  than  that  of  nausea. 
The  writer  found  Cloetta's  digitoxin 
superior  to  the  digitaline  and  other  digi- 
toxins  which  are  in  the  market.  It  can 
be  used  wherever  digitalis  is  indicated. 
Per  os  it  acts  much  more  quickly  than 
the  powder,  hypodermically  (deep  into 
the  muscles)  in  a  few-  hours,  intraven- 
ously at  once.    It  is  not  cumulative  and 


ETHYL  CHLORIDE. 


FLOATING  KIDNEY:     SURGICAL  TREATMENT.       557 


its  effect  is  not  as  lasting  as  that  ob- 
tained from  the  powder.  But  the  effect 
once  reached,  can  be  kept  by  continue:  1 
small  doses.  Its  chief  advantage  is  that 
it  can  be  given  hypodermically  without 
much  pain  and  without  danger  of  infec- 
tion, and  that,  in  emergency,  it  can  be 
injected  into  the  veins  with  almost  in- 
stant effect. 

The  single  dose  of  Cloetta's  digitoxin 
is  l/a  milligram,  corresponding  to  0.1 
digitalis.  This  dose  can  be  given  three 
times  a  day,  or  oftener  per  os,  or  as  an 
injection.  In  emergency,  for  instance, 
in  acute  dilatation  of  the  heart,  the 
writer  has  given  2/a  milligram  by  injec- 
tion three  times  a  day  for  several  days 
in  succession  until  the  danger  was  passed. 
He  considers  its  use  a  safeguard  in  gen- 
eral anaesthesia.  Fritz  Schwyzer  (Med- 
ical News,  November  18,  1905). 

ETHYL    CHLORIDE. 

Ethyl  chloride  occupies  a  position  as 
an  anaesthetic  about  midway  between 
nitrous  oxide  and  ether.  It  is,  as  would 
be  expected  from  its  composition,  more 
toxic  than  the  former,  and  when  used  in 
properly  selected  cases)  nearly  as  safe 
as  the  latter.  Nitrous  oxide,  as  regards 
safety,  is  still  in  a  class  by  itself,  and 
where  it  can  be  administered,  it  should 
be  used.  Ethyl  chloride  should  be  used 
rather  to  replace  chloroform  and  ether 
in  certain  cases,  i.e.,  for  shorl  operations 
needing  longer  and  deeper  anaesthesia 
and  greater  muscular  relaxation  than  is 
afforded  by  nitrons  oxide  alone  or  mixed 
with  oxygen.  As  a  preliminary  anaes- 
thetic, it  is  unequaled.  In  cases  where 
there  is  much  thickening  of  the  tissues 
of  the  neck,  or  any  suspicion  of  laryn- 
gitis, or  oedema  of  the  larynx,  or  nar- 
rowing of  (he  air-way  beyond  (he  mouth, 
it  is  contra-indicated.  The  vapor,  if 
concentrated,    may    originate   spasm    of 


the  larynx,  especially  when  inflamed;  it 
certainly  causes  increased  vascularity  of 
mucous  membranes.  The  mortality  is 
about  1  in  10,000  cases. 

The  most  serious  after-effect  is  col- 
lapse, occurring  principally  after  a  sin- 
gle full  dose  in  which  no  air  has  hem 
allowed.  The  gas  is  inflammable  and 
should  not  be  administered  near  a  light. 
The  best  apparatus  is  a  bag  inhaler  of 
wide  bore  which  can  be  used  for  ether  i  I' 
the  ethyl  chloride  be  insufficient  or  un- 
satisfactory. The  patient  should  be 
told  to  breathe  very  quietly  and  no  air 
is  needed  until  snoring  begins,  as  there 
are  fewer  after-effects  when  narcosis  is 
quickly  produced..  A  too  small  bag 
causes  headache  and  even  collapse,  from 
the  carbon  dioxide  and  other  impurities. 
W.  J.  McCardie  (Lancet,  October  1, 
1905). 

FLOATING  KIDNEY:  SURGICAL  TREAT- 
MENT. 
Floating  kidney  may  produce  impor- 
tant symptoms,  symptoms  having  a  real 
physical  explanation,  of  which  interfer- 
ence with  the  gastric  and  hepatic  func- 
tions are  especially  noteworthy.  The 
"neurotic  condition,"  which  is  so  often 
found  in  the  subjects  of  floating  kidney. 
is  largely  the  result  of  such  symptoms 
long  continued,  and  is  to  be  avoided  in 
many  eases  by  early  fixation  of  the  or- 
gan. AVhile  a  truss  or  belt  pressure  may 
undoubtedly  suffice  in  slight  cases,  ne- 
phrorrhaphy  is  the  most  certain  method 
of  treatment.  Nephrorrhaphy  is  supe- 
rior to  "Semi's  gauze  method."  being 
safer,   more   effectual,   and    involving   a 

-Imrier  period  of  convalescence.  Kan- 
garoo tendon  is  admirably  adapted  for 
nephrorrhaphy,  the  use  of  silk  being  at- 
tended with  the  risk  of  can<iiiLr  tedious 
sinuses.  .1.  llulchinson  (Clinical  Jour- 
nal, October  25,  1905). 


558 


FRACTURE  OF  SPINE. 


GYNECOLOGY,    CONSERVATISM    IN. 


FRACTURE  OF  THE  SPINE. 

Fractures  of  the  spine  may  well  be 
divided  into  two  classes:   first,  fractures 
of  the  spine  with  injury  to  the  cord; 
and,  second,  fractures  of  the  spine  with- 
out injury  to  the  cord.     It  is  not  best 
to  decide  what  the  treatment  of  an  in- 
dividual case  of  fracture  of  the  spine 
should   be   from   the   statistics,   because 
the  lesion  varies  so  widely.     In  many 
cases  it  is  impossible  to  primarily  state 
whether  the  cord  is  crushed  or  pressed 
upon  by  bone,  blood,  or  exudate,  except 
by  an  open  operation.    Only  by  the  per- 
sistence of  total  loss  of  reflexes,  complete 
insensibility  to  touch  and  pain,  and  mo- 
tor paralysis  below  the  level  of  the  le- 
sion, can  total  transverse  destruction  of 
the  cord  be  diagnosticated.     If  pressure 
on  the  cord  is   allowed  to  remain  for 
many  hours,  irreparable  damage  to  the 
cord  may  take  place.     Unless  it  is  per- 
fectly clear  that  the  cord  is  irremediably 
damaged,  an  operation  to  establish  the 
condition  of  the  cord  and  to  relieve  pres- 
sure is  imperative  as  soon  as  surgical 
shock  has  been  recovered  from.    In  cer- 
tain cases  of  fracture  of  the  spine,  when 
the  cord  is  not  injured  but  is  liable  to 
injury  from  displacement  of  the  frag- 
ments of  a  vertebra,  rectification  of  the 
deformity  and  fixation  of  the  spine  may . 
be  used.    If  the  cord  is  crushed,  no  mat- 
ter what  treatment  is  adopted,  there  will, 
of  necessity,  be  a  high  rate  of  mortality. 
H.  L.  Burrell  (Annals  of  Surgery,  Oc- 
tober, 1905). 

GONORRHOEA,  LACTIC  ACID  IN. 

The  writer  states  that  lactic  acid  in- 
jection does  cure  gonorrhceal  infection 
and  has  no  ill  after-effects.  It  stops  the 
spreading  to  the  endometrium  of  the 
body  of  the  uterus  in  acute  cases  if  treat- 
ment is  started  soon  enough.  Ordinary 
douches  and  painting  of  the  cervix  can 


give  only  temporary  relief.  It  is  better 
to  destroy  the  cervical  glands,  and  this 
should  be  done  as  soon  as  the  diagBosis 
is  positive.  An  examination  should  be 
made,  not  only  of  the  discharge,  but,  if 
necessary  (when  that  examination  is 
negative),  of  the  cervical  membrane, 
with  its  glands.  Most  of  the  chronic 
discharges  are  due  to  retained  gonococci. 
It  is  possible  to  cure  this  discharge  by 
injection  by  this  method  into  the  cerv- 
ical glands.  Cervical  infection  is  al- 
ways possible  in  gonorrhoea  in  the  fe- 
male, but  by  prompt  action,  tubes,  etc., 
may  be  spared  future  disease.  So  far 
lactic  acid  used  by  this  method  is  the 
best  drug  for  injection.  A  too  deep  in- 
jection of  the  lactic  acid  may  cause  a 
slough,  which,  while  not  dangerous,  is, 
to  say  the  least,  annoying,  and  lessens 
the  good  results  which  should  be  ob- 
tained from  said  injection.  Swithin 
Chandler  (Journal  of  the  American 
Medical  Association,  October  7,  190§). 

GYNECOLOGY,   CONSERVATISM   IN. 

The  author  states  that  the  greater  the 
number  of  ways  devised  for  utilizing 
the  normal  uterine  ligaments  for  its 
restoration  and  retention  in  its  normal 
position  the  better,  so  long  as.  they  are 
'  rational  and  safe,  and  considered  as 
supplements  to,  instead  of  substitute? 
for,  each  other.  Every  surgeon,  whether 
specialist  or  general  practitioner,  intend- 
ing to  operate  in  such  cases  owes  it  to 
his  profession  and  to  his  clientelle  to 
familiarize  himself  with  all  known  meth- 
ods and  to  be  prepared  to  use  any,  or  all , 
or  to  modify  any  or  all  of  them  to  meet 
the  demands  of  each  individual  case. 

The  skill  and  time  required  to  utilize 
the  natural  ligaments  are  not  excessive. 
The  formation  and  utilization  of  adven- 
titious ligaments  within  the  abdomen 
should  be  reserved  for  cases  manifesting 


HEADACHE  IN  CHILDREN. 


559 


special  indications.  The  operations  of 
ventral  suspension  and  fixation  should 
not  be  performed  because  of  their  ease 
by  pseudo-surgeons  who  could  not  com- 
petently operate  by  using  the  natural 
ligaments. 

The  individual  case  should  determine 
the  method  for  each  tracheoplasty  or 
cervical  amputation  for  the  relief  of  lac- 
eration. Only  principles,  not  details, 
can  be  definitely  described  for  the  plas- 
tic repair  of  the  lacerated  perineum. 
Plastic  surgery  is  minor  only  in  its 
danger  to  the  patient's  life.  The  con- 
servation or  restoration  of  normal  pelvic 
anatomy  is  the  highest  function  of  the 
gynaecologist.  D.  H.  Craig  (Journal 
of  the  American  Medical  Association. 
November  18,  1905). 

HEADACHE   IN   CHILDHOOD. 

The  frequency  with  which  headaches 
occur  in  children  under  5  years  of  age, 
as  well  as  in  quite  young  infants,  is 
pointed  out  by  the  writer.  He  considers 
it  to  be  more  frequent  among  upper- 
class  children,  and  maintains  that  the 
cause  of  the  headache  is  not  sufficiently 
investigated,  as  it  is  a  symptom  of  many 
organic  and  functional  diseases.  Acute 
headache,  accompanied  by  a  rise  of  tem- 
perature, is  usually  a  prodromal  symp- 
tom, indicating  the  onset  of  infectious 
or  toxic  diseases.  In  tuberculous  men- 
ingitis the  intensity  of  the  pain  is  dis- 
proportionate to  the  amount  of  fever; 
it  is  more  constant  than  intense,  and 
does  not  va  *y  with  change  of  position, 
but  there  is  a  desire  for  rest  and  quiet. 
An  acute  headache  not  accompanied  by 
vomiting  excludes  meningitis:  when  ac- 
companied by  an  irregular  and  slow- 
pulse,  it  indicates   meningitis. 

Chronic  headache,  which  may  con- 
tinue for  three  or  four  months,  has  many 
causes.     He  considers  rapid  growth  an 


important  one.  It  is  frequently  met 
with  in  boys  about  9  to  11  years  who  are 
growing  fast;  it  is  generally  frontal 
and  occurs  in  the  morning;  it  is  ac- 
centuated by  work  and  improves  with 
rest.  Such  children  often  complain  of 
vague  pains,  commonly  in  the  knees;  he 
has  seen  them  suffer  from  epiphysitis 
and  from  cardiac  hypertrophy;  they  are 
always  nervous.  Rest  and  tonics  should 
cure  these  headaches;  they  generally 
tend  to  disappear  when  growth  ceases. 

Excessive  fatigue,  either  physical  or 
mental,  will  produce  headache  in  chil- 
dren; it  is  usually  found  among  school- 
children, and  is  quite  as  frequent  in 
slow  and  backward  ones,  to  whom  men- 
tal work  is  an  effort,  as  it  is  among  the 
more  clever.  Among  other  causes  the 
author  notes  defective  vision,  especially 
errors  of  refraction;  naso-pharyngeal 
obstruction,  otitis,  and  carious  teeth. 
Children  of  all  ages  suffer  from  anaemia 
with  its  characteristic  symptoms  and 
headache.  Auto-intoxication  is  a  very 
common  cause;  it  arises  generally  in 
the  gastro-intestinal  tract,  and  may  be 
due  to  disease  or  constipation,  or  to 
the  presence  of  parasites.  In  such  cases 
careful  regulation  of  the  diet  and  bow- 
els will  give  a  favorable  result. 

After  infectious  fevers,  an  unsus- 
pected nephritis  may  be  the  true  source 
of  both  anaemia  and  headache;  the  pain 
may  be  the  forerunner  of  an  attack  of 
uraemia.  External  causes  of  intoxicatiom 
should  not  be  overlooked ;  they  include 
drugs,  and  the  poisoning  by  lead  or  car- 
bolic acid  gas.  Malaria  tends  to  show 
itself  only  by  periodical  attacks  of  head- 
ache without  fever.  Tt  is  neuralgic  in 
character  and  usually  supra-orbital :  it 
may  be  accompanied  by  a  rigor  and  an 
enlarged  spleen.  The  author  finds  that 
hemicrania  is  not  infrequent  in  young 
children,   and    is   often   associated   with 


560 


HYPERTKOPHIED  PROSTATE,  CHOICE  OF  OPERATION  UPON. 


other  rheumatic  affections.  Finally,  he 
deals  with  organic  cerebral  lesions,  cere- 
bral tumors,  and  syphilis,  which  are  al- 
ways accompanied  by  characteristic 
symptoms.  Cattaneo  (Clinical  Medi- 
cine, September  13,  1905;  British  Med- 
ical Journal,   November  4,  1905). 

HYPERTROPHIED   PROSTATE,   CHOICE   OF 
METHOD  IN  OPERATING  UPON  THE. 

The  writer  states  that  we  have  to-day 
three  useful  methods  for  the  operative 
relief  of  prostatic  obstruction,  i.e.,  supra- 
pubic and  perineal  prostatectomy  and 
galvano-caustic  prostatotomy  (Bottini's 
operation).  Unassailable  proof  lias 
been  furnished  to  show  that  all  three 
methods  deserve  to  be  recognized  as 
standard  procedures,  each  being  capable 
of  bringing  permanent  relief. 

Wherever  the  patient's  condition,  ir- 
respective of  age,  seems  to  warrant  it. 
prostatectomy  should  be  done,  since  the 
total  removal  of  the  mechanical  obstruc- 
tion naturally  represents  the  most  sur- 
gical procedure. 

While  it  is  true  that  either  method, 
perineal  or  suprapubic,  can  be  success- 
fully employed  to  the  exclusion  of  the 
other  in  removing  the  hypertrophied 
prostate  gland,  it  certainly  means  facili- 
tating the  work  and  is  in  the  interest  of 
the  patient  if  both  procedures  are  used, 
the  one  that  seems  best  suited  to  the  par- 
ticular  ease  being  chosen  in  each  in- 
stance. The  selection  of  the  route,  on 
stricl  indication,  is  not  an  easy  matter 
at  present.  Further  reports  by  surgeons 
practicing  both  procedures  are  neederl  to 
decide  the  question.  Both  methods  are 
excellent  and  useful  ones.  The  choice 
up  to  the  present  time  is  largely  a  matter 
of  individual  inclination.  On  basis  of 
his  present  experience,  the  writer  thinks 
lie  is  warranted  in  saying  that  (a) 
glands  palpable  per  rectum  and  rising 


not  far  from  the  sphincter  ani  muscles 
can  be  advantageously  attacked  from 
below,  (b)  If  situated  higher  up  and 
if  the  growth  projects  well  back  into  the 
bladder,  they  should  be  enucleated  from 
above,  all  the  more  if  the  cystoscope  has 
shown  the  presence  of  a  median  lobe,  (c) 
A  hypertrophy  of  soft  character  in  the 
early  stages,  so  frequently  found  to  be 
made  up  of  a  number  of  smaller  nodules, 
each  of  which  can  be  enucleated  by  it- 
self, is  best  attacked  from  below,  (d) 
In  the  33  per  cent,  of  cases  in  which  no 
tumor  is  palpable  per  rectum,  but  in 
which  vesical  enlargement  is  recognized 
by  the  residual  urine  or  total  retention, 
and  seen  distinctly  by  means  of  the  cys- 
toscope to  be  the  obstructing  cause,  the 
suprapubic  route  deserves  the  prefer- 
erence.  (e)  If  the  enlargement  be  com- 
plicated by  a  vesical  calculus  or  calculi 
of  larger  dimensions,  too  large  to  be 
easily  extracted  through  the  dilated  in- 
ternal sphincter  muscle,  the  suprapubic 
route  is  indicated,  (f)  If  patients  with 
very  foul  urine,  where  immediate  drain- 
age of  the  bladder  is  imperative,  the 
suprapubic  incision  should  be  chosen. 
The  gland  may  then  be  removed  at  a 
second  sitting,  (g )  The  comparative]  v 
frequent  appearance  of  carcinoma  of  the 
prostate  may  prove  to  become  an  impor- 
tant factor  in  deciding  in  favor  of  com- 
plete removal  of  the  gland  from  above. 
The  question  of  the  preservation  of 
sexual  power  is  an  important  one.  Fur- 
ther experience  and  -  investigation  are 
needed  to  definitely  determine  whether 
there  is  any  difference  in  results  as  to 
this  point  between  the  two  methods  of 
operation.  '  As  it  seems  to-day.  the  supra- 
pubic operation  is  superior  in  this  re- 
spect to  the  perineal  method,  even 
though  in  the  latter  the  portion  of  the 
gland  immediately  -surrounding  the 
prostatic    urethra    and    the    ejaculatory 


INTRAPERITONEAL  TUBERCULOSIS. 


561 


ducts  have  been  preserved.  If  future 
statistics  should  prove  that  with  supra- 
pubic prostatectomy  the  sexual  function 
is  more  frequently  preserved  than  with 
the  perineal  procedure,  this  must  neces- 
sarily decide  the  choice  of  route  in  pa- 
tients in  whom  this  point  has  still  to  be 
considered. 

1\'  operation  with  the  knife  be  refused, 
or  there  be  contraindications  to  such  in- 
tervention, Bottini's  operation  is  in  or- 
der. Only  if  this  operation,  too,  be  re- 
fused or  impossible  are  we  justified  in 
relegating  a  patient  to  the  regular  use 
of  the  catheter. 

Cystoscopy  is  absolutely  necessary  be- 
fore doing  Bottini's  operation ;  it  should 
also  precede  perineal  prostatectomy  in 
order  to  determine  the  presence  or  ab- 
sence of  a  median  lobe  and  calculi ;  it 
may  be  dispensed  with  if  the  suprapubic 
operation  has  been  decided  upon,  al- 
though a  previous,  distinct  knowledge 
of  intravesical  conditions  must  be  wel- 
come to  the  operator.  In  that  33  per 
cent,  of  prostatics  who  present  no  en- 
largement on  rectal  palpation,  the  cysto- 
scope  alone  can  establish  a  distinct  and 
refined  diagnosis. 

The  time  for  operation,  at  least  in  the 
rank  and  file  of  prostatics,  has  come 
when  regular  catheterization  has  become 
imperative.  The  catheter  should  never 
be  entrusted  to  them  for  regular  use. 
Well-to-do  patients,  being  in  a  position 
to  take  the  time  and  care  necessary  for 
the  carrying  out  of  self-catheterization 
on  aseptic  principles,  may  be  allowed  to 
do  so  if  opposed  to  operative  interven- 
tion. Another  strict  indication  for  op- 
eration is  persistent  severe  pains  in  the 
perineum,  neck  of  bladder,  and  glans 
penis,  resisting  ordinary  treatment. 

Surgeons  should  familiarize  them- 
selves with  perineal  and  suprapubic 
prostatectomy  as  well   ns  with   galvano- 


caustic  prostatotomy  (Bottini's  opera- 
tion), in  order  to  be  able  to  do  justice 
to  the  prostatics  entrusting  themselves 
to  their  care,  for  no  one  method  of  op- 
eration can  be  employed  in  all  cases  of 
prostatic  enlargement  to  the  best  ad- 
vantage of  the  patient.  In  other  words, 
the  operation  must  be  selected  that  suits 
the  case.  Willy  Meyer  (Medical  Rec- 
ord, October  7,  1905). 

INTRAPERITONEAL  TUBERCULOSIS. 

Intraperitoneal  tuberculosis  is  fre- 
quently a  local  disease,  probably  occur- 
ring much  more  frequently  in  the  fe- 
male than  in  the  male.  In  a  large  ma- 
jority of  cases  it  is  primarily  visceral, 
and  the  general  peritoneum  is  second- 
arily involved.  The  surgical  treatment 
is  rational,  sometimes  agreeably  surpris- 
ing in  results,  and  again  bitterly  disap- 
pointing. In  this,  as  in  many  other  sur- 
gical conditions,  early  diagnosis  and 
early  operation  will  bring  more  certain 
results. 

In  this  condition  the  greatest  obstacle 
to  overcome  is  the  idea  that  it  is  a  sec- 
ondary condition.  No  case  of  intra- 
peritoneal tuberculosis  should  be  denied 
the  benefits  of  operation,  no  matter  how 
extensive,  so  long  as  there  is  no  positive 
pulmonary  or  pleuritic  involvement,  for 
the  reason  that  some  apparently  hopeless 
cases  fully  recover.  When  there  is  a 
tubercular  peritonitis,  a  sequel  of  tuber- 
cular tubes,  ovaries,  or  appendix,  the 
primary  focus  should  always  be  removed. 
Tn  these  tubercular  cases  the  mesenteric 
glands  have  not  been  found  frequently 
involved,  and  when  they  are,  operation 
accomplishes  very  little  good. 

Tn  tuberculosis  of  tubes  and  ovaries, 
the  adhesions  are  usually  firm  ;  some- 
times, though  not  usually,  very  vascular. 
and  not  infrerpiently  involve  loops  of  the 
small  intestine;    hence  the  greatest  care 


562       INTUSSUSCEPTION  IN  INFANCY. 


LEUCOCYTES,  EXAMINATION  OF. 


is  necessary  to  avoid  serious  injury  to 
bowel,  and  at  the  same  time  separate 
completely  all  adherent  surfaces  and 
provide  complete  drainage.  Drainage  is 
the  great  factor  in  recovery,  when  prop- 
erly carried  out.  F.  F.  Lawrence  (Sur- 
gery, Gynaecology  and  Obstetrics,  No- 
vember, 1905). 

INTUSSUSCEPTION      IN      INFANCY      AND 
CHILDHOOD. 

As  a  result  of  a  study  of  several  cases 
of  his  own  and  of  1028  cases  collected 
from  literature,  the  writer  comes  to  the 
following  conclusion  as  to  the  treatment 
of  intussusception,  a  prompt  recognition 
of  which  and  early  diagnosis  is  most  im- 
portant: No  food  should  be  given,  and 
purgatives  must  be  absolutely  prohibited. 
It  may  be  wise  to  give  some  sedative, 
such  as  opium.  Irrigation  may  be  tried 
once  or  twice  under  proper  conditions 
and  in  selected  cases,  but  it  should  al- 
ways be  accompanied  by  preparation  for 
immediate  laparotomy  in  case  of  fail- 
ure, and  should  always  be  carried  out 
under  complete  anaesthesia.  Hot  salt 
solution  or  plain  water  may  be  used  un- 
der a  pressure  of  not  more  than  three 
feet,  the  fluid  being  allowed  to  remain 
in  the  bowel  not  less  than  ten  minutes. 
Irrigation  should  not  be  employed  after 
a  previous  complete  or  partial  reduc- 
tion, and  it  should  not  be  used  in  acute 
and  severe  types  of  disease  which  result 
in  early  destruction  of  the  bowel.  It 
should  not  be  used  where  the  tempera- 
ture is  subnormal  or  septic  symptoms 
are  pronounced,  as  these  are  signs  of 
gangrene  and  ulceration.  Laparotomy 
should  follow  failure  of  irrigation  with- 
out delay,  and  there  should  be  an  at- 
tempt at  reduction  of  the  bowel  from 
below  upward.  In  irreducible  cases  the 
bowel  should  be  resected;  in  selected 
cases,  or  where  this  is  not  feasible,  re- 


section with  end-to-end  anastomosis 
should  be  attempted  when  the  patient's 
condition  makes  it  practicable.  An  ar- 
tificial anus  or  simple  packing  about  the 
bowel  requires  a  secondary  and  only  too 
frequently  fatal  operation.  J.  H.  Hess 
(Archives  of  Pediatrics,  September, 
1905). 

LARYNGEAL  AND  PULMONARY  TUBER- 
CULOSIS, REST  IN. 
The  great  benefit  derived  from  the 
non-use  of  the  voice,  according  to  the 
writer,  is  so  striking  that  no  one  can 
fail  to  appreciate  it  who  watches  the 
progress  of  the  case.  It  is  not  alone  in 
cases  of  laryngeal  tuberculosis  that  com- 
plete rest  of  the  larynx  and  pharynx  is 
indicated.  In  ordinary  pulmpnary  cases 
efforts  to  phonate  excite  hypersecretion 
and  contraction  of  the  laryngeal  mus- 
cles. Complete  cessation  of  phonation, 
therefore,  will  lessen  the  amount  of 
cough  and  consequent  prostration,  hy- 
perpyrexia, etc.  Rest,  either  partial  or 
complete,  should  be  paramount  in  all 
these  cases.  W.  P.  Porcher  (American 
Journal  of  Medical  Sciences,  Septem- 
ber, 1905). 

LEUCOCYTES,      EXAMINATION      OF,      AS 
DIAGNOSTIC     AID. 

A  thorough  appreciation  of  the  exact 
significance  of  leucocytosis  will  not  be 
possible  until  the  mode  of  origin  of  the 
various  forms  of  the  white  blood  cells 
and  their  relationship  to  each  other 
have  been  definitely  determined.  Never- 
theless, study  of  these  cells  in  the  vari- 
ous diseases  and  pathologic  conditions 
has  demonstrated  beyond  a  doubt  that 
their  determination  is  of  real  practical 
help  in  the  diagnosis  and  prognosis  of 
disease. 

There  are  only  a  few  diseases  in  which 
an  absolute  diagnosis  can  be  made  from 


MASTOIDITIS,  ACUTE,  OPERATING  IN. 


MYOPIA,  PROGRESSIVE. 


563 


the   blood    examination   alone;     in   the 
vast  majority  of  cases  the  condition  of 
the  leucocytes  aids  in  making  the  diag- 
nosis;   in  many  cases,  however,  it  is  an 
important  point  without  which  the  diag- 
nosis  would   be   even    more   incomplete 
than,  of  necessity,  it  is  often  forced  to 
be.     Thus,  the  study  of  the  leucocytes 
has  rendered   possible  the  diagnosis  of 
a  certain  number  of  diseases,  as  the  leu- 
kaemias and  trichinosis,  besides  render- 
ing marked  assistance  in  the  diagnosis 
of  others,  as  tuberculosis,  typhoid  fever, 
pneumonia,    and    various    inflammatory 
and    suppurative    conditions.      It    tells 
much  in  regard  to  the  prognosis  of  all 
forms    of   infection    and   inflammation. 
It  has  aided  in  discriminating  disease? 
presenting    clinical    pictures    markedly 
alike,   such   as   central   pneumonia   and 
typhoid   fever,   appendicitis   and   condi- 
tions simulating  it,  but  of  entirely  dif- 
ferent   origin,    peritonitis    and    gastro- 
intestinal   auto-intoxication,    lymphatic 
leukaemia  and  Hodgkin's  disease,  mye- 
logenous leukaemia  and  Banti's  disease, 
measles  and  scarlet  fever,  etc.     It  has 
provided  the  surgeon  and  gynaecologist 
with  a  ready  means  of  determining,  in 
the  first  place,  whether  or  not  he  is  deal- 
ing with   inflammatory   or  suppurative 
processes;    in  the  second  place,  whether 
the  process  is  diminishing  or  increasing, 
while   in  the  third   place   it  tells  him 
much,  if  he  can  but  read   the  figures 
aright,  regarding  the  prognosis  of   his 
cases.     Leucocyte   counting,   the   writer 
believes,  has  not  and  never  will  reach  the 
point  at  which  it  and  it  alone  will  fur- 
nish an  absolutely  correct  diagnosis  and 
prognosis,  but  in  the  past  it  has  been  a 
great,  and  it  will  be  in  the  future  an 
even  greater,  help  to  the  physician  and 
surgeon  who  values  correctly  its  possi- 
bility and  its  limitations.     T.  E.  Brown 
(American      Medicine,      November     4, 
1905). 


MASTOIDITIS,  ACUTE,  INDICATIONS  FOR 
OPERATING  IN. 
The  indications  for  operation  in  acute 
mastoiditis  are  summarized  by  the 
writer  as  follows:  (1)  Sudden  cessa- 
tion of  the  aural  discharge,  other  symp- 
toms persisting,  with  deep-seated  pain 
in  mastoid  region.  Marked  sensitiveness 
to  pressure  on  the  mastoid  over  an  area 
extending  well  beyond  the  limits  of  the 
antrum.  (2)  In  the  absence  of  fever, 
the  above  symptoms,  unless  yielding 
promptly,  i.e.,  in  from  twenty-four  to 
forty-eight  hours,  to  abortive  measures. 

(3)  Marked  tenderness  over  the  antrum, 
persisting  from  four  to  five  days  after 
free  incision  of   Shrapnel's  membrane. 

(4)  Marked  variations  in  the  quantity 
of  pus  discharged;  its  maximum  flow 
being  apparently  too  great  to  be  ex- 
plained by  the  tympanic  lesion;  its  pe- 
riod of  diminution  being  coincident  with 
the  development  of  mastoid  pain  or 
tenderness.  (5)  Mastoid  tenderness 
having  been  present  and  having  disap- 
peared, a  discharge  from  the  tympanic 
vault,  which  resists  all  rational  non- 
operative  measures.  (6)  Finally,  evi- 
dences of  mastoid  involvement  having 
been  present,  the  development  at  any 
time  during  convalescence  of  symptoms 
of  septic  absorption.  P.  D.  Kerrison 
(Medical  Eecord,  October  28,  1905). 

MYOPIA,    CAUSE    OF   PROGRESSIVE. 

Myopia  is  a  result  of  deficiency  of  the 
posterior  half  of  the  sclerotic  generally 
due  to  absence  or  poor  development  of 
the  elastic  fibers,  which  normally  are 
very  abundant.  The  lateral  pressure 
exerted  by  the  external  muscles  of  the 
eye  will  cause  a  bulging  of  the  posterior 
pole,  as  a  result  of  which  the  sagittal 
axis  will  become  longer.  The  thickness 
of  the  sclerotic  is  also  of  importance, 
since  a  thin  layer  will  hasten,  a  thick 


564 


NASOPHARYNGEAL  ADENOIDS. 


one  retard,  the  process.  The  stretching 
of  the  sclerotic  at  the  posterior  pole 
will  also  cause  tension  of  the  internal 
tunics,  hence  diminished  visual  acuity. 
This  tension  may,  however,  be  also  due 
to  deficiency  of  the  circular  portion  of 
the  ciliary  muscle.  In  this  case  the 
longitudinal  libers  will  cause  tension 
during  accommodation.  According  to 
the  author,  all  three  defects  (absence  of 
elastic  fibers,  thin  sclerotic,  deficiency  of 
circular  muscle  fibers)  are  congenital 
and  inherited,  and  all  three,  or  the  first 
and  second,  are  responsible  for  progres- 
sive myopia.  Proper  glasses  will  not 
prevent,  but  may  inhibit,  the  process. 
G.  Seggel  (Mtinchener  medicinische 
Wochenschrift,  June  20,  1905;  Med- 
ical News,  September  30,  1905). 

NASO-PHARYNGEAL  ADENOIDS. 

The  obstructive  and  non-obstructive 
adenoid  tissue,  when  diseased,  is  a  men- 
ace to  health,  hearing,  mental  and  phys- 
ical development,  and  should  be  radic- 
ally dealt  with.  It  is  far  more  serious 
in  effects  than  disease  and  enlargement 
of  the  faucial  tonsils.  Frequently,  when 
the  pharyngeal  tonsil  is  thoroughly  re- 
moved, the  enlarged  faucial  tonsils  rap- 
idly assume  normal  size  and  function. 
While  this  is  not  the  rule,  the  writer 
states  that  he  has  seen  it  occur  so  fre- 
quently that  he  considers  it  safe  to  say 
it  is  far  more  than  the  exception  to  the 
rule. 

The  question  is  frequently  asked,  do 
these  growths  recur?  Occasionally  they 
do,  especially  in  the  so-calltd  lymphatic 
and  neurotic  temperament.  The  more 
delicate,  undeveloped,  and  poorly  nour- 
ished or  overfed  the  child,  the  more  apt 
are  we  to  find  a  recurrence.  Whether 
this  is  strictly  a  recurrence  of  the  devel- 
opment of  some  tissue  not  removed  is 
still  an   open  question.     For  these  rea- 


sons, in  cases  like  the  one  just  referred 
to,  alterative  tonics  should  be  given  at 
intervals  for  some  months  after  operat- 
ing. 

As  to  the  method  of  operating,  the 
author  thinks  it  safe  to  predict  that  it 
will  not  be  long  before  the  forceps  will 
be  entirely  discarded  and  the  curette  and 
linger  alone  will  be  relied  upon.  Also 
that  the  position  of  the  patient  will  be 
on  the  side  instead  of  the  back,  so  as  to 
eliminate  much  of  the  danger  of  suction 
of  blood  into  the  larynx  and  the  preven- 
tion of  swallowing  blood  and  growth  re- 
moved, thereby  preventing  much  of  the 
nausea  generally  attributed  to  the  anaes- 
thetic. The  writer  states  that  he  knows 
of  no  operation  so  far  reaching  and  pro- 
ductive of  greater  good,  in  that,  while  it 
is  immediate  in  its  results,  it  is  also 
preventive  of  so  many  serious  conditions. 

The  technique  of  adenectomy  is  sim- 
ple as  compared  with  many  other  sur- 
gical operations,  but  should  be  just  as 
conscientiously  carried  out.  When  the 
proximity  of  the  growth  to  the  brain 
and  meninges,  the  nasal  accessory  sinu- 
ses, the  communication  with  the  ear 
through  the  Eustachian  tube  is  con- 
cerned, especially  the  danger  of  injury 
to  a  bulging  orifice  of  this  tube,  to  say 
nothing  of  the  very  delicate  and  vas- 
cular location  of  the  growth,  the  opera- 
tion cannot  be  considered  a  simple  or 
trivial  one.  A  third  tonsil  or  adenoid 
cannot,  with  safety,  he  hurriedly  scraped 
or  jerked  out  without  serious  risk  to  the 
patient  and  to  the  reputation  of  the 
operator.  When  carefully  and  thor-' 
oughly  done,  the  time  consumed,  while 
short,  the  risks  and  responsibilities  in- 
volved, "and  the  results  obtained,  are 
only  equaled  by  some  of  the  so-called 
major  operations  done  by  the  general 
surgeon.  J.  A.  Stucky  (Cincinnati 
Lancet-Clinic,  October  14,  1905). 


OBESITY,  TREATMENT  OF. 


PAROTITIS,  SECONDARY. 


565 


OBESITY,    TREATMENT    OF. 

The  authors  endeavor  to  emphasize 
the  importance  of  the  chlorides  in  the 
urine  in  the  obese.  Their  experimental 
investigations  show  that  treatment  with 
saline  mineral  waters  causes  no  appre- 
ciable difference  in  the  chlorides,  and 
also  that  the  weight  of  the  obese  is  not 
reduced  by  a  considerable  diminution  in 
the  quantity  of  food  taken.  A  dry  diet 
(relatively  free  from  fluids)  dehydrates 
the  tissues,  and  therefore  concentrates 
the  chlorides,  the  serum,  and  the  lymph. 
It  may  consequently  have  a  very  bad 
effect  upon  the  heart  and  kidneys.  In 
other  words,  such  a  diet,  though  now 
quite  in  vogue,  is  dangerous,  painful, 
and  ineffective.  On  the  other  hand,  the 
ingestion  of  a  normal  or  even  abundant 
quantity  of  fluids,  with  abstinence  from 
chlorides,  may  produce  durable  and  reg- 
ular results.  With  such  a  diet  the  elim- 
ination of  chlorides  proceeds  regularly. 
This,  therefore,  should  be  one  factor  in 
the  regime  of  the  obese,  while  proper 
restriction  and  regulation  of  the  food 
the  other.  H.  Labbe  and  Furet  (Revue 
de  Medecine,  September,  1905;  New 
York  Medical  Journal  and  Philadelphia 
Medical  Journal,  November  IS,   1905). 

PAROTITIS,    SECONDARY. 

Secondary  parotitis  is  an  acute  in- 
flammatory affection  of  the  parotid 
gland,  which  is  characterized  and  dis- 
tinguished from  primary  parotitis,  or 
mumps,  in  three  ways:  (1)  It  invari- 
ably occurs  as  a  complication  during 
Ihe  course  of  some  other  affection — acute 
or  chronic  diseases  and  post-operative 
states;  (2)  it  is  not  contagious;  (3) 
it  not  infrequently  suppurates  and  gives 
rise  to  a  parotid  abscess.  Among  the 
acute  diseases  it  follows  may  be  men- 
tioned typhus,  enteric,  and  scarlet  fever, 
diphtheria,    etc.      The   chronic    diseases 


most  frequently  complicated  by  it  are 
diabetes,  mercurial  stomatitis,  general 
paralysis  of  the  insane,  and  iodism. 
The  operations  most  frequently  followed 
by  parotitis  are  almost  invariably  those 
upon  the  abdomen  and  pelvic  organs. 
Operations  where  sepsis  has  been  pres- 
ent are  the  ones  most  frequently  fol- 
lowed by  parotitis.  The  parotitis  may 
arise  during  the  first  few  days  after  op- 
eration or  not  until  a  month  later.  As 
a  rule  it  appears  from  the  sixth  to  the 
eighth  day.  It  begins  with  pain  and 
swelling  in  the  parotid  region,  later 
spreading  to  other  areas  supplied  by 
the  fifth  nerve.  Finally  the  whole  cheek 
becomes  brawny  and  the  eyelids  puffy 
and  closed.  The  general  symptoms  con- 
sist of  fever,  malaise,  depression,  and 
thirst.  If  suppuration  occurs  the  symp- 
toms become  worse,  and  the  swelling 
may  become  soft  and  fluctuating.  But 
in  many  cases  the  actual  presence  of  pus 
is  hard  to  determine,  the  skin  being  pale 
and  fluctuation  not  obtainable,  the  pus 
lying  deeply  beneath  the  tense  parotid 
fascia.  If  pus  forms  it  may  (a)  be  ab- 
sorbed ;  (b)  drain  into  the  mouth 
through  the  parotid  duct;  (c)  escape 
through  an  incision  if  the  abscess  be 
opened ;  or  (d)  burst  into  the  mouth 
or  into  the  external  auditory  meatus. 
Fortunately,  the  following  results  are 
rare,  however:  The  patient  may  die  of 
septic  poisoning,  many  sinuses  may 
form,  or  the  pus  may  destroy  the  joint 
of  the  jaw,  cause  necrosis  of  the  jaw, 
broach  the  jugular  vein  or  the  facial 
artery.  Thrombosis  of  the  facial  or 
jugular  vein  may  lead  to  embolic  pyae- 
mia. The  mild  cases  recover  if  the  pri- 
mary disease  is  not  fatal. 

The  author's  observations  make  it 
highly  probable  that  secondary  parotitis 
is  invariably  due  <o  an  infection  of 
Stenson's   duct,  dependent  on  a  septic 


566      PERICARDITIS  AND  ACUTE  LOBAR  PNEUMONIA. 


PHLEBOSCLEROSIS. 


condition  of  the  mouth,  and  that  its 
i nisei  may  be  prevented  by  attention  to 
the  following  details:  The  patient's 
mouth  should  be  carefully  cleansed  and 
rendered  aseptic  before  operations  and 
at  the  commencement  of  long  febrile  ill- 
nesses; if  necessary,  causes  of  nasal 
obstruction  leading  to  mouth  breathing, 
such  as  adenoids,  should  be  removed. 
The  anaesthetic  apparatus  should  be 
ile.  The  mouth  should  be  period  u 
cleansed  afterward,  especially 
every  attack  of  vomiting.  The  bowels 
should  be  opened  early,  and  food  by  the 
mouth,  and  especially  solid  food,  should 
be  given  as  soon  as  possible.  Opium 
should  not  be  given  unless  absolutely 
necessary.  The  head  should  not  be 
placed  too  low  nor  the  binder  iixed  too 
tightly,  and  the  dorsal  decubitus  should 
be  given  up  as  soon  as  possible. 

If  parotitis  appears,  the  cleansing 
the  mouth  should  receive  redoubled  at- 
tention, and  a  sialagogue  and  an  aperienl 
should  be  given.  If  the  disease  pro- 
gresses, the  region  of  the  swelling  should 
be  incised  without  waiting  for  fluctua- 
tion— usually  by  the  fourth  day.  A 
transverse  incision  should  be  used,  with 
due  regard  to  the  branches  of  the  facial 
nerve  and  Stenson's  duet.  The  parotid 
:  i  should  be  freely  incised  and  the 
ringer  introduced  into  the  abscess  cavity 
to  break  down  all  septa  and  loculi.  The 
process  of  duct  infection  is  due  to  (a) 
the  presence  of  specific  micro-organisms 
(mumps,  typhoid  fever,  etc.)  in  the 
mouth  ;  (b )  increase  in  number  or  vir- 
ulence of  the  normal  mouth  organisms 
(staphylococci,  etc.)  ;  and  (c)  anything 
interfering  with  the  quantity  or  quality 
of  the  saliva  protectively  draining  down 
the  duct.  It  is  probable  that  all  forms 
of  parotitis,  acute  as  well  as  chronic, 
except  those  due  to  syphilis,  pyaemia, 
and  direct  spread  from  neighboring  tis- 


sues, are  due  to  duct  infection.  The 
submaxillary  and  sublingual  glands  may 
be  affected  in  an  exaetly  similar  manner. 
R.  T.  11.  Bucknall  (Lancet,  October  31, 
1905). 

PERICARDITIS      COMPLICATING      ACUTE 
LOBAR   PNEUMONIA. 

Pericarditis  developing  during  the 
course  of  an  acute  lobar  pneumonia,  is 
a  most  serious  and  important  complica- 
tion occurring  more  especially  in  young 
adults,  frequently  insidious,  latent,  and 
often  not  recognized  during  life.  It 
appears  to  arise  as  frequently  by  a 
static  process  as  by  direct  exten- 
sion. Treatment  is  very  unsatisfactory 
and  often  unavailing,  except  when  fluid 
is  present,  in  which  case  it  is  more  sur- 
gical than  medical.  In  all  patients  with 
pneumonia,  a  most  careful  watch  should 
be  kept  on  the  heart,  as  this  complica- 
tion appears  to  be  much  more  frequent 
than  is  generally  supposed,  and  urgent 
treatment  in  the  early  stages  may  mate- 
rially reduce  a  high  mortality.  J.  A. 
Chatard  (Bulletin  of  the  Johns  Hop- 
kins  Hospital,   October.   1005). 

PHLEBOSCLEROSIS. 

■bosclerosis  is  described  by  the 
authors  as  a  very  common  condition. 
which  has  been  recognized  as  such  only 
by  pathoL  ime  of  whom  regard  it 

as  a  process  analogous  to  similar  disease 
in  the  arteries.  These  writers,  however, 
find  that  it  exists  commonly  quite  apart 
from  diseased  arteries,  and  that  it  is  ex- 
tremely common  in  peripheral  veins, 
especially  those  of  the  lower  extremities. 
Their  findings  and  conclusions  may  be 
epitomized  thus:  1.  Peripheral  scle- 
rosis is  very  common,  existing  in  nearly 
60  per  cent,  of  patients  examined  by 
them  in  hospitals.  2.  It  is  much  more 
common  in  young  people  than  is  gener- 


PLEURISY  AND  TUBERCULOSIS. 


POTASSIUM  PE I ;manganate. 


567 


ally  supposed,  especially  in  the  saphena 
veins.  3.  It  is  frequently  present  with- 
out any  arteriosclerosis.  4.  Sections 
show  no  signs  of  marked  inflammation 
or  degeneration.  Proliferation  an< 
pertrophy  of  intima  and  media  are  the 
chief  pathological  pictures.  5.  The 
usual  causes  of  arteriosclerosis  are  ab- 
sent. G.  The  condition  is  allied  to  a 
process  of  functional  hyperplasia  rather 
than  to  chronic  inflammation  and  is  not 
associated,  as  a  rule,  with  injury,  though 
with  prolonged  strain  from  movement, 
posture,  and  changes  of  blood  tension. 
C.  F.  Martin  and  J.  C.  Meakins  (Amer- 
ican Medicine,  October  7,  1905). 

PLEURISY  AND   TUBERCULOSIS. 

The  pleural  cavities  are  readily  ac- 
cessible to  bacterial  invasion.  The  great 
majority  of  pleurisies  with  effusion 
which  occur  in  otherwise  healthy  indi- 
viduals are  due  to  infection  with  tuber- 
cle bacillus.  This  is  proved  by  aui 
findings,  by  methods  of  exact  diagnosis, 
and  by  the  subsequent  clinical  histories 
of  the  majority  of  persons  who  have 
been  the  subjects  of  such  attacks.  There 
is  ample  evidence  to  indicate  that  the 
so-called  idiopathic,  dry  pleurisies  are 
likewise  usually  tuberculous. 

The  subjective  symptoms  of  inflam- 
mation of  the  pleural  apices  often  sim- 
ulate those  of  myalgia  or  rheumatism. 
In  every  case  of  pleuris}-,  or  of  persistent 
pain  in  the  chest  or  shoulder,  which 
cannot  be  satisfactorily  ascribed  to  other 
causes,  tuberculosis  should  be  suspected 
and  a  careful  physical  examination 
should  be  instituted  to  determine,  if  pos- 
sible, the  existence  of  a  tuberculous  proc- 
ess in  the  lungs,  or  elsewhere.  Even 
if  physical  examination  in  such  cases 
prove  negative,  the  patients  should  be 
regarded  as  tuberculous  until  the  con- 
trary is  proved,  and  should  at  least  be 


kept  under  prolonged  observation  and 
iL'-examined  from  time  to  time.  The 
tuberculin  test  may  be  relied  upon  to 
confirm  or  exclude  the  tuberculous  na- 
ture of  pleurisy  in  case  of  doubt. 

The  application  of  these  principles 
will  always  lead  to  an  earlier  recognition 
of  tuberculous  disease  of  the  lungs,  es- 
pecially, and  to  the  institution  of  treat- 
ment at  a  period  which  will  in  many 
cases  secure  to  the  patient  most  impor- 
tant advantages  in  his  prospects  for  re- 
covery. Silvio  von  Euck  (New  York 
Medical  Journal  and  Philadelphia  Med- 
ical Journal,  September  30,  1905). 

POTASSIUM  PERMANGANATE  AS  A  HiEM- 
OSTATIC. 

The  writer  speaks  of  the  various  dis- 
advantages attending  the  application  of 
all  the  ordinary  haemostatics.  Even 
compression  is  often  impracticable  in 
the  minor  surgery  that  the  practitioner 
is  most  frequently  called  upon  to  do, 
becau.se  of  the  undesirably  conspicuous 
dressing  it  entails.  He  has  found  in 
potassium  permanganate  an  extremely 
efficient  haemostatic  which,  owing  to  its 
antiseptic  nature,  does  not  introduce  the 
risk  of  infection,  does  not,  to  any  ex- 
tent, destroy  the  tissues,  and  has  the 
further  advantage  of  being  very  cheap. 
He  uses  it  either  in  strong  solution,  in 
powder  form,  or  in  a  paste.  He  obtains 
a  fine  powder  by  triturating  it  with  one- 
half  its  weight  of  diatomaceous  earth, 
after  having  first  moistened  and  then 
dried  the  mixture.  The  paste  is  made 
with  vaseline  in  the  proportion  of  one 
part  to  three.  This  is  most  conveniently 
used  in  collapsible  tubes.  If  there  is 
bleeding  to  any  extent  after  the  excision 
of  warts,  condylomata,  small  tumors, 
etc.,  the  bleeding  surface  is  to  be  wiped 
dry  with  a  piece  of  gauze,  and  the  per- 
manganate in  one  form  or  the  other  ap- 


568 


PROSTATE,  CARCINOMA  OF. 


SCARLET  FEVER,  INFECTION. 


plied  instantly.  Usually  a  single  appli- 
cation suffices,  but  occasionally  more  are 
necessary.  Any  discoloration  of  the 
skin  about  the  wound,  accidentally  pro- 
duced, is  readily  concealed  by  covering 
it  with  a  piece  of  zinc  plaster.  About 
mucous  membrane  the  paste  is  prefer- 
able, but  epistaxis  is  well  controlled  with 
the  solution.  The  patients  complain  of 
slight  burning  after  the  application  of 
the  permanganate.  Vomer  (Munch- 
ener  medizinische  Wochenschrift,  Sep- 
tember 19,  1905;  Medical  Eecord,  Oc- 
tober 14,  1905). 

PROSTATE,    CARCINOMA    OF    THE. 

From  a  study  of  40  cases  of  carcinoma 
of  the  prostate,  the  writer  concludes  that 
it  is  more  frequent  than  is  usually  sup- 
posed— occurring  in  about  10  per  cent, 
of  the  cases  of  prostatic  enlargement,  as 
shown  also  by  Albarran.  It  may  begin 
as  an  isolated  nodule  in  an  otherwise 
benign  hypertrophy  or  a  prostatic  en- 
largement which  has  for  many  years  fur- 
nished the  symptoms,  and  signs  of  be- 
nign hypertrophy  may  suddenly  become 
evidently  malignant.  Marked  indura- 
tion, if  only  an  intralobar  nodule  in  one 
or  both  lobes  of  the  prostate  in  men 
past  50  years  of  age,  should  be  viewed 
with  suspicion,  especially  if  the  cysto- 
scope  shows  little  intravesicular  out- 
growth, and  pain  and  tenderness  are 
present. 

The  posterior  surface  of  the  prostate 
should  be  exposed  as  for  an  ordinary 
prostatectomy,  and  if  the  operator  is 
unable  to  make  a  positive  diagnosis 
of  malignancy,  longitudinal  incisions 
should  be  made  on  each  side  of  the 
urethra  (as  in  prostatectomy)  and  a 
piece  of  tissue  excised  for  frozen  sections, 
which  can  be  prepared  in  about  six  min- 
utes and  examined  by  the  operator  at 
once.     If  the  disease  is  malignant  the 


incisions  may  be  cauterized  and  closed 
and  the  radical  operation  performed. 

Cancer  of  the  prostate  remains  for 
a  long  time  within  the  confines  of  the 
lobes,  the  urethra,  bladder,  and  especially 
the  posterior  capsule  of  the  prostate 
resting  inviolate  for  a  considerable  pe- 
riod. Extraprostatic  invasion  nearly 
always  occurs,  first,  along  the  ejecula- 
tory  ducts  into  the  space  immediately 
above  the  prostate  between  the  seminal 
vesicles  and  the  bladder  and  beneath  the 
fascia  of  Denonvilliers.  Thence  the  dis- 
ease gradually  invades  the  inferior  sur- 
face of  the  trigone  and  the  lymphatics 
leading  toward  the  lateral  walls  of  the 
pelvis,  but  involvement  of  the  pelvic 
glands  occurs  late  and  often  the  disease 
metastasises  into  the  osseous  system 
without  first  invading  the  glands. 

Cure  can  be  expected  only  by  radical 
measures  and  the  routine  removal  of  the 
seminal  vesicles,  vasa  deferentia  and 
most  of  the  vesical  trigone  with  the  en- 
tire prostate  as  carried  out  in  4  cases  by 
the  writer  and  described  by  illustrations 
is  shown  to  be  necessary  by  the  40  cases, 
including  8  autopsies  and  10  operations 
reported.  The  4  cases  in  which  the 
radical  operation  was  done  demonstrated 
its  simplicity,  effectiveness,  and  the  re- 
markably satisfactory  functional  results 
furnished.  H.  H.  Young  (Bulletin  of 
the  Johns  Hopkins  Hospital,  October, 
1905). 

SCARLET      FEVER,      INFECTION      WITH, 
THROUGH   OPEN   WOUNDS. 

Cases  of  scarlatinal  infection  through 
open  wounds  have  the  following  char- 
acteristics.: (a)  The  period  of  incuba- 
tion is  short,  (b)  There  is  a  character- 
istic change  in  the  appearance  of  the 
wound  following  infection,  (c)  The 
neighboring  lymph. nodes  become  en- 
larged,    (d)  The  rash  usually  (but  not 


SCOPOLAiVUNE-MUKPiiLNE  ANESTHESIA. 


569 


necessarily)  begins  at  the  point  of  in- 
oculation, (e)  The  throat  symptoms 
are  mild.  There  is  no  exudate  or  marked 
involvement  of  the  submaxillary  glands. 
(f)  After  the  rash  has  reached  its 
height,  the  wound  improves  rapidly  in 
appearance,  (g)  Desquamation  usually 
(but  not  necessarily)  begins  around  the 
wound. 

Extrabuccal  infection  with  scarlet 
fever  is  probably  more  frequent  than  is 
generally  supposed.  It  should  be  looked 
for  in  cases  in  which  the  period  of  incu- 
bation is  unusually  short,  in  which  the 
throat  symptoms  are  slight,  and  in 
which  the  rash  makes  its  first  appear- 
ance in  an  unusual  location.  All  chil- 
dren exposed  to  scarlatinal  infection 
should  have  open  wounds  (including 
vaccination)  covered  by  a  protective 
dressing. 

The  period  of  incubation  in  scarlet 
fever  depends  on  the  virulence  of  the 
contagious  material,  the  receptivity  of 
the  individual,  and  the  portal  of  entry 
of  the  infectious  material.  An  indi- 
vidual who  is  immune  to  infection  in 
the  ordinary  way,  may  contract  the  dis- 
ease by  direct  inoculation.  Charles  Her- 
mann (Archives  of  Pediatrics,  October, 
1905). 

SCOPOLAMINE-MORPHINE    ANESTHESIA. 

The  greatest  difficulty  lias  been  found 
in  determining  the  best  proportion  of 
the  drugs  to  employ.  Too  much  mor- 
phine will  affect  the  heart  dangerously, 
while  too  much  scopolamine  produces  a 
state  of  excitement  similar  to  that  fol- 
lowing atropine  poisoning.  The  pa- 
tients become  restless  and  talk  as  if  in 
a  delirium.  The  pupils  are  widely  di- 
lated and  rigid  and  the  fare  is  Hushed. 
They  demand  water  constantly  and  com- 
plain of  dryness;  but  the  dryness  soon 
wears  off.  and  neither  in  man  dot  in  dogs 
have    any    cases    become    known    where 


scopolamine  alone  has  produced  death. 

Scopolamine-morphine  is  used  for  two 
purposes:  First,  with  the  intention  of 
performing  the  whole  operation  under 
this  anaesthetic  alone;  secondly,  as  a 
preliminary  to  anaesthesia  by  inhalation 
of  chloroform  or  ether.  If  the  case  is  a 
complete  success  the  patient  becomes 
sleepy  after  the  first  injection,  is  fast 
asleep  after  the  second,  and  is  uncon- 
scious and  insensible  to  pain  after  the 
third.  The  operation  may  begin  one- 
half  hour  after  the  last  injection. 

According  to  the  writer's  experience, 
the  sleep  may  be  so  slight  that  the  pa- 
tient awakes  when  spoken  to  or  moved. 
Some,  if  aroused,  cannot  answer  intelli- 
gently, but  mumble  a  few  unconnected 
words.  Others  again,  though  they  can- 
not be  aroused,  move  when  being  han- 
dled, or  even  complain.  It  then  be- 
comes necessary  to  add  some  other  anaes- 
thetic to  the  scopolamine-morphine.  The 
author  has,  in  a  number  of  cases,  added 
infiltration  anaesthesia  with  a  0.06  per 
cent,  salt  solution,  without  cocaine,  to 
the  complete  exclusion  of  chloroform. 
When  chloroform  is  given  very  little  is 
required,  and  in  many  cases  after  the 
first  few  drops  have  been  given  for  the 
first  incision  no  more  chloroform  is  nec- 
essary, so  that  operations  lasting  fifteen 
to  thirty  minutes  can  be  finished  with 
less  than  a  teaspoonful  of  chloroform. 
Complete  muscular  relaxation  does  not, 
as  a  rule,  result. 

Scopolamine-morphine  has  been  used 
by  the  author  on  72  patients  in  92  op- 
erations. Of  the  72  patients.  r>  died. 
In  none  could  the  scopolamine-morphine 
be  accused.  Of  the  deaths  reported  as 
i]\\o  (o  it.  only  1,  in  the  writer's  opinion, 
seemed  to  be  due  to  the  scopolamine-mor- 
phine. He  has  used  hyoscine  instead  of 
the  scopolamine,  and  with  both  had  the 
same  result. 


570       SLEEPLESSNESS  AND  PAIN. 


SPINE,  TUBERCULAR  CONDITIONS  OF. 


Scopolamine,  when  dissolved  in  water, 
does  not  keep  long,  and  it  has  been  the 
writer's  rule  to  have  a  new  solution  made 
every  week.  Even  then  it  was  noticed 
that  the  effects  of  the  drug  would  de- 
crease toward  the  end  of  the  week,  so  that 
in  the  future  he  will  have  a  new  solution 
made  every  three  days.  Ries  (Annals 
of  Surgery,  August,  1905). 

SLEEPLESSNESS  AND  PAIN. 

In  treating  insomnia  the  remedies 
which  bear  upon  the  circulation  should 
first  be  considered.  Where  the  arteries 
are  atheromatous  their  contractility  must 
be  restored,  by  means  of  iodide  of  potas- 
sium, massage,  or  the  high  frequency 
current,  which  last  is  often  very  effica- 
cious in  cases  of  arteriosclerosis  or  con- 
tracting kidney.  All  sources  of  local 
irritation  must  be  removed.  Where  in- 
digestion produces  insomnia,  no  food 
should  be  given  during  four  hours  or 
more  before  sleeping  time.  Where  flat- 
ulence and  acidity  prevent  sleep,  a  dose 
of  soda  mint  is  often  better  than  a  sleep- 
ing draught.  When  patients  awake  in 
the  middle  of  the  night  and  cannot  get 
to  sleep  again,  a  little  warm  food  is  often 
of  great  service.  But  it  must  not  be  too 
hot.  Where  the  action  of  the  heart  is 
kept  up  by  a  high  temperature,  as  in 
fevers,  sponging  the  skin  and  leaving 
the  body  exposed  under  a  cradle,  o 
work  wonders.  Among  drugs  the  vari- 
ous urethanes  (combinations  of  urea) 
have  considerable  power  to  lessen  cere- 
bral activity  and  to  produce  sleep  with- 
out exerting  any  marked  influence  on 
the  circulation.  Veronal  is  a  goo;! 
ampin.  Alcohol  is  sometimes  a  powerful 
hypnotic,  exerting  a  sedative  effect  upon 
the  nervous  structures.  The  more  pow- 
erful hypnotics  (opium,  hyoscyamus, 
etc.)  relieve  pain  as  well  as  induce 
Increased  sensibility  to  pain  is  sonic 


due  to  lessened  alkalinity  of  the  blood, 
and  may  be  remedied  by  the  administra- 
tion of  alkalies.  L.  Brunton  (British 
Medical  Journal,  October  21,  1905). 

SPINE,  TUBERCULAR  CONDITIONS  OF 
THE. 

Complete  methodical  and  long-con- 
tinued fixation  of  the  spine  in  the  posi- 
tion of  hyperextension,  with  healthy 
surroundings  in  the  sunlight,  are  the 
prime  factors  in  securing  new  ossific 
deposit  necessary  to  replace  the  various 
bone. 

Laminectomy  for  paraplegia  is  advis- 
able only  after  long-continued  and  pa- 
tient treatment  along  the  above-named 
lines  from  one  to  two  years,  since  the 
prognosis,  especially  in  children,  under 
these  conditions  is  favorable,  and  good 
powers  of  locomotion  may  be  confidently 
expected.  The  operation  is  justifiable  in 
selected  cases  where  loss  of  motion  and 
sensation  are  progressively  worse  and 
the  symptoms  threaten  life.  If  the  tu- 
bercular masses  within  the  spine  can  be 
removed,  and  if  extradural  pachymenin- 
gitic  deposits  or  pus  can  be  taken  away, 
improvement  may  be  expected,  and  in 
many  cases  relief  occurs.  The  operation 
has  a  mortality  of  about  25  per  cent, 
from  immediate  shock,  36  per  cent, 
within  a  month ;  while  one-half  the  eases 
die  within  the  year,  their  lives  being 
probably  shortened  by  the  operative  pro- 
cedure. Cases  of  non-improvement  and 
death  equal  nearly  65  per  cent. 

Forcible  immediate  straightening  of 
the  kyphosis  is  an  unsurgical  and  dan- 
gerous proceeding;  it  is  liable  to  re- 
awaken the  tubercular  disease  and  to 
weaken  the  column.  Forcible  gradual 
straightening  by  supporting  the  kyphotic 
area  upon  n  pedestal  is  a  valuable  agent 
in  relieving  deformity.  The  weight  of 
the   shoulders   and    pelvis   can    thus   be 


SURGERY  DURING  THE  RUSSO-JAPANESE  NAVAL  WAR. 


571 


utilized  as  straightening  forces  and  the 
weight  of  the  column  thrown  upon  the 
posterior  arches.  In  this  position  it  is 
permanently  fixed   by  plaster  of  Paris. 

Complete  erasion  of  the  carious  bodies 
of  the  vertebra3  is  an  uncertain  opera- 
tion; in  the  dorsal  region  requiring 
section  of  ribs,  with  danger  of  wounding 
the  pleura.  Wiring  of  the  spinous  pro- 
cesses has  never  been  sufficiently  tried  to 
demonstrate  its  helpfulness. 

Spinal  abscesses  which  contain  only 
liquefaction  of  caseation  should  be  aspi- 
rated. When  true  pus  has  formed,  asep- 
tic through  drainage  is  advisable.  De 
Forest  Willarcl  (Annals  of  Surgery,  Oc- 
tober, 1905). 

SURGERY  DURING  THE  RUSSO-JAPANESE 
NAVAL  WAR. 

At  the  meeting  of  the  Association  of 
Military  Surgeons  of  the  United  States, 
Surgeon-General  Suzuki,  of  the  Imperial 
Japanese  Navy,  made  an  address  on  his 
experiences  during  the  Eusso-Japanese 
naval  war.  He  served  on  the  flagship 
of  Admiral  Togo  as  surgeon-in-ch  Led 
the  combined  fleets.  He  considered  the 
treatment  and  management  of  wounds 
and  the  sanitary  arrangements  of  the 
Beets. 

The  instructions  issued  by  him  before 
leaving  the  naval   base  were:     (1)    the 
strictest  attainable  asepsis ;  (2)  conserva- 
tive surgery :    (3)  avoidance  of  amp 
tions  on  war  ships,  and  ii  ce  of 

the  wounded  to  hospital  ships  B 
possible   after   the   engagement.      1 
February,  1904,  to  August,  1905,  ovl\  of 
1891  casualty  deaths,  i  i  18  were  due  to 
shipwreck  through  mines,  and  only  563 
to  wounds  in  battle.     <  >''  L791  worn 
during  the  same  period,  6  l  i'  wire  i  rans- 
I'erred   In  hospital  with  only  32  d< 
The  methods  n  led   were  those  generally 

employed. 


He  divided  the  proper  treatment  of 
(he  wounded  in  war  into  two  stages: 
during  action,  only  first  aid;  after  ac- 
tion, temporary  relief  in  the  ship's  sur- 
gery, the  patient  being  then  transferred 
to  the  hospital  ship. 

General  Suzuki  then  discussed  the 
proper  location  of  the  ship's  surgery, 
which  he  said  should  be  below  the  water 
line;  the  transportation  of  the  wounded ; 
the  supply  of  dressing  materials,  which, 
with  praiseworthy  liberality,  had  been 
made  amply  large  for  all  the  needs  of 
the  fleet;  he  described  the  first  aid  pack- 
age issued  by  him;  the  attention  paid 
in  the  Japanese  navy  to  the  eyesight  of 
gunners;  the  number  and  character  of 
I  he  wounds  inflicted;  the  sanitary  ar- 
rangements, among  which  may  be  par- 
ticularized the  diet,  consisting  of  biscuit, 
6  ounces,  or  bread,  3  ounces;  rice,  12 
ounces ;  barley,  crushed,  4  ounces ;  meat, 
preserved,  5  ounces,  or  fresh,  7  ounces ; 
fish,  preserved  or  fresh,  5  ounce-:  vege- 
tables, fresh.  15  ounces,  or  dried,  3 
ounces;  tea,  y2  drachm;  barley,  roast. 
3  drachms;  sugar,  6  drachms.  To  this 
must  be  added  the  following  weekly  al- 
lowance for  cooking:  peas  or  beans.  •?'  ■_■ 
ounces;  wheat  flour,  2  ounces;  sugar, 
3%  ounces;  soy,  3  ounces;  sesame  oil. 
1  drachm;  salt,  V/j  ounces;  fat,  1 
ounce.  Supper  ration:  biscuit,  'i'j 
ounces,  or  bread.  5  ounces;  tea,  '  j 
drachm  ;  sugar,  1  drachms.  Water  was 
supplied  by  two  water  ships  distilling 
daily  about  three  hundred  tons  of  water, 
as  well  as  by  water  transports.  Every 
one  w;is  required  to  take  a  bath  and  I" 
pul  on  a  change  of  clothing  before  going 
into  acl  ion,  and  <  ieneral  Suzuki  ati  rib- 
uted  to  this  fad  the  comparative  free- 
dom from  sepsis  of  the  Japanese  in 
the  war.  (St.  Louis  Medical  Review, 
October  21,   L905). 


572 


SYPHILIS,  FEVER  0¥  LATE. 


TUBERCULOSIS,  PULMONARY. 


SYPHILIS,  THE  FEVER  OF  LATE  (VIS- 
CERAL). 

Late  (visceral)  syphilis  is  attended 
with  persistent  fever  much  more  fre- 
quently than  is  generally  supposed;  a 
fever  apart  from  secondary  infections 
and  complications.  The  fever  is  vari- 
able in  type,  but  is  commonly  of  low 
grade  and  intermittent.  It  is  chiefly  in 
those  cases  where  the  liver  is  involved  in 
the  specific  process  that  it  occurs,  and 
may  be  explained  by  "hepatic  insuffi- 
ciency" permitting  the  leakage  of  tox- 
ins into  general  circulation.  It  may  bo 
associated  (occasionally)  with  chills, 
night  sweats,  and  emaciation  so  as  to 
simulate  tuberculosis,  sepsis,  or  malaria 
— especially  the  first.  The  "tuberculin" 
test  is  of  little  value  in  attempting  the 
syphilis  -  tubercle  differentiation,  and 
may  be  risky.  No  difficulties  and  errors 
have  occurred  in  the  experience  of  lead- 
ing clinicians,  the  only  safeguard  being 
eternal  vigilance  and  an  exhaustive 
search  for  the  stigmata  of  past  syphilis 
in  every  obscure  case  of  chronic  fever. 
The  therapeutic  test,  though  unscien- 
tific, is  permissible. 

The  fever  of  late  sphilis  (apart  from 
secondary  infections)  is,  in  the  great 
majority  of  cases,  rapidly  amenable  to 
treatment  by  Hg  and  KI.  The  best 
method  is  by  the  "mixed"  treatment,  and 
heroic  doses  are  unnecessary  and  may  be 
harmful.  Arthur  Birt  (Montreal  Med- 
ical Journal.  October,  1905). 

TABES,   EARLY   DIAGNOSIS   OF. 

Kecognizing  the  great  importance  of 
early  diagnosis  in  tabes,  with  the  possi- 
bility of  prompt  treatment,  the  writer 
draws  attention  to  two  signs  in  addition 
to  those  commonly  looked  for  in  tliis 
disease.  These  are,  first,  the  condition 
of  the  Achilles  tendon  reflex;  and,  sec- 
ondly, the  examination  of  the  cerebro- 


spinal fluid  by  lumbar  puncture.  With 
regard  to  the  first,  it  is  lost  at  quite  an 
early  stage  in  the  disease.  The  best 
method  of  testing  this  reflex  is  to  have 
the  patient  kneeling  with  the  feet  hang- 
ing over  the  bed  or  chair.  If  lumbar 
puncture  is  practiced,  it  is  probable  that 
if  tabes  is  present  there  will  be  an  excess 
of  leucocytes  in  the  cerebro-spinal  fluid, 
especially  the  small  lymphocytes.  This, 
of  course,  might  be  due  to  any  chronic 
inflammatory  process  in  the  cerebro- 
spinal tract,  and  is  not  necessarily  evi- 
dence of  the  specific  process  which  causes 
the  symptoms  of  tabes  dorsalis;  but,  if 
other  signs  and  symptoms  of  tabes  are 
present,  it  is  of  considerable  help  in  the 
differential  diagnosis  as  opposed,  for  ex- 
ample, to  a  mere  neurosis.  Severino 
(Eiforma  Medica,  April  29,  1905;  Brit- 
ish Medical  Journal,  October  14,  1905). 

TUBERCULOSIS,  PULMONARY,  AFTER- 
TREATMENT  OF. 
The  writer  emphasizes  the  great  ten- 
dency toward  relapse  and  chronicity  of 
tuberculous  ulceration  in  the  lungs  as 
well  as  in  other  parts,  e.g.,  the  skin  and 
bones,  and  thinks  there  is  a  tendency  at 
the  present  time  to  take  too  optimistic  a 
view  of  its  curability.  The  disease  is 
practically  always  more  or  less  advanced 
from  the  pathological  standpoint  before 
it  is  recognized  clinically.  .  Although 
some  patients  have  such  good  resistance 
that  they  recover  in  spite  of  unfavorable 
surroundings  and  methods  of  living,  the 
majority  require  a  continuous  life  for 
years  rather  than  months  under  the  most 
favorable  hygienic  and  meteorologic  con- 
ditions before  there  is  assurance  that 
their  lesions  are  permanently  healed. 
Placing  the' patient  under  proper  condi- 
tions for  a  short  time  often  causes  the 
disease  to  become  quiescent,  but  this  is 
only  the  first  step  in  the  cure  of  a  dis- 


VOMITING  OF  PREGNANCY. 


573 


ease  that,  on  account  of  the  nature  and 
severity  of  the  pathological  lesions,  is 
essentially  of  long  duration. 

In  an  analysis  of  100  cases  of  pul- 
minary  tuberculosis  that  have  been  at 
least  quiescent  lor  from  one  year  to 
ten  years,  the  average  period  of  quies- 
cence being  three  years  nine  months,  he 
finds  that  at  the  present  time  87  are 
either  quiescent  or  cured  and  able  to 
work.  Twenty-five  of  the  100  cases  have 
at  some  time  relapsed.  Thirteen  of  these 
have  relapsed  and  recovered,  8  have  re- 
lapsed and  died,  and  4  are  at  present 
chronic  invalids.  One  patient  died  from 
cancer  of  the  stomach  without  relapse  of 
his  pulmonary  trouble.  Of  these  cases 
67  were  originally  classified  as  incipient 
and  33  as  moderately  advanced  or  ad- 
vanced. The  period  of  quiescence  before 
working  or  returning  home  varies  from 
no  time  to  thirty-six  months,  the  aver- 
age being  eight  months.  J.  A.  Wilder 
(American  Medicine,  October  7,  1905). 

VOMITING  OF  PREGNANCY. 

The  writer  divides  the  cases  of  serious 
vomiting  in  pregnancy  into  the  follow- 
ing groups:  1.  Keflex  vomiting;  this 
may  be  due  to  abnormalities  of  the  gen- 
erative tract  or  ovum  existing  prior  to 
or  coincident  with  pregnancy.  Among 
such  conditions  are  (a)  displacement  of 
the  uterus,  particularly  retro-flexions; 
(b)  ovarian  tumors ;  (c)  certain  cases 
of  endometritis,  and  (d)  abnormalities 
of  the  ovum,  such  as  hydatidiform  mole, 
hydramnios,  and  twin  pregnancy.  2. 
Neurotic  vomiting.  Many  cases  are 
more  or  less  closely  allied  to  hysteria, 
and  are  amenable  to  suggestive  treat- 
ment. But  this  variety  should  be  ding- 
nosed  only  after  excluding  organic  le- 
sions and  demonstrating  the  absence  of 
toxaemia  by  a  thorough  urine  examina- 
tion.    3.  Toxaemia  vomiting. 


That  pernicious  vomiting  in  preg- 
nancy is  due  to  toxaemia  is  a  view  that 
has  been  widely  adopted  in  late  years, 
and  all  sorts  of  theories  have  been  ad- 
vanced as  to  the  nature  and  origin  of  the 
toxic  material.  That  disturbed  function 
of  the  liver  stands  in  some  relation  to 
pernicious  vomiting  was  suggested '  by 
Duncan  in  1879.  In  a  certain  propor- 
tion of  cases  of  toxaemic  vomiting,  char- 
acteristic lesions  are  found  at  the  nec- 
ropsy and  are  identical  with  those  ob- 
served in  acute  yellow  atrophy  and  ic- 
terus gravis.  These  consist  in  the  de- 
generation and  necrosis  of  the  central 
portions  of  the  liver  lobule  and  the  fatty 
degeneration  and  necrosis  of  the  secre- 
tory portions  of  the  kidneys.  They  can 
only  be  explained  by  the  assumption  that 
some  powerfully  toxic  substance  is  cir- 
culating in  the  blood.  At  present  we  are 
absolutely  ignorant  as  to  the  exact  nature 
of  such  toxic  substances,  but  it  is  possi- 
ble that  they  are  metabolic  in  origin  and 
directly  connected  with  pregnancy. 

Associated  with  the  above-mentioned 
lesions  is  a  striking  change  in  metab- 
olism, manifested  by  a  marked  increase 
in  the  percentage  of  nitrogen  put  out  as 
ammonia  compared  with  the  total  nitro- 
gen of  the  urine.  The  former  may  rise 
from  3  per  cent.,  as  normal,  to  16  or 
even  46  per  cent.,  as  in  one  of  the  au- 
thor's cases.  The  excess  of  ammonia 
probably  represents  an  attempt  to  neu- 
tralize an  excessive  production  of  acid 
— a  so-called  acid  intoxication,  as  in 
diabetes,  phosphorus  poisoning,  etc.  The 
presence  of  a  marked  increase  in  the 
ammonia  coefficient  in  women  suffering 
from  pernicious  vomiting  indicates  a 
serious  toxaemia,  and  abortion  should  be 
induced  as  soon  as  the  condition  is  de- 
fcected.  A  coefficient  of  10  per  cent,  is 
the  danger  signal.  Albumin  and  am- 
monia are  not  present  in  the  urine  until 


574 


X-RAY  IN  MALIGNANT  DISEASE. 


BOOK  REVIEWS. 


shortly  before  the  fatal  outcome.  In 
eclampsia  they  are  present  early.  The 
total  amount  of  nitrogen  is  greatly  di- 
minished, and  the  ammonia  coefficient 
remains  practically  normal.  J.  W.  Will- 
iams (Lancet,  October  21,  1905). 

X-RAY  IN  MALIGNANT   DISEASE. 

Basing  his  observations  upon  the  re- 
sult of  over  three  years'  tireless  investi- 
gation, the  writer  discusses  the  value  of 
x-ray  in  the  treatment  of  cancer,  in- 
cluding sarcoma.  During  the  time 
specified  176  patients  were  treated,  a? 
follows:  68  cases  of  sarcoma;  36  of 
carcinoma  of  the  breast;  44  of  epithe- 
lioma of  the  head,  face,  and  neck,  in- 
cluding tongue;  14  of  deep-seated  ab- 
dominal growths,  probably  carcinoma; 
5  not  classified;  3  of  tuberculous  glands 
of  the  neck;  3  of  Hodgkins  disease; 
3  of  lupus.  In  5  cases  of  sarcoma  there 
was  complete  disappearance  of  the 
growth,  but  in  all  it  recurred  a  few 
months  later.  In  two  of  these  the  re- 
current growth  disappeared  under  com- 
bined x-ray  and  toxin  treatment,  the 
patients  remaining  well  to  date.  The 
36  cases  of  carcinoma  of  the  breast  fur- 
nished nearly  every  variety  of  this  dis- 
ease.    The  treatment  was  almost  wholly 


negative.     In  only  one  patient  did  the 
tumor  disappear,   and  in  this  case  the 
diagnosis  was  in  doubt.     Of  the  44  cases 
of   epithelioma   of   the  head,   face,   and 
neck,  in  only  4  did  the  disease  disap- 
pear entirely.     In  every  case  in  which 
there  was  glandular  involvement,  no  im- 
provement  whatever   was    noticed,    and 
the    rays   had    little,    if    any,    effect    in 
retarding  the  disease.     One  patient  suf- 
fering with  Hodgkin's  disease  improved 
markedly   at   first,  but  later   died   sud- 
denly.    No  autopsy.     There  was  com- 
plete disappearance  of  lupus  in  two  pa- 
tients,  and   improvement  in   the  third. 
In    one    patient   tuberculous    glands    of 
the  neck  decreased  in  size;   in  one  they 
disappeared,  and  in  the  third  there  was 
slight  involvement.     Eeports  from  sev- 
eral  other   series  of   observations   agree 
fully  with  this.     Of  late  the  x-ray  as  a 
pre-operative    measure    has   been    advo- 
cated, the  reason  given  being  that  the 
operative  field  is  thus  cleared..    The  fal- 
lacy of  such  reasoning  is  twofold:    (1) 
It  presupposes  that  the  agent  is  cura- 
tive, and   (2)   it  takes  for  granted  that 
no   harm   can   come   to   the   patient   by 
reason   of   delay.     Both   of  these   argu- 
ments   are    pernicious.      W.    B.    Coley 
(Annals  of  Surgery,  August' 1905). 


f}ool{  Reviews. 

Pathology  and  Moihud  Anatomy.  By  T.  Henry  Green,  M.D.,  F.R.C.P..  Consulting  Physician 
and  Emeritus  Lecturer  on  Clinical  Medicine  at  Charing  Cross  Hospital,  etc.  Tenth  Amer- 
ican. Bcvised  from  the  Tenth  English  Edition.  Revised  and  Enlarged  by  W.  Cecil  Bosan- 
quct.  ALA..  M.D.  (Oxon.),  F.R.C.P.  (Lond.),  Assistant  Physician  (Late  Pathologist)  to 
Charing  Cross  Eospital,  etc.  With  a  Colored  Plate  and  348  Illustrations  in  the  Text.  Lea 
Brothers  &  Co.,  Philadelphia  and  New  York.  1005. 

In  the  Lancet  of  September  2,  1905,  is  to  be  found. a  list  of  those  text  books  recommended 
by  the  consensus  of  opinion  of  a  representative  group  of  London  teachers  for  the  examination 
.,f  (lie  London  conjoint  qualifications.  In  the  third  and  last,  examination  in  which  pathology 
is  to  be  passed  by  the  studenl  Green's  "Pathology"  is  mentioned  first  and  is  described  as 
being-  an  excellent  work,  with  which  statemenl  we  heartily  agree.  "The  other  pathological 
books  recommended  are  Lazarus  Barlow's  "General  Pathology,"  Bowlby's  "Surgical  Pathology," 


BOOK  REVIEW  s.  575 

and  Curtis's  "Essentials  of  Bacteriology."  This  work  therefore,  is  written  with  the  idea  of 
supplying  the  student  with  such  special  information  upon  pathology  as  he  may  need  in 
passing  an  examination,  perhaps  before  the  very  person  whose  opinions  are  quoted.  For 
this  reason  a  careful  perusal  of  its  pages  will  show  that  the  earlier  editions  of  this  work  were 
based,  more  than  the  present  one  upon  Ziegler.  there  being  a  marked  tendency  in  the  pi 
edition  to  devote  special  attention  to  the  school  of  English  pathologists.  Among  pathologies 
the  popularity  of  this  work  in  America  is  surpassed  in  the  order  named  by  the  text-books  of 
Stengel,  Delafield  and  Prudden.  Ziegler,  and  Coplin,  as  is  seen  from  a  recent  analysis  made 
by  the  reviewer  of  the  books  recommended  in  the  catalogues  issued  by  fifty-live  members  of 
the  Association  of  American  Medical  Colleges. 

The  difficulty  of  covering  the  entire  subject  of  pathology  in  a  book  of  610  pages,  espe- 
cially if  it  be  well  illustrated,  as  in  the  present  case,  is  well  shown  by  the  fact  that  the  index 
does  not  even  refer  to  such  important  and  suggestive  pathological  subjects  as  abortion,  abrine, 
acromegaly,  adiposis  dolorosa,  angina  (Vincent's),  arthropathies,  carotid  bodies,  cryoscopy, 
etc.  It  may  be  noted  in  recent  works  upon  pathology  that  more  and  more  attention  is  being 
paid  to  clinical  conditions  and  terms.  Thus,  one  finds  in  this  work  information  supplied  in 
regard  to  agraphia,  ankle-clonus,  anorexia,  aphasia,  Argyll-Robertson  pupil,  Babinski's  sign, 
carphology,  catalepsy,  color-blindness,  etc. 

Professor  Green  was  distinctly  a  clinical  teacher,  and  the  present  edition  has  been  con- 
scientiously revispd  and  considerably  enlarged  by  V.  Cecil  Bosanquet,  of  the  Charing  Cross 
Hospital,  London,  whose  name  is  well  known  to  American  readers  through  his  contributions 
to  the  "International  Clinics."  We  congratulate  all  who  had  anything  to  do  with  the  getting 
out  of  this  book,  as  it  is  a  fine  piece  of  press-work,  sold  at  a  reasonable  price,  and  contains 
an  up-to-date  digest  of  the  subject  of  pathology. — H.  W.  C. 

A  Text-Book  on  the  Practice  of  Gyx.kcoich.y.  For  Practitioners  and  students.  By  W. 
Easterly  Ashton,  M.D.,  LL.D.,  Fellow  of  the  American  Cynsecologic  Society;  Professor  of 
Gynaecology  in  the  Medico-Chirurgical  College  of  Philadelphia.  Octavo  Volume  of  1079 
pages,  containing  1040  new  and  entirely  original  line  drawings.  Philadelphia  and  London: 
W.  B.  Saunders  &  Co.,  1905.     (loth.  $6.50,  net.     Half  morocco.  $7.50,  net. 

Dr.  Ashton  has  written  for  the  medical  student  the  best  Nook  on  (.ynsecology  in  the 
English  language.  He  has  taken  nothing  for  granted  in  the  de>cription  of  gynaecologic  diseases 
or  procedures.  He  assumes  that  the  student  has  no  special  knowledge  on  this  subject,  and 
then  proceeds  to  give  him  detailed  and  ace  urate  descriptions  of  conditions  and  elaborate  and 
precise  instructions  as  to  the  preparation  of  the  patient,  selection  of  instruments,  and  of  the 
successive  step-  of  the  surgical  procedure  advised.  To  older  practitioners  and  specialists  in 
gynaecology,  this  reiteration  and  repetition  may  seem  a  little  tiresome  and  unnecessary;  but 
for  the  student  and   the   novice   in    gyn  practice,   it   is   exactly    what    is    required   to 

impress  the  necessity  for  aseptic  technique  and  for  surgical  accuracy.  To  tin'  teacher  of 
gynaecology  1  he  book  is  a  boon;  it  is  systematically  arranged  and  ever  keeps  in  mind  the 
requirements  of  th<  lical  student,  who  each  year  becomes  mere  and  more  burdened 

with  new  specialties  of  which  he  must  have  general  knowledge  before  he  can  secure 

the  coveted  diploma. 

Dr.  Ashton's  book  contains  1046  new  line  drawings,  which  amply  illustrate  the  text.  Both 
the  medical  and  surgical  aspects  0  logy  have  been  carefully  discussed;    and  the  best 

methods  of  operations  for  the  treatment  of  a  disease  are  described  rather  than  a  multiplicity 
of  methods  which  tend  I  ige  mind.     The  book  i-  arranged  on  an  anatomic 

basis,  which  pern  n  of  the  methods  id'  examining  each  organ  before  describing 

its  diseases,  and  renders  unnecessary  the  usual  chapter  on  physical  examination.  The  author 
has  wisely  discussed  the  subjects  of  appendicitis  and  movable  kidney  ^<>  often  associated  with 
diseases  of  the  pelvic  organs.     A  complete  i  to  the  value  of  the  book. 

After  a  careful  review  id'  this  volume  we  have  no  hesitation  in  recommending  il  .<  a  work 
which    with    extreme    lucidity    presen  and    best     knowledge    of    gynaecologic 

science.     \V.    K. 


576  BOOKS  AND  MONOGRAPHS  RECEIVED. 

Text-Book  of  Human  Physiology,  Including  Histological  and  Microscopical  Anatomy  with 
Especial  Reference  to  the  Practice  of  Medicine.  By  Dr.  L.  Landois.  Tenth  Revised  and 
Enlarged  Edition.  Edited  by  Albert  P.  Brubaker,  M.D.,  and  Translated  by  Augustus  A. 
Eshner,  M.D.  With  394  Illustrations.  Philadelphia:  P.  Blakiston's  Son  &  Co.  Octavo, 
1028  Pages.     Cloth,  $7.00.     Leather  or  Half-Morocco,  $8.00. 

Landois's  Physiology,  translated  under  the  direction  of  Professor  Brubaker,  is  unques- 
tionably one  of  the  best  and  most  reliable  works  of  the  kind  in  the  English  language.  This 
is  said  after  a  very  careful  perusal  of  the  book,  and  after  many  of  its  parts  had  been  used  as 
guide.  Moreover,  it  shows  evidence  of  a  careful  review  of  the  general  literature.  This  is 
well  shown  in  the  position  taken  by  the  author  in  respect  to  the  interchange  of  gases  between 
the  blood  in  the  pulmonary  capillaries  and  the  air  in  the  alveoli.  The  writer  of  this  review 
has  emphasized  the  fallaciousness  of  the  prevailing  doctrines  on  this  subject,  and  particularly 
the  fact  that  the  absorption  of  oxygen  is  not  due  to  a  diffusion  process.  Landois  says  in  this 
connection:  "The  absorption  of  oxygen  from  the  alveolar  air  for  the  purpose  of  oxidation 
of  the  venous  blood  in  the  pulmonary  capillaries  is  a  chemical  process,  as  the  gas-free  haemo- 
globin in  the  lungs  takes  up  oxygen  to  form  oxyhaemoglobin.  That  this  absorption  depends, 
not  on  diffusion  of  the  gases,  but  on  the  atomic  combination  pertaining  to  the  chemical  process, 
is  shown  by  the  fact  that  the  blood  does  not  take  up  more  oxygen  Avhen  the  pure  gas  is 
respired  than  when  atmospheric  air  is  respired ;  further,  that  animals  that  are  made  to  breathe 
in  a  small,  closed  space  will  absorb  into  their  blood  all  of  the  oxygen  but  traces,  to  the  point 
of  suffocation.  If  the  respiratory  absorption  of  oxygen  were  a  diffusion-process,  much  more 
oxygen  would  have  to  be  taken  up  in  the  first  case  in  accordance  with  the  partial  pressure 
of  the  gas;    while  in  the  latter  case  such  an  extensive  absorption  could  not  take  place." 

Another  excellent  feature  which  renders  this  book  more  useful  than  many  other  Avork*  on 
physiology,  is  the  presence  of  several  sections  upon  comparative  physiology  and  the  history  of 
each  subject  studied.    On  the  whole,  this  work  is  heartily  recommended. — C.  E.  de  M.  S. 


IJooks  and  /Vlonographs  Received. 

The  editor  begs  to  acknowledge,  with  thanks,  the  receipt  of  the  following  books  and 
monographs:  — 

"Operative  Surgery."  For  Students  and  Practitioners.  By  John  J.  McGrath,  M.D.,  Pro- 
fessor of  Surgical  Anatomy  and  Operative  Surgery  at  the  New  York  Post-Graduate  Medical 
School,  Surgeon  to  the  Harlem,  Post-Graduate,  and  Columbus  Hospitals,  New  York.  Second 
Edition,  Thoroughly  Revised.  With  265  illustrations,  including  many  Full-Page  Plates  in 
Colors  and  Half-tone.  628  Royal  Octavo  Pages,  Extra  Cloth,  $4.50,  net;  Half-Morocco,  $5.50, 
net.  Sold  only  by  subscription.  F.  A.  Davis  Company,  Publishers,  1914-16  Cherry  Street. 
Philadelphia,  Pa. — —A  Treatise  on  Diagnostic  Methods  of  Examination.  By  Prof.  Dr.  H. 
Sahli.    Additions  by  Francis  P.  Kinnicutt,  M.D.,  Nathaniel  Bowditch  Potter.    W.  B.  Saunders 

&  Co.,  Philadelphia,   1905. Operative   Surgery.     By  John  Fairbairn   Binnie,   A.M.C.M.     T. 

Blakiston's  Son  &  Co.,  Philadelphia.- Pathology  and  Morbid  Anatomy.    By  T.  Henry  Green, 

M.D.     Lea  Brothers  &  Co.,  New  York  City. Superstition  in  Medicine.     By  Dr.  Hugo  Mag- 
nus.    Translated  by  Dr.  Julius  L.  Salinger.     Funk  &  Wagnalls  Company. Carbonic  Acid 

in    Medicine.     By   Achilles   Rose,   M.D.     Funk   &.   Wagnalls   Company. Text-Book    of   the 

Practice  of  Medicine.     By  Dr.  James  M.  Anders.     W.  B.  Saunders  &  Co.,  Philadelphia. 

Text-Book  of  Diseases  of  Women.     By  Barton  Cooke  Hirst.     W.  B.  Saunders  &  Co.,  Philadel- 
phia.  Anatomy  of  the  Brain.     By  J.  F.  Burkholder,  M.D. .  C.  P.  Engelhard  &  Co. Notes 

on  the  Composition  of  Scientific  Papers.     By  Clifford  Allbutt. A  Manual   of  Diseases  of 

Infants  and  Children.    By  John  Ruhrah,  M.D.    W.  B.  Saunders  &  Co.,  Philadelphia. A  Text 

Book  of  Physiology.     By  William  II.  Howell.     W.  B.  Saunders  &  Co.,  Philadelphia. Four 

Epochs  of  Woman's  Life.     By  Anna    M.  Galbraith.     W.  B.  Saunders  &  Co.,  Philadelphia. 

Health.  Strength,  and  Power.     By  Dudley  A.  Sargent    H.  M.  Caldwell  &  Co. Disorders  of 

Metabolism:    Nephritis.     By  Prof.  Carl  von  Noorden.     Treat  &  Co. Drink  Restriction.     By 

Carl  von  Noorden.     Treat  &  Co. Obesity.     By  Carl  von  Noorden.     Treat  &  Co. Colitis. 


BOOKS  AND  MONOGRAPHS  RECEIVED.  577 

By  Carl  von  Noorden.    Treat  &  Co. Saline  Therapy.    By  Carl  von  Noorden.     Treat  &  Co. 

Diabetes.      By    Carl    von    Noorden.      Treat    &    Co. Auto-Intoxication.      By    Carl    von 

Noorden.      Treat   &   Co. Diseases   of   Children,   Third   Edition.      By   L.   Emmet   Holt.     D. 

Appleton  &  Co. ''Transactions  of  the  Thirty-Eighth  Annual  Session  of  the  West  Virginia 

State  Medical  Association,  1905."' "A  Dissertation  on  Temperament,  Diathesis,  Dyscrasia, 

Predisposition  Cachexia,  Susceptibility,  Idiosyncrasy,  and  Heredity."     By  Homer  Wakefield, 

New  York,  1905. "Pathology  of  Katabolism  in  Relation  to  the  Etiology  and  Pathology  of 

Cancer  and  Allied  States."    By  Homer  Wakefield,  New  York,  1902. "Some  Observations  on 

Modern  Cardio-Therapy."    By  Homer  Wakefield,  New  York,  1901. "A  Contribution  to  the 

Etiology  of  Malaria,  and  to  the  Analysis  of  Meteorology  to  Chemical  Pathology."  By  Homer 
Wakefield,  New  York,  1905. "The  Heart  Cure;  Its  Terminology,  Purposes  and  Achieve- 
ments, Including  the  Etiology  of  Fatty  Degeneration."  By  Homer  Wakefield,  New  York, 
1903. "Katabolism  and  Eyestrain."  By  Homer  Wakefield,  New  York,  1905. "Commen- 
taries upon  Lues  and  Leprosy  as  Subcatabobc  Diseases."     By  Homer  Wakefield,  New  York. 

1904. "The  Rational  Treatment  of  Malignant  Tumors."     By  Homer  Wakefield,  New  York, 

1904. "Why  Surgical  Fixation  of  a  Movable  Kidney  will  Not  Relieve  Dyspeptic  and  Nervous 

Symptoms."  By  C.  D.  Aaron,  Detroit,  Mich.,  1905. "How  to  Palpate  a  Movable  Kid- 
ney."    By   C.    D.   Aaron,   Detroit,   Mich.,    1905. "Gastrojejunostomy    for    Benign    Steno>is 

of  the  Pylorus."     By  W.  H.  Morrison,  Philadelphia,  1905. "Report  of  the  Progress  Made 

in  the  Treatment  of  Laryngeal  Tuberculosis  Since  the  Last  International  Congress."    By  J.  W. 

Gleitsmann,  New  York,  1897. "Subglottic  Sarcoma  Removed  Endolaryngeally  with  Galvano 

Cautery  Snare."     By  J.  W.  Gleitsmann,  New  York,  1902. "Intratracheal  Injections."     By 

J.  W.  Gleitsmann,  New  York,  1905. "Tuberculosis  of  the  Larynx."     By  J.  W.  Gleitsmann, 

New  York,  1904. "Reminiscences  of  the  International  Medical  Congress  at  Moscow."     By 

J.   W.    Gleitsmann,   New   York,    1S97. "Some    Phases    of    Syphilis,    Especially    the    Larval 

Syphilis  of  Woman."  By  William  Murrell,  London,  1905. "Jargon  and  Hypocrisy  in  Medi- 
cine."    By   A.   Rose,   New   York,    1905. "The   Vapor   Method   of   Anaesthesia."     By   J.   T. 

Gwathmey,  New  York,  1905. "A  Clinical  and  Laboratory  Study  of  the  Therapeutic  Value  of 

Hydrochloric  Acid  in  Diseases  of  the  Stomach."    By  R.  F.  Chase,  Boston,  Mass.,  1905, "The 

Ocular  Symptoms   of  Affections  of  the  Accessory  Sinuses   of  the  Nose."     By  W.  C.  Posey, 

Philadelphia,  1905. "Conjunctival  Irritation  Excited  by  Proximity  to  a  Horse."     By  W.  C. 

Posey,  Philadelphia,  1905. "Unilateral  Exophthalmos  in  Exophthalmic  Goiter,  with  Report 

of  a  Case."     By  W.  C.  Posey  and  W.  C.  Swindells,  Philadelphia,  1904. "Unusal  Choreiform 

Alterations  in  the  Width  of  the  Palpebral  Fissure  of  Both  Eyes,  Occasioned  by  Spasm  of  the 

Levator  Palpebral  Muscles."    By  W.  C.  Posey,  Philadelphia,  1902. "The  Correction  of  Nasal 

Deformities  by  Subcutaneous  Operations."     By  John  O.  Roe,  Rochester,  N.  Y.,  1905. "The 

Removal  of  Obstructions  and  Cicatricial  Contractions  of  the  Nose  by  the  Plastic  Method."    By 

John  O.  Roe,  Rochester,  N.  Y.,  1904. "The  Correction  of  the  Deviations  of  the  Nasal  Septum, 

with  Special  Reference  to  the  Use  of  the  Author's  Fenestrated  Comminuting  Forceps."  By 
John  O.  Roe,  Rochester,  N.  Y.,  1901. "A  Scientific  Classification  of  the  Methods  of  Modi- 
fying Cow's  Milk  for  Infant  Feeding."  By  G.  R.  Pisek,  New  York,  1905. "A  Further  Con- 
tribution to  the  Study  of  Pruritus  Ani,  with  Special  Reference  to  its  Local  Treatment."     By 

L.  H.  Adler,  Jr.,  Philadelphia,   1905. "A  Consideration  of  Some   of  the  Methods  for   the 

Treatment  of  Cancer  of  the  Rectum."     By  L. 'H.  Adler,  Jr.,  Philadelphia,  1904. "Internal 

and  External  Haemorrhoids,  With  Special  Reference  to  Their  Treatment."    By  L.  H.  Adler,  Jr., 

Philadelphia,   1905. "The  Treatment   of  Internal  Haemorrhoids  by  the   Injection  Method." 

By  L.  H.  Adler,  Jr.,  Philadelphia,  1905. "The  Results  of  Decapsulation  of  the  Kidneys  for 

Nephritis  in  Children,  with  Report  of  a  Case  in  a  Child  of  Twenty-six  Months."  By  E.  E. 
Graham,  Philadelphia,  1905. "A  Fata]  Case  of  Acute  Rheumatic  Endocarditis  with  Rheu- 
matic Symptoms  in  Joints  and  Muscles  Barely  Noticeable."     By  E.  E.  Graham,  Philadelphia, 

1905. "Artificial  Feeding  of  Infants  During  the  First  Year."    By  E.  E.  Graham,  Philadelphia, 

1905. "The  Non-Susceptibility  of  the  New-born  to  Measels."  By  E.  E.  Graham,  Philadel- 
phia, 1904. "Mechanical  Vibration:  Its  Theory  and  Application  in  the  Treatment  of  Dis- 
ease."   By  M.  F.  Pilgrim,  New  York,  1903. "Cardio- Vascular  Changes  due  to  Litheeinia." 


578 


BOOKS  AND  MONOGRAPHS  RECEIVED. 


By  A.  B.  Conklin,  Ambler,  Pa.,  1905. "Researches  in  the  Sun-spot  Spectrum,  Region  F  to 

a."     By  Walter  M.  Mitchell.  Princeton,  N.  J.,   1905. "A  New  Micro-Chemical  Reaction  of 

the  Sperma  and  Its  Application  in  Medico-Legal  Investigations."    By  Michele  Barberio,  Naples, 

Italy,  1905. "Mines  de  Houille  Rendues  Refractaires  a  L'Ankylostome  par  des  Eaux  Salees 

de  Filtration."    Par  le  Dr.  A.  Manouvriez.  Valenciennes,  France,  1905. 

From  the  United  States  Department  of  Agriculture,   Washington,  D.  C,  the  following: 

"Report  of  the  Secretary  of  Agriculture,  1905."' "Cattle,  Sheep,  and  Hog  Feeding  in  Europe." 

By  W.  J.  Kennedy,  1905. "Imports  of  Farm  and  Forest  Products,  1902-1904,  by  Countries 

from   Which   Consigned."      1905.- -"Exports    of    Farm    and    Forest    Products,    1902-1904,    by 

Countries  to  Which  Consigned."     1905. "Crop   Export   Movement  and  Port   Facilities   on 

the  Atlantic  and  Gulf  Coasts."     By  F.  Andrews,  1905. "Okra:     Its  Culture  and  Uses."    By 

W.  R.   Beattie,   1905. "Spraying  For   Cucumber   and  Melon  Diseases."     By   W.  A.   Orton, 

1905. "The  Guinea  Fowl  and  its  Use  as  Food.*'     By  C.  F.  Langworthy,  1905. "The  Pro- 
duction of  Good  Seed  Corn."    By  C.  P.  Hartley;    with  an  "Appendix  on  Selection  and  Care  of 

Seed  Corn."    By  H.  J.  Webber,  1905. "Experiment  Station  Work,"  xxxi,  1905. "A  Study 

of  Rock  Decomposition  Under  the  Action  of  Water."    By  A.  S.  Cushman,  1905. "The  Cotton 

Red  Spider."    By  E.  S.  G.  Titus,  1905. "The  Joint- Worm."    By  F.  M.  Webster,  1905. 


EDITORIAL    STAFF. 

Sajous's  Analytical  Cyclopaedia  of  Practical  Medicine. 


J.  GEORGE  ADAMI,  M.D., 

MONTREAL,  F.  Q. 

LEWIS  H.  ADLER,  M.D., 

PHILADELPHIA. 

JAMES  M.  ANDERS,  M.D.,  LL.D., 

PHILADELPHIA. 

THOMAS  G.  ASHTON,  M.D.. 

PHILADELPHIA. 

A.  D.  BLACKADER,  M.D., 

MONTREAL,  P.  Q. 

E.  D.  BONDURANT,  M.D.. 

MOBILE,  ALA. 

DAVID  BOVAIRD.  M.D.. 

NEW  YORK  CITY. 

WILLIAM  BROWNING,  M.D., 

BROOKLYN,  N.  Y. 

WILLIAM  T.  BULL,  M.D., 

NEW  YORK  CITY. 

CHARLES  W.  BURR,  M.D., 

PHILADELPHIA. 

HENRY  T.  BYFORD,  M.D.. 

CHICAGO,  ILL. 

HENRY  W.  CATTELL,  M.D.. 

PHILADELPHIA. 

WILLIAM  B.  COLEY,  M.D.. 
NEW  YORK  CITY. 

FLOYD  M.  CRANDALL,  M.D., 

HEW  YORE  CITY. 
ANDREW  F.  CURRIER,  M.D.. 

NEW  YORK  CITY. 

ERNEST  W.  CUSHING,  M.D.. 

BOSTON,  MASS. 

GWILYM  G.  DAVIS,  M.D.. 

PHILADELPHIA. 

N.  S.  DAVIS,  M.D., 

CHICAGO,  ILL 

AUGUSTUS  A.  ESHNER,  M.D., 

PHILADELPHIA. 

SIMON  FLEXNER,  M.D., 

PHILADELPHIA. 

LEONARD  FREEMAN,  M.D.. 

DENVER.  COL. 

8.  G.  GANT.  M.D., 
NEW  YORK  CITY. 

J.  MoFADDEN  GASTON,  SB.,  Ml) 

ATLANTA,  GA. 

J.  McFADDEN  GASTON,  JR.,  M.D. 

ATLANTA,  GA. 

E.  B.  GLEASON,  M.D.. 

PHILADELPHIA. 

EGBERT  H.  GRAN  DIN,  M.D., 
MBV  TMS  <MTT. 


ASSOCIATE    EDITORS. 

J.  P.  CROZER  GRIFFITH,  M.D., 

PHILADELPHIA. 

C.  M.  HAY,  M.D., 

PHILADELPHIA. 

FREDERICK  P.  HENRY,  M.D., 

PHILADELPHIA. 

L.  EMMETT  HOLT,  M.D., 

NEW  YORK  CITY. 

EDWARD  JACKSON,  M.D., 

DENVER,  COL. 

W.  W.  KEEN,  M.D., 

PHILADELPHIA. 

EDWARD  L.  KEYES,  Jr.,  M.D., 

NEW  YORK  CITY. 

ELWOOD  R.  KIRBY,  M.D., 

PHILADELPHIA. 

L.E.  La  FETRA.  M.D.. 

NEW  YORK  CITY. 

ERNEST  LAPLACE,  M.D.,  1.1.  D., 

PHILADELPHIA. 

R.  LEPINE,  M.D., 

LYONS,  TRANCE. 

F.  LEVISON,  M.D.. 

COPENHAGEN,  DENMARK. 

A.  LUTAUD,  M.D., 

PARIS,  PRANCE. 

G.  FRANK  LYDSTON,  M.D.. 

CHICAGO,  ILL. 

F.  W.  MARLOW,  M.D., 

SYRACUSE,  IT.  Y. 
SIMON  MARX.  M.D.. 

NEW  YORK  CITY. 

ALEXANDER  McPHEDRAN,  1!  II 

■    TORONTO,  ONT. 

E.  E.  MONTGOMERY,  M.D.. 

PHILADELPHIA. 

HOLGER  MYGIND,  M.D., 

COPENHAGEN,  DENMARK. 

W.  P.  NORTHRUP.  M.D., 

NEW  YORK  CITY. 

RUPERT  NORTON,  M.D., 

WASHINGTON,  D.  C. 
H.  OBER8TEINER.  M.D.. 

VIENNA,  AUSTRIA. 

CHARLE-  A.  OLIVER.  M.D.,     " 

PHILADELPHIA. 

WILLIAM  OSLER.  NED., 

BALTIMORE,  MD. 

LEWIS  8.  PILCHER,  M.D., 

BROOKLYN.  N    Y 

WILLIAM  CAMPBELL  1'OSEY,  M.D., 

PBILADJUJ'HIA. 


W.  B.  PRITCHARD,  M.D., 

NEW  YORK  CITY. 

JAMES  J.  PUTNAM,  M.D., 

BOSTON. 

B.  ALEXANDER  RANDALL,  M.D., 

PHILADELPHIA. 

CLARENCE  C.  RICE,  M.D., 

NEW  YORK  CITY. 

ALFRED  RUBINO,  M.D., 

NAPLES,  ITALY. 

REGINALD  H.  SAYRE,  M.D., 

NEW  YORK  CITY. 

JACOB  E.  SCHADLE,  M.D., 

ST.  PAUL,  MINN. 

JOHN  B.  SHOBER,  M.D., 

PHILADELPHIA. 

J.  SOLIS-COHEN.  M.D., 

PHILADELPHIA. 

SOLOMON  SOLIS-COHEN,  M.D., 

PHILADELPHIA. 

H.  W.  STELWAGON,  MD., 

PHILADELPHIA. 

D.  D.  STEWART,  M.D., 

PHILADELPHIA. 

LEWIS  A.  STIMSON,  M.D., 
NEW  YORK  CITY. 

J.  EDWARD  STUBBERT,  M.D., 

LIBERTY,  N.  Y. 

A.  E.  TAYLOR,  M.D., 
SAN  FRANCISCO,  CAL. 

J.  MADISON  TAYLOR,  M.D., 
PHILADELPHIA. 

M.  B.  TINKER,  M.D.. 

PHILADELPHIA. 

CHARLES  S.  TURNBULL.  M.D.. 

PHILADELPHIA. 

HERMAN  F.  VICKERY.  M.D., 

BOSTON,  MASS. 

F.  E.  WAXHAM,  M.D., 

DENVER,    COL. 

J.  WILLIAM  WHITE,  M.D., 

PHILADELPHIA. 

JAMES  C.  WILSON,  M.D., 

PHILADELPHIA. 

C.  SUMNER  WITHERSTINE.  M.D., 

PHILADELPHIA. 

ALFRED  C.  WOOD,  M.D., 

PHILADELPHIA. 

WALTER  WYMAN,  M.D, 
VA1MXHOTOH,  B.C. 


Names  of  Authors  Quoted  in  the  Monthly  Cyclopaedia  of 
Practical  Medicine  During  the  Year  1905. 


Abbe,    R.,   313. 

Abrikossoff,    A.    J.,    91. 

Ackerman,  W.,  and  L.  M. 
Gompertz,    329. 

Adami,   J.    G.,   278. 

Adams,    E.    O.,   43. 

Ahlberg,    A.,    277. 

Albu,    A.,    353. 

Allen,    165. 

Allen,    Lyman,    133. 

Alter,    F.    W.,    369. 

Anders,   J.   M.,   39,   368. 

Anders,  J.  M.,  and  A.  C.  Mor- 
gan,  421. 

Andrade,   E.,  333. 

Archambault,   L.,   410 

Armstrong,  H.,  406. 

Aronstam,    N.    E.,   43. 

Auer,    John,   86. 

Aurness,   P.   A.,   416. 

Ayers,    Winfield,    403. 

Baer,   W.    S.,   and   H.   W.   Ken- 

nard,  78. 
Bain,  William,  431. 
Bain  and  Frankling.   308. 
Bainbridge,   F.   A.,   78. 
Ball,   Charles,   127. 
Ballenger,  E.  G.,  126. 
Ballin,  L.,  452. 
Barclay,    R.,   510. 
Barker,  A.  E.,  59,   133. 
Barnett,   C.  E.,  126. 
Barr,   Martin   W.,   392. 
Barrett,  C.  W.,  211,  447. 
Barstow,  D.  M.,  251. 
Barwell,    H.,   367. 
Bashford,  E.   F.,  215. 
Bastedo,  W.  A.,  20. 
Beach,  W.   M.,  425. 
Beates,   Henry,   Jr.,   7. 
Beauvy,  58. 
Beck,   Carl,  405. 
Behr,  40. 
Belot,   127. 
Bennett,  W.  H.,  73. 
Berkeley,  W.  N.,  119. 
Bettmann,  H.  W.,  85. 
Bevan,  399. 
Bevan,  A.  D.,  and  H.  B.  Favill, 

446. 
Bibergiel,    556. 
Billings,    F.,   332. 
Binnie,  J.  F.,  311. 
Birt,  Arthur,   572. 
Blake,   C.   J.,   521. 
Blumreich,   113. 
Boas,  I.,  276. 
Boenninghaus,    36. 
Boggs,  R.  H.,  40,  268. 
Bokenham,  115. 
Bosanquet,   W.   C,  257. 
Bossuet,  G.,  86. 
Bottomley,  447. 
Bovaird,  David,  Jr.,  236. 
Bovee,  J.  Wesley,  64. 
Boyd,    F.   D.,   315. 
Bradford,   J.   R.,  454. 
Branson,   W.   P.   S.,  90. 
Brickmer,   S.   M.,   457. 
Briggs,   J.   B.,  448. 
Broadbent,  William.  406. 
Broadbent,   W.  H.,  350. 
Bronowski,   F. ,   169. 
Brooks,   Harlow, 
Brose,    L.,    188. 
Brow*  i 

Brower,   D.   B.,   509. 
Brown,  E.  D.,  407. 
Brown,  J.  T.,  506. 
Brown,    T.   R.,   562. 
Brown  and  OsgocI 
Browning,   C.    H,   4C6. 
Bruening,    H.,    323. 


Brunton,   Lauder,   402,   570. 
Brunton,    S.    Lauder,    and    Bo- 
kenham,  115. 
Brush,   C.  E.,  402. 
Bryan,   415. 

Bucknall,  R.   T.  H.,  565. 
Bulkley,    L.   D.,   35. 
Bullock,  E.  S.,  103. 
Bulson,  A.  E.,  325. 
Bulson,   A.   E.,   Jr.,   553. 
Bumm,   E.,   182. 
Bunch,  J.  L.,  181. 
Bunting,   C.   H.,   400. 
Bunting,   T.   L.,   19. 
Burrell   H.    L.,   558. 
Byford,   H.   T.,   211. 

Cabot,   I.   R.   C,   236. 

Cadwalader,  W.   B.,  119. 

Caiger,   E.   F.(  45. 

Calabrese,   121. 

Camac,   C.   N.   M.,  251. 

Campani,  Arturo,  270,  326. 

Cannaday,  J.  E.,  521. 

Cannon,  W.  P.,  132. 

Canter,  C,  184. 

Capaldi,  311. 

Carpenter,    D.    N.,    and    R.    L. 

Sutton,   66. 
Carter,  W.  W.,  136. 
Casciani,   P.,   222. 
Cattaneo,  559. 
Cattle,  C.  H.,  118. 
Ceriolo,  A.,  379. 
Chandler,   Swithin,  558. 
Charrin  and  Leplay,  73. 
Chase,   H.   M.,  358. 
Chase,  R.  F.,  519. 
Chatard,  J.  A.,  566. 
Cheney,  W.  W.,  414. 
Child,   C.   G.,   Jr.,   381. 
Christian,  H.   M.,  438. 
Churchill,   F.   S.,  320. 
Churchman,   J.   W.,   78. 
Claiborne,  J.  H.,  40. 
Clairmont,  P.,  and  H.  Haberer, 

372. 
Claparede,  132. 
Clark,  L.   P.,  A.  S.  Taylor,  and 

T.   P.   Prout,  503. 
Clark,  Raymond,  36. 
Clarke,  J.  M.,  404. 
Clarke,   T.   W.,  140. 
Clenet,  C,  67. 
Coakley,  C.  G.,  233. 
Cobb,  J.  O.,  44. 
Codman,     E.     A.,     and     H.     M. 

Chase,  358. 
Coggeshall,  H.,  308. 
Cohen,   Sigismund,  23. 
Cohen,  S.  Solis,  80,  342. 
Cokenower.    J.    W.,   37. 
Coley,  T.  L.,  31. 
Coley,  William  B.,  428,  574. 
Colles,   C.  J.,  504. 
Collins,  Joseph,  49,  513. 
Colombo,   Carlo,  36. 
Comroe,   J.   H.,   327. 
Connell,    F.   G.,   221. 
Cook,  H.  W.,  61. 
Cooper,   Arthur,  86. 
Corning,  J.   L.,  68. 
Cotton,   F.   J.,   117. 
Couch,  L.   B.,  376. 
Cowie,   D.    M.,   and  F.   A.    Inch, 

455 
Craig,   C.   F.,   350. 
Craig,   D.   H.,  426,  558. 
Craig,  F.  A.,    171. 
Crede,  B.r  180. 
Crile,  G.  W.,  328.  460. 
Croftan,  A.  C,  352. 
Crothers,  T.   D.,  410. 
Cumstou,  C.  G.,  162,  347,  501. 


Cunningham,    J.    H.,    Jr.,    and 

F.   H.   Lahey,  260. 
Cushing,     E.     F.,     and     T.     W 

Clarke,  140. 

D'Amito,  Luigi,  39. 

Dana,  C.  L.,  385. 

Dancourt,  C,  477. 

Danis,   G.,   137. 

Davis,  B.   B.,   473. 

Dawson,  E.  M.,  168. 

Dearborn,  S.  S.,  27. 

Decherf,  30,  167. 

Dehrain,  84. 

de  la  Carriere,  G.  Carron,  466 

Delageniere,  68. 

Delore   and   Duteil,   209. 

Denker,  A.,  361. 

Derby,  G.   S.,  174. 

De    Ybarra,    A.    M.    Fernandez, 

Dickey,  W.  A.,  327. 
Diller,  Theodore,   97. 
Dittrick,  Howard,  478. 
Dock,  George,  33,  450. 
Dolley,   D.   H.,   88. 
Douglass,   Beaman,   133. 
Dowd,   C.   N.,   422. 
Dreuw,   374. 
Dukes,   Clement,   499. 
Dun,  R.   C,  308. 
Dunn,   C.   H,   377. 
During,  266. 
Duteil,   209. 
Dyball,  Brennan,  37. 
Dyer,  Isadore,  412. 

Edkins,  J.   S.,   409. 
Edwards,    William   A.,   152 
Effertz,  O.,  30. 
Ehret,  H.,   261. 
Einhorn,   Max,  366. 
Eisenberg,  P.  Y.,  379. 
Ellinger  and  Seelig,  274. 
Elliott,   A.   R.,   467. 
Elliott.   T.    R.,   445. 
El  wood,    C.    R.,    325 
Ely,    L.    W.,   418. 
Emery,    W.    D'Este,   230. 
Escat,  E.,  502. 
Evans,  J.  J.,  415. 
Evans,   T.   H.,  218. 
Evenhof,    I.,   446. 
Ewald,   352. 
Ewart,   William,    125. 
Ewing,    177. 

Fabre,   M.,  516. 

Fabre,   P.,  365. 

Fagge,  225. 

Farmer,    J.    B.,    and    J.    E.    S. 

Moore,  466. 
Fauntleroy,  A.   M.,  310. 
Faure,  330. 
Faure,   Maurice,  521. 
Favill,   H.   B.,   446. 
Fawcett,    Edward,    468. 
Federmann,  225. 
Ferguson,  A.  H.,  549. 
Findley,   Palmer,  426. 
Fischer,    171. 
Fischer,    H.    M.,    166. 
Fischer,    Louis,    534. 
Fischkin,   406. 
Flamini,    Mario.   21. 
Flint,   C.   P.,   130,  157. 
Foster,   Frank  P.,  47. 
Fowler,    11.    A  ,    128. 
Fox,   T.   C,    273. 
Fraenkel,   420. 
Fraenkel,  H.  S.,  475. 
Francis,  Alexander,  16. 
Franke,  F.,  69. 
Franklin,   Milton,   188,  283. 


(579) 


580 

Frankling,  308. 
Freeman,  R.  G.,  321. 
French,   Herbert,  27. 
Freund,  W.  A.,  214. 
Friedenwald,    Julius,    199. 
Friedrich,   183. 
Fullerton,   A.,   121. 
Fulton,    J.    S.,   79. 
Fiirbringer,    399. 
Furet,  L.,  565. 
Futcher,  T.  B.,  30. 

Galbraith,   J.   J-,   279. 

Galbraith,  W.  J.,  124. 

Galdi,   F.,  310. 

Galenga,   P.,  7o. 

Gallant,    A.    E.,   267. 

Gardner,  A.   H.,  466. 

Garriere,   G.,   and   C.   Dancourt, 

477. 
Gasparini,  Alberto,  171. 
Gaston,    James    McFadden,    481. 
Gelpke,  113. 

Gennari,    Carlo,    243,    263,    351. 
Gianasso,   A.    B.,   411. 
Gibson,   G.   A.,   501. 
Gildersleeve,   N.,  311,  537. 
Gobbi,    Guglielmo,    357. 
Gompertz,   L.   M.,   329. 
Goodall,  A.,  175,  476. 
Gould,   G.   M.,   SI. 
Go.wers,   W.   R.,   S7. 
Graham,    Christopher,    474. 
Grober,  A.,  216. 
Gros,    B.    L.,    510. 
Grulee,  C.  G.,  and  D.  B.  Phem- 

ister    471. 
Gullan'd,  G.  L.,  and  A.  Goodall, 

175,  476. 
Gurich,   89. 

Haberer,   H.,   372. 
Haemann,   Charles,  568. 
Hall,  G.   Stanley,  241. 
Hall,  H.  J.,  77. 
Hamilton,    Alice,    233. 
Hamilton,  A.   McL.,   28. 
Hardon,  R.  W.,  113,  554. 
Hare,   F.,   252,   360,   550. 
Harlan,  Earl,  414. 
Harrington,   F.   B.,  210. 
Harris,  477. 
Hart,  Berry,  272. 
Hartigan,   W.,  232. 
Hassin,   G.   B.,   510. 
Hastings,  C.  J.  C.  O.,  178. 
Hawk,  P.  B.,  186. 
Hay,  John,  554. 
Hayd,  237. 
Hecht,  A.,  451. 
Heim,   P.,   18. 
Heiman,    Henry,    bll. 
Heineke,  H.,  85. 
Helbron,   267. 
Henry,   F.   P.,   166. 
Henry,  J.  N.,  326. 
Herman,  271. 
Herold,  J.,  352. 
Herter,   G.,   401. 

Herz,  M.,  15,  361. 

Hess,  J.   H  ,  562. 

Hessert,  William,   504. 

Heubner,   O.,   403. 

Hibbert,   J.   C,  333. 

Hildebrandt,    112. 

Hill,   Edward  C,  145. 

Hill,   T.    C,   118. 

Hilliard,    H.,    70. 

Hirschfeld,   E.,   502. 

Hochhaus,  H.,  222. 

Hoffmann,  P.,  19. 

Hofmann,  J.  A.,  184. 

Holmes,  A.  M.,  74. 

Holmes,   E.   W.,   18. 

Holmes,   R.   W.,  372. 

Holt,  L.  E.,  167. 

Holz,  158. 

Hose,  C,  552. 

Houghton,    H.   A.,    US. 

Howard,  C.   P.,  46. 

Howe,  J.   S.,  376. 


NAMES  OF  AUTHORS    QUOTED. 


Howe,   W.    C,   164. 
Hoyt,    D.    M.,   306. 
Hudson-Makuen,  G.,  232. 
Huggard,    W.    R.,    and    E.     C 

Morland,   379. 
Huguier,   H.,   456. 
Hiihner,   M.,  229. 
Huizinga,   J.   G.,  469. 
Hunt,   J.    Ramsay,   307. 
Hunter,   J.  W.,  Jr.,   6o. 
Hutchinson,    J.,   557. 
Hutchison,   355. 
Hutchison,   W.,   353. 
Hutinet,   114. 
Hyde,  J.  N.,  274. 

Inch,   F.   A.,  455. 
Isnardi,  277. 
Itzkowitz,  L.,  79. 
Jack,   G.   N.,   449. 
Jackson,  G.  T.,  158. 
Jarecky,    Herman,    181. 
Jastrow,  Joseph,  193. 
Jaworski,  J.,  84. 
Jellinck,   117. 
Job,  456. 

Johnson,  A.  B.,  128. 
Johnson,    J.    C,   120. 
Joslin,   E.   P.,  453. 
Jones,   R.,   264. 
Jones,  R.   L.,  272. 
Journal    American    Medical   As- 
sociation,  14,   71,    150,   348,   522. 
Juliusberg,   M.,   257. 
Justus,   J.,   448. 

Kelly,   Howard  A.,  231,   519. 
Kelly,  J.  A.,  111. 
Kemp,   R.   C,  370. 
Kennard,  H.  W.,  78. 
Kermauner,  F.,  31. 
Kerrison,  P.  D.,  563. 
Kilmer,  T.  G.,  79. 
Kilvington,   B.,  268. 
King,  H.  M.,  90. 
Kinnaman,  G.   C,  46o. 
Kionka,   H.,   508. 
Kitasato,    S.,    92. 
Klebs,  A.   C,   332. 
Klemperer,   556. 
Klotz,    Oskar,   208. 
Knapp,    Herman,   64. 
Knopf,   S.   A.,  91. 
Knott,  John,  32. 
Knott,  Van   Buren,    419. 
Kocher,  A.,  331. 
Kochmann,    Martin,    400. 
Kohn,    S.,   449. 
Kolipinski,   Louis,  467. 
Koplik,   H.,  417. 
Kottmann,  556. 
Kramer,   Henry,  137. 
Krashevski,   L.  G.,  322. 
Krouse,   L.   J.,  361. 
Kucharzewski,  131. 
Kunwald,   136. 
Kuyk,   75. 

Labbe,   H.,  and  L.  Furet,  565. 

Lahey,  F.   H.,  260. 

Lambert,  A.,  263. 

Lancereaux,    499. 

Landis,   H.   R.   ML,   332. 

Lane,  W.   A.,  255. 

Lange,  131. 

Lapinsky,   472. 

Latham,   P.  W.,  18. 

Law,  C.  K.,  124. 

Lawrence,   F.   F.,  463,  561. 

Lea,  375. 

Leale,   Medwin,  259. 

Lebreton,    Paul,    477. 

Le  Filliatre,   M.,   471. 

Lenhartz,  H.,  254. 

Lennander,   470. 

Leole,   P.,  524. 

Leonard,     Charles     Lester,     99, 

382. 
Leplay,    73. 

Leszynsky,    W.    M.,   518. 
Levaditi,  554. 


Leven,  37. 

Levin,    I.,    129. 

Lewin,   L.,   74. 

Liebermann,   J.   M.,   172. 

Litten   and    Michaelis,    229. 

Lockwood,  C.  B.,  254. 

Lohlein,    M.,   313. 

Londe,  P.,  251. 

Long,   J.   W.,   259. 

Longo,  Pasquale,  462. 

Longyear,  H.   W.,  252. 

Loomis,    H.    P.,   173,   476. 

Lord,   F.    T.,   264. 

Lothrop,     H.     A.,     and     D.     D. 

Scannell,   213. 
Loveland,  H.  H.,  229. 
Lucca,  375. 

Mackenzie,   James,  500. 

Macrae,    Farquhar,    523. 

Maignan,   F.,  414. 

Malcolm,  J.   D.,  518. 

Maiden,  Walter,  428. 

Mally  and  Richoo,  412. 

Malsbary,   G.   E.,  422. 

Manges,   M.,  38. 

Mann,  J.  D.,  324. 

Marcus,   408. 

Martin,  C.  F.,  and  J.  C.  Meak- 

ins,   566. 
Martin,    F.   H.,   427. 
Martin,   G.,   253. 
Martin,  J.   M.   H.,   46. 
Marx,   S.,   116. 
Massalongo,   R.,   135. 
Massalongo,    R.,   and  G.   Danio, 

Mathieu  and  Passier,  263. 
Mayo,  W.  J.,  and  C.  H.,  220 
Mays,  T.   J.,  506. 
McBurney,    Charles,    223. 
McCallum,    H.   A.,  185. 
McCardie,  W.  J.,   557. 
McCarthy,  D.  J.,  274. 
McCaskey,  G.   W.,  33. 
McCrae,    Thomas,    173. 
McEwen,    E.    L.,    329. 
McFarland,    Joseph,    314. 
McGillivray,    A.,   24. 
McHardy,    M.    M.,   21. 
Mcintosh,   W.    Page,   317. 
McKee,    James    Herbert,    487. 
Meakins,   J.  C,  566. 
Medical  News,   13. 
Medical   Record,   133,   137. 
Meltzer   S.    J.,   and   John   Auer, 

86. 
Meunier,   Leon,   267. 
Meyer,  Willy,  560. 
Michaelis,    229. 
Mitchell,   H.    W.,   2S1. 
Moon,  R.  O.,  65. 
Moore,   J.   E.,   309. 
Moore,  J.   E.    S.,  466.  ' 
Moore,   N.,  373. 
Morgan,  A.    C,  421. 
Moritz,    F.,   169. 
Morland,    E.   C,   379. 
Morris,   Malcolm,   217. 
Morris,   R.   T.,  307. 
Morse,   J.   L.,  176,   445. 
Mott,    F.   W.,   552. 
Muir,  114. 

Mumford,    J.    G.,    212. 
Mummery,  J.   P.   Lockhart,  234. 
Munson,   J.   E.,   279. 
Musgrave,   W.   E.,  224. 
Musser,  J.  H.,  332. 

Naumym   and   Kottmann,   556. 

Navratil,    D.    V.,    227. 

Neff,   I.   H.,  43. 

Netter,   Louis,   464. 

Neujean,  HI-  ,        , 

New  York  Medical  Journal  and 
Philadelphia  Medical  Jour- 
nal, 356. 

Newcomet,  W.   S.,  70. 

Newman,    413. 

Nicoll,   James  H.,   42. 

Niles,   H.  _D.,   41. 


NAMES  OF  AUTHORS    QUOTED. 


581 


Norbury,   F.   P.,   160. 
Northrup,  W.  P.,  116. 

Oberndorfer,    S.,    520. 
Oefele,   407. 

Oettinger,    Bernard,    512. 
Ogden,  J.   B.p  381. 
Oliver,  Charles  A.,  55. 
Oliver,   T.,   500. 
Onuf  B.,  260,  289. 
Osborne,  O.  T.,  81. 
Osgood,  273. 

Ott,    Isaac,    and    J.    F.    Ulman, 
365. 

Palier,   E..   47. 
Pancoast,  H.   K.,  333. 
Paramore  W.   E.,  552. 
Pari,  G.  A.,  331. 
Passier,  31. 
Patek,    A.   J.,   31. 
Paterson,    P.,   224. 
Paton,   D.   N.,  165. 
Payne,  460. 
Perkins,   I.  B.,  273. 
Perochaud,    93. 
Pesci,  Ernesta,  17,  62. 
Petroff,   B.    F.,   512. 
Phemister,   D.   B.,   471. 
Phillips,   W.   C,   364,   369. 
Pilcher,   P.   M.,  230. 
Pirera,   Alfonso,   183. 
PlowrightT"  C.  B.,  50S. 
Polya,  223. 
Polya,  E.  A.,  358. 
Porcher,  W.   P.,  562. 
Porter,  C.   A.,   160. 
Potts,   E.   T.,   3S0. 
Powers,   D'Arcy.  26. 
Prager,  J.   B.(  322. 
Pratt,  J.  H.,  63. 
Price-Brown,  J.,  489. 
Priesich,  K.,  and  P.  Heim,  18. 
Prinz,    Hermann,    454. 
Prout,   T.   P.,  503. 
Priissmann,    119. 
Pugh,  W.  T.  G.,  130. 

Quenstedt,    472. 
Quenu,  406. 
Quincke,    H.,   457. 

Rachford,   B.  K.,  94. 

Randall,    B.   Alex.,    301. 

Ranney,    A.   L.,   28. 

Ransdell,   R.   C,  176. 

Ransom,  C.  C,  185. 

Reber,    Wendell,    420 

Reed,  C.  A.  L.,  26. 

Reed,  C.   B.,  266. 

Rhein,  J.  H.  W.,  328,   529. 

Rhodes,    F.   A.,  20. 

Richardson,    F.    L.,    102. 

Richon,   412. 

Ricketts,   B.   M.,  409. 

Riedel,  314. 

Riedel,    N.   E.,   16. 
Ries,  569. 

Ring,  G.  Oram,  371. 
Robb,  Hunter,  415. 
Robin,   A.,   79. 
Robinson,   Beverley,  38. 
Robinson,    F.,   and  E.   T.  Potts 

380. 
Robinson,    J.    Wirt,    525. 
Rodman,   W.  L.,  34. 
Rodgers,    Leonard.    213. 
Rolleston,  J.  D.,  120,  149. 
Romberg,   E.,   503. 
Rommel,   O.,  268. 
Rosenberger,    R.    C.,    369. 
Rosenheim,    171. 
Rost,   E.   R.,   226. 
Rothrock,  J.   L.,   516. 
Roiissoll   and  Job,   456. 
Roy,   Dunbar,  44. 


Ruault,  65. 

Rugh,   J.   Torrance,    433. 
Ruhemann,   323. 
Russell,  J.  W.,  113. 

Sabourin,  265. 
Sahli,  H.,  262. 
Sajous,    C.   E.   de   M.,   1,    10,   55. 

249. 
Sampson,  John  A.,  140. 
Sanderson,   S.  E.,   135. 
Sanderson-Wells,  T.  G.    411 
Satterlee,    F.    LeRoy,    517. 

Scannell,   D.   D.,  213. 

Schaeffer,    R.,    67. 

Schmidt,  F.   E.,  515. 

Schreiber,   J.,  129. 

Schulz,   A.,   63. 

Schwyzer,    Fritz,    556. 

Scott,  James,  254. 

Scott,  J.  A.,   280. 

Sears,  G.   G.,  228. 

Secord,   E.   R.,  42. 

Seelig,   274,   472. 

Seggel,   G.,   563. 

Senator,    59. 

Senator  and   Bibergiel,   556 

Senn,    N.,   2,   465. 

Severino,   572. 

Sharpe,  N.   W.,  71. 

Shaw,  H.  L.  K.,  69. 

Sheen,  William,  413. 

Shenton,    E.    W.    H.,    505. 

Sherman.    Harry    M.,    388 

Sheve,   Haldor,   404. 

Shober,   J.    B.,    476. 

Shumway,    E.    A.,    77. 

Sicard,    M.    H.,   452. 

Sicuriani,    418. 

Silvestri,    Torindo,    175. 
■  Sinnhuber,   61. 

Slade,    G.    R.,    313. 

Smith,  Allen  J.,   4. 

Smith,    Morton,    517. 
Smith,    S.    MacCuen,    115 

Sollmann,    Torald,    and    E.    D 

Brown,   407. 
Sollmann,    Torald,    and    J     A 

Hoffmann,  184. 
Souther,  C.  T.,  371. 
Southworth,    T.    S.,    170. 
Speer,   G.    G.,   216. 
Sprathing,   W.    P.,   28,   507. 
Stackhouse,   C.   P.,  270. 
Standish,   Myles,  64. 
Stein,    B.,   115. 
Stepp,  H.,  187. 
Stern,    Heinrich,    362 
Sterne,   A.   E.,   41. 
Stewart,   A.   H.,  256. 
Stewart,   D.   D.,   306,   324 
Stewart,   J.    C.,   446. 
Stockton,   C.   G.,   215. 
Stone,    I.    S.,   127. 
Stoney,  R.  A.,  424. 
Strassmann,  F.,  and  A.  Schulz, 

63. 
Strumpell,   A.,  507. 
Stucky,    J.    A.,   564. 
Summers,   J.   E.,  Jr.,  505. 
Sutton,   R.   L.,   66. 
Suzuki,     Surgeon-General,     571. 

Taylor,   A.   S.,  503. 

Taylor,     J.     Madison,     21,     106 

I"-",     179,     205,     244,     303,     343* 

394,    440,    494,    545. 
Taylor,    R.    W.,   474. 
Taylor,    Wm.    J.,    298. 
Tenney,    Benjamin,    47S. 
Terrien,    M.    E.,   409. 
Thevennet,  Victor,  509, 
Thompson,   \\\    \i.,  282. 
Thomson,    H.    Hyslop,   71. 
Tinker,    M.    B.,    83 
Tlssier,    H.,   461. 


Todd,    J.    B.,    250. 
Traube,   J.,   121 
Turck,  F.   B.,  551. 
Turner,   G.   Grey,  523. 
Turner,  W.  A.,  166,  219 
Turton,    Edward,   269 
Tuttle,   J.   p.,   375.      ' 
Tyrrell,  J.   B.,  416. 
Tyson,  James,  53,  141. 

Uhle,  R.  V.,  410. 

Ullmann,    Julius,    67 

UUom,  J.   T.,   and  F.   A.   Craig, 

Ulman,  J.   F.,  365. 
Upham,  J.  H.  J.,  217. 

Vaquez,   H.,   514. 

Vaughan,   V.   C,   Jr.,   255. 

Vinay,   27. 

Vincent,   E.,   276. 

Voerner,   H.,   322 

Von  Ruck,   332,   567. 

Von  Tobora,  359. 

Vomer,  567. 

Voorhees,   J.   D.     83 

Vos,,  R.  H.,  and  W.   C.  Howe, 

164. 
Vossius,   A.,   329. 

Wadsworth,   William   S      201 

Waite,   Lucy,   94. 

Walker     J.    w.    Thomson,    60. 

^\  alko,  K.,  210. 

Walbaum,   312. 

Wallich    and    Levaditi,    554. 

Walhs,   F.   C,  374 

Walton,   G.   L.,   356. 

Wassermann,    M.     91 

Wathen,  W.   H.,  315 

Watson,  277. 

Watson,   D.   C.,   168.  ■ 

Watson,   Edward  W,    t35 

Watson,    F.    S.,    141. 

Watson,   L.   H.,   4."9 

Webster,   J.    (J.,   261. 

Webster,   J.   p.,  88. 

Werner,    R.,    172. 

Westenhoffer,    450.  ' 

Wheeler,   D.   E.,   450. 

Whitacre,    H.   J      66 

White,    F.    W.,   506.  ' 

White,    W.    H.,    554. 

Whitehead,   A.    L.,    113 

Whitman,    Royal,    408.  ' 

Wiatt,    W.    S.,    459. 

Wilcox,    R.    W.,    354. 

Wilder,    J.    A..    62,    572. 

Wilkinson,   Oscar,   401. 

Willard,    DeForcst,    322,    570 

Williams,   E.   T.,   329. 

Williams,    J.    W.',   573 

Willson,   R.   N.,   424. 

Wilson,   H.   A.,   276. 

Wilson,    J.    C,    332. 

Wilson,   J.   T.,   181. 

Winternitz,    2S2. 

Winters,    J.    E.,    355. 

Witte,    E.,    94. 

Witzel,    521. 

Wood,  G.   B.,  8,  2S0. 

Wood,   H.   C,  419. 

Woods,    Hiram,    24, 

Woods,    Matthew,   337. 

Wright,   A.    E., 

Wright,    II.,   552. 

Young,   H.   H.,  271,   568. 

Zaaljer,  J.   II.,   c:;i. 
Zamboni,    G.,   123. 
Zangger,    T.,   310. 
ZelenkoTBkl,  Jr..  421. 
Zenner,    Philip,   :'i7. 
Zejitmayer,    William,    J63. 
Zherbovski,    E.    A,    '.'69 


INDEX. 


Abdomen,    new    method    of    exploring    the.      A. 

H.    Ferguson    549 

Abdominal    injuries.     C.    P.    Flint 157 

Pain   from   adhesions.     C.    G.    Cumston 347 

Symptoms,    acute.      W.    W.    Cheney 444 

Acetanilid   poisoning.     D.   D.    Stewart 306 

Aeetonuria  elsewhere  than  in  diabetes.     Beauvy.    58 
Acid  autointoxication  in  infancy.     J.  L.  Morse.  445 

Intoxications.     Medical   News 13 

J.    A.    Kelly 1U 

Acne  and  its  treatment.     G.  T.  Jackson 158 

Actinomycosis,    treatment   of.     Bevan 399 

Adenoid  vegetation,    the   cure  of  exophthalmos 

and  chorea  by  removal  of.     Holz 158 

Adenoids  in  the  adult.     D.  M.  Barstow 251 

Adolescence.     G.   Stanley   Hall 241 

Disorders  of.     J.  Madison  Taylor 244 

Adrenalin,    action   of.     Neujean Ill 

T.    R.    Elliott    445 

In    surgery.      Hildebrandt 112 

Agglutination   tests,    some   fallacies   in.      Oskar 

Klotz    208 

Air  in  veins  during  surgical  operations.     Delore 

and    Duteil    209 

Albumin    in    the    urine    of    apparently    healthy 

children.     William  A.   Edwards 152 

Albuminuria.    Journal  of  the  American  Medical 

Association     14 

And  adolescents.     Clement  Dukes 499 

And   diabetes,   connection   between.     Lance- 

reaux    499 

And  glycosuria  from  fatigue.     Gobbi 357 

Due   to  palpation.     Journal  of  the  American 

Medical    Association    150 

Physiological  and  pathological.     Senator 59 

Prognosis  and  treatment  of.     Furbringer 399 

Alcohol,  action  of,  upon  the  circulation.    D.  M. 

Hoyt     306 

Martin  Kochmann   400 

Local   therapy.     K.    Walko 210 

Alcoholism,    borderline    psychoses    of.      F.    P. 

Norbury   160 

Alkaline  beverages  in  pneumonia.     C.  E.  de  M. 

Sajous    249 

Amenorrhcea    and    systemic    disease.      Journal 

of  the  American  Medical  Association 348 

Amoebas  infecting  the  human  intestine.     C.   F. 

Craig    350 

Anaemia,   diagnosis  and  treatment  of.     Harlow 

Brooks     550 

Pernicious,  etiology,  and  pathogenesis  of.     C. 

H.    Bunting    400 

Pathology  of.     G.  L.  Gulland  and  A.  Good- 
all    175 

Theory  of.     Litton  and  Michaelis  229 

Anaerobic  cellulitis.     J.   C.   Stewart 416 

Anaesthesia,  local.     A.   E.   Barker 59 

Preceded     by     injections     of     strychnine:       I. 

Evenhof    4i6 

Anaesthetics,  poisonous  effects  of.    A.  D.  Bevan 

and  H.   B.   Favill 446 

Aneurism     and     arteriosclerosis.       C.      N.      M. 

Camac    251 

(582) 


Angina  pectoris.     T.    Oliver 500 

And  pseudo-angina.     W.  H.   Broadbent 350 

Etiology  of.     James  Mackenzie 500 

New  symptoms  in.     G.  A.  Gibson.. 501 

Angiosclerosis   of  the   extremities,    intermittent 

claudication  due  to.     J.  Ramsay  Hunt..  307 

Announcement    1 

Antistreptococcic  serum,   administration  of.     J. 

W.  Thomson  Walker 60 

Aortic  insufficiency,   trauma  as  cause  of.     Sin- 

huber    61 

Appendicitis,   causes  of.     Bottomley 447 

Changes  of  view  on.     R.  T.  Morris 3o7 

In  children.     R.  C.   Dun 308 

Method  of  opening  abdomen  in.     F.   B.   Har- 
rington      210 

Mortality  of.     C.  W.  Barrett 211 

Perilous  calms  of.     R.  W.   Hardon 113 

Treatment  of.     C.  A.  Porter 160 

Urinary  disturbances  in.     C.  G.  Cumston 501 

Appendix,  relation  of  pelvic  disease  to.     C.  W. 

Barrett    447 

Arsenic  poisoning,  test  for.     J.  Justus 448 

Arterial  hypertension,  chronic.     H.  W.  Cook...    61 

Arteries,  the  effect  of  cold  on.     M.  Hertz 15 

Arteriosclerosis,  hot  baths  in.     E.   Hirchfeld...  502 

Hypertensive  crises  in.     J.   B.   Briggs 448 

Threatening  epistaxis  in.     E.   Escat 502 

Treatment  of.     E.   Romberg 503 

Arthritis  deformans.     F.  L.  Richardson 162 

Artificial  drumheads  and  other  aids  of  hear- 
ing, some  facts  about.  B.  Alex.  Ran- 
dall      301 

Respiration.     G.  Herter  401 

Aseptic   operating,   points   in   the   technique   of. 

H.*T.  Byford  211 

Asthenia.     P.   Londe   251 

Asthma.      S.    Kohn 449 

Nasal  treatment  of.     Alexander  Francis 16 

Prognosis  of.     G.   N.  Jack -. 449 

The  food  factor  in.     Francis  Hare 550 

The    relation    of   ethmoidal    inflammation    to. 

H.    Cgogeshall 308 

Atony  of  the  rectum  and  colon.    F.  B.  Turck...  551 
Atropine,    action    of,    on    the    intestine.      N.    E. 

Riedel    16 

And  homatropine  as  cycloplegics,  relative  ac- 
tions of.     Oscar  Wilkinson 401 

Barium  chloride  in  therapeutics.     E.  Pesci 62 

Medicinal  value  of.     Ernesta  Pesci 17 

Baths  and  electricity,  effects  of,  on  metabolism, 

and  blood-pressure.     Bain  and  Franklin.  308 

Beriberi.    H.  Wright,  C.  Hose,  and  F.  W.  Mott.  552 

Bile  duct  disease.     J.  G.  Mumford 212 

Biliary  tract,  infection  of.     H.  W.  Longyear...  252 

Biliousness,  the  hepatic  factor  in.     F.  Hare 252 

Bladder,    papilloma    of,    diagnosis    of.      C.     G. 

Cumston     162 

Primary  sarcoma  of.     J.  A.  Wilder 62 

Blood  coagulability.     A.   E.   Wright  and  W.  E. 

Paramore     552 

Internal  use  of  thyroid  extract  to  "increase. 

William  J.  Taylor 298 


INDEX. 


583 


Blood     platelets,    origin     of.       K.     Priesich     and 

P.    Heim    IS 

Poisoning,    perchloride    of    iron    in.      P.     W. 

Latham     18 

Blood-pressure   and   the   position   of   the   hody. 

C.  Gennari   351 

Observations.     C.  E.  Brush 402 

Bone  cavities,  treatment  of.     J.  E.   Moore 309 

Book  Reviews: — 

Surgical   Treatment  of   Bright's   Disease 142 

Lectures  to  General  Practitioners  on  Diseases 

of  the  Stomach  and  Intestines 188 

Saunders's    Question    Compends:      Essentials 

of  the  Practice  of  Medicine 189 

Disease  and  Marriage:  The  Relation  between 
Disturbances  of  Health  and  the  Mar- 
riage   State    189 

Betton     Massey's     Conservative     Gynaecology 

and    Electro-Therapeutics    237 

Transactions  of  the  American  Roentgen   Ray 

Society    238 

Mental      Defectives:       Their      Training      and 

Treatment     238 

Hare's  Text-Book  on  the  Practice  of  Medi- 
cine       238 

Blood-Pressure  as  Affecting  the  Heart,  Brain, 

Kidneys,   and  General   Circulation 239 

The    Roentgen    Rays    in     Therapeutics    and 

Diagnosis     285 

Diet  in  Health  and  Disease 286 

Nursing  in  Eye,  Ear,  Nose,  and  Throat  Dis- 
eases       286 

Practical  Pediatrics:  A  Manual  of  the  Med- 
ical and  Surgical  Diseases  of  Infancy 
and   Childhood   287 

Schultz's  Atlas  and  Text-Book  of  Topog- 
raphic  and  Appleid   Anatomy   334 

Harrington's  Manual  of  Practical  Hygiene 
for  Students,  Physicians,  and  Health 
Officers,    etc 334 

Saunders's  Pocket  Medical   Formulary 334 

Nothnagel's  Practice  (Vol.  X):  Malaria,  In- 
fluenza, and  Dengue.  American  Edi- 
tion      335 

Dudley's  Principles  and  Practice  of  Gynae- 
cology      335 

Nothnagel's  Practice  (Vol.  XI):  Diseases  of 
the  Kidneys,  Diseases  of  the  Spleen,  and 
Haemorrhagic  Diseases  383 

The    Pharmacopoeia   of   the    United    States    of 

America    383 

A  Treatise  of  Diagnostic  Methods  of  Exami- 
nation      525 

Anders's  Text-Book  of  the  Practice  of  Medi- 
cine       526 

Health  and  Disease  in  Relation  to  Marriage 
and  the  Married  State.  English  Trans- 
lation      526 

The  Eye,   Mind,   Energy,  and  Matter 526 

Superstition    in    Medicine 527 

Green's  Pathology  and  Morbid  Anatomy 514 

Ashton's  Text-Book  on  the  Practice  of  Gynae- 
cology      575 

Landois's  Text-Book  of  Human   Physiology..  576 
Brachial  birth   palsy.     L.  P.   Clark,  A.   S.  Tay- 
lor, and  T.  P.  Prout 503 

Bradycardia.     George   Dock    450 

Brain  tumor  and  trauma.     E.  W.  Holmes 18 

Breast-feeding  for  infants.     G.   Martin 2".3 

Breathlessness,  especially  in  relation  to  cardiac 

diseases.     Lauder   Brunton 402 


Bright's  disease.     A.   C.  Croftan 352 

Lavage  of  renal  pelves  in.  Winfleld  Ayres.  403 
Bronchial    asthma,    vasomotor    origin    of.      F. 

Galdi    310 

Bronchitis,   capillary,  treatment  of.     O.   Heub- 

ner    403 

Broncho-pneumonia  in   children,    treatment  of. 

T.    Zangger    310 

Burns  of  the  third  degree.    A.  M.  Fauntleroy..  310 

Treatment  of.     Haldor  Sheve 404 

Bursitis,  treatment  of  chronic.    P.  Hoffmann...    19 

Cachexial    fever,    the    leucopenia   of.     Leonard 

Rogers     213 

Calomel  as  a  poison.     T.  L.  Bunting 19 

Cancer    and    tuberculosis,    the    association    of. 

W.  A.  Bastedo  20 

Effects  of  Roentgen  rays  on.    R.  H.  Vose  and 

W.    C.    Howe 164 

In  and  about  the  mouth.     H.  A.  Lothrop  and 

D.  D.  Scannell 213 

Natural  history   of.     W.   A.   Freund 214 

The  growth  of.     E.  F.   Bashford 215 

Carbohydrate  metabolism.     F.  A.  Rhodes 20 

Carbolic  acid  gangrene.     J.  Herold 352 

Carbonic  oxide  poisoning.     F.   Strassmann  and 

A.    Schulz    63 

Carcinoma     of     the     stomach,     diagnosis     of. 

Ewald    352 

Cardiac  insufficiency,  causes  of.    J.  H.  Pratt. .    63 
Cardio-vascular  disease,  question  of  posture  in. 

Allen   J.    Smith 4 

Suprarenal  extract  in  treatment  of.     James 

Tyson     141 

Cataract,  immature.     A.  E.  Bulson,  Jr 553 

Artificial  maturation  of.     M.  M.   McHardy..     21 
Cellular    elements    of    colostrum    and    human 

milk.     Wallich  and  Levaditi 554 

Cerebral  haemorrhage.    J.  W.  Russell 113 

Tumors,   symptoms  of.     J.   M.   Clarke 404 

Cerebro-spinal  fever.     C.  G.   Stockton 215 

Meningitis.     G.  G.  Speer 216 

Ear  complications  in.     C.  J.   Colles 504 

Epidemic,   treatment  of.     H.   Lenhartz 254 

Ruhemann    323 

Manner  of  infection  in.     Westenhoffer 450 

Cervical    rib,    surgical    importance    of.      Carl 

Beck   405 

C(  rvix  interi,  cancer  of,  treatment,  in  advanced 

stages.     J.  Wesley  Bov6e 64 

Chancre   and   chancroid,    treatment   of.     D.    E. 

Wheeler    450 

Changes  in  the  pharmacopaeia 429 

Chest,    new   physical   signs   in   diseases   of.     A. 

Grober     216 

Children,   diagnosis   of  disease   in.     J.    Madison 

Taylor    21 

Chloroform,      elimination      of,      by      vomiting. 

Gelpke     H3 

Cholecystitis.     R.   W.   Hardon 554 

Experimental    contribution    to    treatment    of. 

William   Bain    451 

Treatment.      A.    Hecht 451 

Chromaffin  substance  in  relation  to  vasomotor 
ataxia,    and   the   equilibrium   of   internal 

secretions,    Solomon   Solis-Cohen 342 

Ciliary-body,  syphiloma  of.     Herman  Knapp..     64 
Cirrhosis    of    the    liver,    Talma's    operation    in. 

William  Hessert  504 

Clinical    facts    relating    to    superheated    milk. 

Louis  Fischer  534 

Significance  of  the  reflexes.     Philip  Zenner...  247 


584 


INDEX. 


Cobra  venom,  the  influence  of,   on  the  proteid 

metabolism.     James  Scott  254 

Colitis  and   appendicitis,    relationship   between. 

C.  B.    Lockwood 254 

High-frequency  currents  in.     E.  W.  H.  Shen- 

ton     505 

Membranous.     W.    H.   White 554 

Surgical  treatment  of.     J.   E.   Summers,  Jr...  505 
Colon   bacillus,   action  of  the  intracellular  poi- 
sons on  the.    V.  C.  Vaughan,  Jr 255 

Colostrum   and  human   milk,    cellular  elements 

of.     Wallich   and  Levaditi 554 

Conjunctivitis,    purulent,    treatment  of.     Myles 

Standish     64 

Constipation   as   a  cause  of   intrauterine   infec- 
tion.    Capaldi  311 

Chronic.     W.   A.   Lane 255 

Dietetics    in    the    Treatment    of.      Sigismund 

Cohen     23 

Spastic,   treatment  of.     A.   Albu 353 

Consumption  diathesis.     T.  J.   Mays 506 

Treatment  of.     W.    Hutchinson 353 

Convulsions   in   children   and   their   relation    to 

epilepsy.     R.  O.  Moon 65 

In  nephrectomized   rabbits.     Blumreich 113 

Copper,    action   of   colloidal    solutions   of,    upon 

bacillus  typhosus.     A.   H.  Stewart 256 

And  zinc  poisoning.     M.  H.   Sicard 452 

Bactericidal     action     of,      on     organisms     in 

water.     N.   Gildersleeve 311 

Corneal   therapeutics.     A.    McGillivray 24 

Correspondence:    works  and  not  words 284 

Coryza,  acute,  abortive  treatment  of.     Ruault..    65 

In  nurslings,  treatment  of.     L.   Ballin 452 

Course    of   public    health   at   the   University   of 

Pennsylvania    142 

Cutaneous    affections,     refrigeration     in     treat- 
ment.    M.    Juliusberg 257 

Syphilis.     Fischkin   405 

Defensive  powers  of  the  body  in  disease.    Muir.  114 

Degeneration  of  the  heart.     John  Hay 554 

Delirium    tremens,    cold    affusion    in.      William 

Broadbent    406 

Injection  of  saline  solution  in.     Quenu 406 

Dengue.     D.  N.  Carpenter  and  R.  L.  Sutton 66 

Dentition,    the   medical    aspects   of   the   second. 

H.    Armstrong    406 

Dermatitis    herpetiforms    in    children.      J.     T. 

Brown    506 

Dermatology,    some   new   therapeutic   measures 

in.      Malcolm    Morris 217 

Diabetes,    contagiousness   of.      Hutinet 114 

Etiology  of.     J.  H.  J.  Upham 217 

Loaf   Sugar   in.     Oefele 407 

Insipidus,   treatment  of.     B.   Stein 115 

Mellitis,    adrenalin    and    thyroid    extract    in. 

D.  N.    Paton 165 

Improvement  in  treatment  of.     E.  P.  Joslin.  453 
Mastoid   disease  complicating.     S.   MacCuen 

Smith     115 

The  nature  of.  'W.  C.  Bosanquet 257 

Oral  manifestations  of.     Herman  Prinz 454 

Pancreatic,  origin  of  sugar  in.     E.  Pfliiger....  513 
Diabetic  gangrene  of  the  lower  extremity.     H. 

J.   Witacre    66 

Diagnosis,  errors  in.     J.  R.  Bradford 454 

Diaphoresis  in  ophthalmology.     Hiram  Woods..    24 

Diarrhoea,  chronic:    treatment.     R.  W.  Wilcox.  354 

In  children,  treatment  of.     J.  E.  Winters 355 


Digestive  disorders,  treatment  of.     J.  W.  Hun- 
ter,  Jr 65 

Disturbances    in     early     infancy.      P.     Ker- 

mauner   311 

Digestion  in  the  insane.     D.   M.   Cowie  and  F. 

A.    Inch    455 

Digitaline  in  the  treatment  of  nutritional   dis- 
orders.    Henry   Beates,   Jr 7 

Digitalis,  treatment,  remarks  on.     Fritz  Schwy- 

zer   556 

Diphtheria.     Roussell  and  Job 456 

Cardiac      disturbances      following.        F.      W. 

White     506 

Lesions  of  the  kidney  in.     Mario  Flamini 24 

Toxin,    action   of   liver   on.      Lauder    Brunton 

and   Bokenham    115 

Dipsomaniac  phases.     T.  H.   Evans 218 

Disovery    of    surgical    anaesthesia.      James    Mc- 

Fadden   Gaston    481 

Disinfection    of    hands,    antiseptic    or    mechan- 
ical?    R.    Schaeffer 67 

Dislocations  of  the  shoulder-joint,  reduction  of. 

H.   Huguier   456 

Disorders  of  adolescence.     J.  Madison  Taylor..  244 

Drug  medication,  future  of.     Edward  C.  Hill...  145 

Duodenal    ulcer    and    its    treatment.       D'Arcy 

Power    26 

Dyspepsia,    chronic,    surgical    cure    of    certain 

cases  of  so-called.    C.  A.  L.  Reed 26 

Dietetic,    treatment  of.     Hutchison 355 

Early   recognition   and   care   of   mental    defects 

in  children.     Martin  W.   Barr 392 

Eclampsia.     Allen   165 

Ectopic  pregnancy.     S.   M.  Brickmer 457 

Eczema,     chronic,     as    a    complication    of    the 

senile  degenerations.     Medwin  Leale 259 

Infantile:     treatment.     C.    Clenet.  ..• 67 

Electric    shocks.      Wallbaum 312 

Electro-therapeutics.     John  H.  W.  Rhein 539 

Elements   of   sucess  in   treatment  of   laryngeal 

tuberculosis.     E.    S.    Bullock ;  103 

Embolism  following  operation.     S.  S.  Dearborn.    27 
Endocarditis,     infective,     course     of.       Herbert 

French    27 

Enteritis,    traumatic.     Vinay 27 

Enteroptosis     and     pendulous     abdomen.       H. 

Quincke    457 

Enterostomy.     J.   W.   Long 259 

Enuresis.     Julius   Ullmann 67 

Epilepsy.     Brower  4^9 

Autopsy  findings  in.     B.   Onuf 260 

Convulsions  in  children  and  their  relation  to. 

R.    O.   Moon 65 

Dentition  in.     W.  P.  Spratling 28 

Emotional  shock  and  fright  as  causes  of.     W. 

P.    Spratling    507 

Home  treatment  of.     Charles  L.   Dana 385 

Management  of.     Matthew  Woods 337 

Prognosis  of.    W.  A.  Turner 219 

Treatment  of.     W.  A.  Turner 166 

Treatment  of.     A.   Strumpcll .rjii7 

By    ligation    of    longitudinal    sinus.      Dela- 

geniere    68 

In    connection    with    auto    and    hcterotoxis. 

A.    McL.    Hamilton 28 

Without  drugs.     A.  L.  Rapney 28 

Ergot,   intravenous  injection"bf ;    effects  on  the 
mammalian     circulation.       Torald    Soll- 

mann  and  E.  D.  Brown 407 

Erotomania.     J.   L.   Corning 68 


INDEX. 


585 


Erysipelas:     treatment.      F.    Franke 69 

Erythema  infectiosum.     H.  L.  K.  Shaw 69 

Ether  narcosis  by  rectum.     J.  H.  Cunningham, 

Jr.,  and  F.  H.   Lahey 260 

Ethyl   chloride.     H.    Hilliard 70 

W.  J.   McCradie 557 

Exophthalmic  goiter,  new  ocular  symptoms  of. 
New  York  Medical  Journal  and  Phila- 
delphia   Medical    Journal 356 

Reduced  by  radium.     R.  Abbe 313 

Eye-strain.     G.    L.    Walton 356 

Fatigue,     albuminuria     and     glycosuria     from. 

Guglielmo    Gobbi    357 

Fatty  degeneration,   nature  of.     M.   Lohlein 313 

Feasibility   and   value   of   accurate   methods    in 

clinical    investigations.      B.    Onuf 289 

Feeding  in  infancy.     W.   P.   Northrup 116 

Femoral    hernia,     new    radical     operation    for. 

E.   A.   Polya 353 

Fibroid  tumors  and  pregnancy.     S.  Marx 116 

Floating      kidney:       surgical      treatment.        J. 

Hutchinson     557 

Formaldehyde    and    formalin,    toxic    effects    of. 

H.    M.    Fischer 166 

Fracture  of  the  carpal  scaphoid.  E.  A.  Cod- 
man  and  H.   M.   Chase 338 

Of    the    neck    of    the    femur,     treatment    of. 

Royal   Whitman    408 

Of  the  spine.     H.   L.   Burrell 558 

Fractures,  care  of,  from  standpoint  of  general 

practitioner.     W.    S.    Newcomet 70 

Fungus  poisoning.      C.    B.    Plowright 508 

Furuncles  and  carbuncles,  new  local  treatment 

for.     Marcus   408 

Future  of  drug  medication.     Edward  C.  Hill...  145 

Gall-bladder,  rupture  of  the.     B.  M.  Rickets...  409 

Gall-stone  disease.     W.  J.  and  C.  H.  Mayo 220 

Fever  in.     H.  Ehret 261 

Gall-stones  and  carcinoma.     G.  R.  Slade 313 

Gases  of  the  body.     L.  H.  Watson 459 

Gastric  affections,  significance  of  so-called 
"occult    haemorrhages"    in    diagnosis    of 

certain.     Julius   Friedenwald 199 

Cancer,  pathology  of.     Von  Tobora 3."9 

Haemorrhage,  treatment  of.     F.   G.  Connell...  221 
Intolerance    in    young    children.      M.    E.    Ter- 

rien     409 

Pain,    left-sides.      Riedel 314 

Secretion.     J.   S.   Edkins 409 

Influence   of   sodium   chloride    solutions   on. 

P.    Casciani    222 

Ulcer,  etiology  and  pathology  of.     Joseph  Mc- 

Karland     314 

Medical  treatment  of.     F.  P.  Henry 166 

Rest  in  the  treatment  of.     F.  D.   Boyd 315 

Gastro-enteritis,  buttermilk  in.     Decherf ;!0,  167 

Enterostomy.     W.    11.    Wathen   315 

Gonococcus  infections  in  children.     L.   E.  Holt.  167 
Gonorrhoea,      active      t  ■-• -:t  tun -n  t      nf,      in      early 

stages.      F.    J.    Cotton 117 

In  the  female.     L.   Archambaull 410 

Lactic  acid  in.     Switliin  Chandler 558 

Gout.     II.    Kionka    508 

Etiology   and   pathology  of.     T.    H.    Futcher     .     80 
Excessive  meat  diet  in  the  Induction  of.     I). 

C.    Watson    jgg 

The  carbon  factor  in:    hyperpyraemla.     Fran- 
cis   Hare    360 


Graves's    disease,    pigmentation    of    eyelids    in. 

Jellinck     117 

Gynaecology,  conservatism  in.     D.  H.   Craig 558 

Haemophilia,  researches  in.     H.   Sahli 262 

Haemoptysis:    treatment.     H.   Hyslop  Thomson.    71 

C.    H.    Cattle 118 

H.    Hochhaus    222 

Haemorrhage,   internal.     T.   L.   Coley 31 

Haemorrhages,  sodium  bicarbonate  infusions  in 

severe.     E.    M.   Dawson 168 

Of  the  intestines,  treatment  of.     Mathieu  and 

Passier    263 

Haemorrhoids,    external,    pathology    of.      L.    J. 

Krouse    361 

Surgical  treatment  of.     Charles  McBurney...  223 

Treatment  of.     T.  C.   Hill 118 

Hand  sterilization.     J.   C.   Webster 261 

Hay  fever,  massage  of  the  nose  in.    A.  Denker.  361 

Head  injuries.     W.   S.   Wiatt 459 

Headache  in  childhood.     Cattaneo 559 

Nasal   disease  as   a  cause  of.     A.   L.   White- 
head     , 119 

Heart,  action  of  strychnine  on  the.     Gennari...  263 
Change  in  size  of,  on  change  of  position.    F. 

Moritz    169 

Lesions   and    kidney    affections.      F.    Bronow- 

ski    169 

Muscle,   functional   test  for.     M.    Herz 361 

Strain  in  growing  boys.     A.   Lambert 263 

Hepatic  abscess.     N.  W.  Sharpe 71 

Hernia    following   abdominal    section,    the   pre- 
vention of.     Payne 460 

Of   the   pelvic    floor,    new   operation   for.     G. 

W.  Crile  460 

Radical   cure   of.     Polya 223 

Hiccough  of  infants.     Victor  Thevennet 509 

Hints    for    the    interpretation     of     urinalysis. 

Nathaniel    Gildersleeve    537 

Hyperaemesis    gravidarium,    treatment    of.      R. 

V.    Uhle    410 

Hypodermoclysis.     W.    Page   Mcintosh 317 

Hypertrophied    prostate,    choice    of    method    in 

operating  upon    the.      Willy   Meyer 560 

Hypothesis  on  the  etiology  of  scoliosis  in  chil- 
dren.    J.  Madison  Taylor 303 

Icterus,    pathology   of.     Journal   of  the   Ameri- 
can   Medical   Association 71 

Immunity,   inherited,   instead   of   inherited   pre- 
disposition.    O.  Effertz 30 

Through  exposure.     Edward  W.   Watson 435 

Inebriate  manias.     T.   D.   Crothers 410 

Infant-feeding.     F.    S.    Churchill 320 

T.    G.    Sanderson-Wells 411 

Alkalies  in.     T.    S.    Southworth 170 

Infantile  intestinal  infection,  treatment  of.     H. 

Tissier     461 

Marasmus,  the  fat  question  in   Its  relation  to 
the   production    and    cure    of.     Helnrlch 

Stern     :K2 

Tuberculosis.    R.  G.  Freeman 321 

Inferior  turbinated   bone,   disorders  of.     W.   C. 

Phillips     3G4 

Influenza  bacilli,   Infections  of  the   respiratory 

tract  with.     F.  T.   Lord 264 

Ingrown    Toe-nail,    simple    treatment    of.      Al- 
berto Gasparini ]7i 

tn  anity,  acute,  therapeutics  of.    D.  R.  Brower.  509 

Medical   treatment  of,     R.   Jones 264 

Nature  and  treatment  of.     Theodore  Diller. ..     97 
Insect  stings.     P.  Fabre 365 


586 


INDEX. 


Intermitent  claudication.     A.  J.   Patek 31 

Internal  haemorrhage.     T.   L.   Coley 31 

Use    of   thyroid    extract   to    increase   the    co- 
agulability   of    the    blood.      William    J. 

Taylor     298 

International    Medical    Congress 429 

Interpretation     of     urinalysis,     hints     for     the. 

Nathaniel    Gildersleeve    537 

Intestinal    amebiasis,     tropical.      W.     E.     Mus- 

grave    224 

Antisepsis,  effect  of,  on  excretion  of  hippuric 

acid  in  the  urine.     J.  B.   Prager 322 

Button,  soluble.     P.   Paterson 224 

Catarrh,    dietetic   treatment  of.     Rosenheim..  171 

Exclusions.      Pasquale    Longo 462 

Obstruction.     F.    F.    Lawrence 463 

After  suppurative  appendicitis.    Federmann.  225 

Peristalsis.     Isaac  Ott  and  J.   F.  Ulman 365 

Intestine,     role    of    poisons    in.      Charrin    and 

Leplay     73 

Intraperitoneal  tuberculosis.     F.  F.  Lawrence..  561 

Intussusception  in  children.     Fagge 225 

In  infancy  and  childhood.    J.  H.  Hess 562 

Invagination,  acute,  in  infants:    medical  treat- 
ment of.     Louis  Netter 464 

Iodine    and    iodides,    changes    in    the    blood    of 

children  due  to.     A.   B.   Gianasso 411 

Anti-microbic  action  of.     G.  C.  Kinnaman 465 

In  surgery.     Nicholas  Senn 465 

Iron,  therapeutic  virtues  of.     John  Knott 32 

Ischochymia,  treatment  of.     Max  Einhorn 366 

Joint  injuries,   functional   impotence   following. 

Mally  and  Richon 412 

Kernig's    sign    and    its    pathogenesis.       G.    B. 

Hassin     510 

Knee  injuries.     DeForest  Willard 322 

Knee-joint    effusion,    recurrent.      W.    H.    Ben- 
nett        73 

Labor,    bimanual    dilatation    of    the    cervix    in. 

S.    G.    Krashevski    322 

Prophylactic    use    of    ergot    during.      Pruss- 

mann    119 

Lacerations   of  the   cervix  uteri.     A.   H.    Gard- 
ner       466 

Lactic   acid   formation,    experimental   study   of, 

etc.     E.  Palier  47 

Laryngeal  and  pulmonary  tuberculosis,  rest  in. 

W.    P.    Porcher 562 

Paralyses    and    their    diagnostic    value.      H. 

Barwell     367 

Tuberculosis,  elements  of  success  in  treat- 
ment of.     E.   S.   Bullock 103 

Larynx,    removal    of   foreign    bodies    from.      R. 

Barclay     510 

Lead-poisoning,   basophilis   granulations  of  the 

erythrocyte  in.     W.   B.   Cadwalader 119 

Eye  lesions  of  chronic.    L.  Lewin 74 

Lecithin,   r61e   of,    in   action   of  radium   and   x- 

rays.      R.    Werner 172 

Leg  ulcer,  treatment  of.     H.  Voerner 322 

Leprosy,  cure  of.     Isadore  Dyer 412 

Pathology  and  treatment  of.     E.  R.  Rost 226 

Lessons  in  physiology  from  surgery.     J.  Madi- 
son Taylor   545 

Leucocyte  counting,  convenient  method  of.     E. 

L.     Gros 510 

Counts  in  broncho-pneumonia,  lobar  pneumo- 
nia, and  empyema  in  children.  Henry 
Heiman     511 


Leucocytes,    diagnostic    value    of.      G.    W.    Mc- 

Caskey    33 

Examination    of,    as    diagnostic    aid.      T.    R. 

Brown    562 

In    malignant    growths,    behavior    of.      J.    B. 

Farmer  and  J.  E.   S.  Moore 466 

Leucocytosis    in    pertussis.      C.    G.    Grulee    and 

D.    B.    Phemister 471 

Nature  and  significance  of.     A.  M.  Holmes...    74 
Leukaemia,   acute  lymphatic.     Thomas  McCrae.  173 

Mixed-cell.     C.  H.   Browning 466 

Roentgen   rays  in   the  treatment  of.     George 

Dock     33 

Ligature    of    the    innominate    artery.      William 

Sheen     413 

Litten's  "diaphragm  phenomenon"  in  diagno- 
sis.    W.    N.    Berkley 119 

Lobar  pneumonia,  prophylaxis  of.  J.  M.  An- 
ders       368 

Locomotor  ataxia,  treatment  of,  by  ultra-violet 

rays.     J.    M.   Liebermann 172 

Lymphatic  leukaemia,  acute.     Thomas  McCrae.  173 

Malaria,  heart  in.     P.  Galenga..> 75 

White  cells  in.     B.  F.  Petroff 512 

Mammary    gland,    carcinoma    of    the.      W.    L. 

Rodman    34 

Mastoid   operations,   choice   of   time   of  election 

in.     D.  A.  Kuyk 75 

Mastoiditis.     W.   C.  Phillips 369 

Acute,    indications    for    operating    in.      P.    D. 

Kerrison     563 

Measles,    Koplik's    spots    in    diagnosis    of.      H. 

Bruening    323 

Prodromal  rashes  of.     J.   D.   Rolleston 120 

Melanoma.     J.  C.  Johnson 120 

Meningitis    epidemic    cerebro-spinal,    treatment 

of.     Ruhemann    323 

Menstrual     fever    in    phthisical    women.       Sa- 

bourin    265 

Mental    defects    in    children,    early    recognition 

and  care  of.    Martin  W.  Barr 392 

Mesenteric  glands  in  their  relations  to  tuber- 
culosis.    R.   C.   Rosenberger 369 

Metabolism,  disease  of  the  skin  connected  with 

errors  of.     L.    D.   Bulkley .- 35 

Influence  of  diet  poor  in  chlorides  on.     Cala- 

brese    121 

Metal  ferments,   action  of,   on  metabolism  and 

in  pneumonia.     A.   Robin 79 

Mentoposterior  positions.     C.   B.   Reed 266 

Mercury,   action   of.     During 266 

Methaemoglobin    as    a    factor    in    conservative 

metabolism.      Bernard   Oettinger 512 

Migraine   and   cannabis   indica.     G.    Carron   de 

la  Carriere   466 

Milk,  digestion  of.     Leon  Meunier 267 

Diet,    influence    of,    on    the    circulation.      Carlo 

Colombo    36 

Superheated,      clinical      facts      relating      to. 

Louis    Fischer    534 

Movable  kidney,  new  operation  for.  A.  Fuller- 
ton"  121 

Treatment  of.     Newman 413 

Muscles,  production  of  alcohol  and  acetone,  by 

the.     F.  Maignan   414 

Muscular  rheumatism  and  aTlicd  painful  states, 

remarks  on.     J.   Madison  Taylor 394 

Treatment.     J.   Madison  Taylor  440 

Myopia.     Helbron    267 

Cause  of  progressive.     G.  Seggel 563 


INDEX. 


587 


Myocardium,     degenerative     changes     in     the. 

Raymond   Clark    3G 

Myxoedema  in  its  relations  to  the  adrenal  sys- 
tem.    Charles  E.  de  M.  Sajous 55 

Narcosis,  physical  basis  of.     J.   Traube 121 

Nasal  catarrh,   treatment  of  chronic.     L.   Kop- 

linski    467 

Headache.      Somers    414 

Septi,   deflected,   submucous  resection  of.     F. 

W.   Alter   369 

Naso-pharyngeal  adenoids.     J.    A.    Stucky 564 

Nature  and  treatment  of  "insanity."    Theodore 

Diller   97 

Nephritis,  medical  treatment  of.     A.  R.  Elliott.  467 

Nephropexy.     A.  E.   Gallant 267 

Nephroptosis.      Earl   Harlan 414 

Nerves,   regeneration  of.     B.   Kilvington 268 

Nervous   and    mental    diseases,    relation   of   the 

gastro-intestinal  tract  to.     R.   C.   Kemp.  370 
System,   diagnosis  of  diseases  of  the.     Joseph 

Collins     513 

Throat  pain.     Boenninghaus ! 36 

Neurasthenia    plus    chronic    intoxications.       J. 

Madison  Taylor  106 

Work  as  a  remedy  in.    H.  J.  Hall 77 

Neurology,  present  status  of.     Joseph  Collins..    49 
Nitroglycerine,   the  limitations   of,   as   a  thera- 
peutic agent.     H.   P.   Loomis 173 

Tolerance   to.     D.    D.    Stewart 324 

Non-malignant   diseases,    treatment   of,    by   the 

Roentgen  rays.     R.   H.   Boggs 26S 

Nursing,   technique  of.     O.   Rommel 268 

Nutritional  disorders,  digitaline  in  the  treat- 
ment of.     Henry  Beates,   Jr 7 

Obesity.     Leven    37 

Treatment  of.    H.  Labbe  and  L.  Furet 565 

CEdema,   treatment  of.     J.   D.   Mann 324 

(Esophagus,  new  suture  for.     D.  V.  Navratil...  227 
On  the  home  treatment  of  epilepsy.    Charles  L. 

Dana     385 

Management  of  epileptics.     Matthew  Woods..  337 

Ophthalmia  neonatorum.     C.  T.  Souther 371 

Optic  nerve,   injuries  of  the.     J.  J.   Evans 415 

Neuritis   and   facial   paralysis.     E.    A.    Shum- 

way     77 

During  lactation.     G.   S.    Derby 174 

Orbital  sarcoma.     G.   Oram   Ring 371 

Orthopaedic  surgery,  diagnostic  value  of  tuber- 
culin  in.     W.   S.   Baer  and  H.  W.  Ken- 

nard    78 

Ossification   of    the   lower  jaw.      Edward    Faw- 

cett    468 

Otitis  media,  acute  suppurative.     C.  R.  Elwood.  325 

Treatment  •£     A.  E.  Bulson 325 

J.   G.   Huizinga   469 

Ovaries,  conservative  operations  on  the.    J.  W. 

Cokenower    37 

Pancreas,  effects  of  removing.     Torindo  Silves- 

tri     17.", 

Lymph  flow  from.     F.  A.  Bainbridge 78 

Rdle  of  the  nerves  of.     G.   Zamboni 123 

Pancreatic  diabetes,  origin  of  the  sugar  in.     E. 

Pfliig<  r    513 

Panophthalmitis,  sympathetic  inflammation  fol- 
lowing.     William    Zmtmayer 409 

Paralysis  agitans  and  certain  forms  of  chronic 
acquired   tremor,   remarks  on   the  treat- 

l.n  nt   of.     J.    Madison    Taylor 205 

Paratyphoid  fever.     J.   N.   Henry 326 


Paraurethritis.     J.   W.    Churchman 78 

Parotid  gland.     E.  A.  Zherbovski 269 

Parotitis    following    injury    or    disease    of    the 
abdominal  and  pelvic  viscera.     Brennan 

Dyball     37 

Secondary.     R.   T.   H.   Bucknall 565 

Pelvic    operations,    inflammatory    conditions    of 

appendix  in.     Hunter  Robb 415 

Peptic  ulcer,  treatment  of.     G.  G.  Sears 228 

Pericarditis   complicating   acute   lobar  pneumo- 
nia.    J.   A.    Chatard 566 

Pericolitis   dextra.     J.    F.    Binnie 341 

Sinistra.     H.   D.   Rolleston 149 

Perinephritic    abscess.      Bryan 415 

Peritoneum,    physiology   and   pathology   cf.      P. 

Clairmont  and   H.   Haberer 372 

Peritonitis,    acute:     treatment.     Lennander 470 

Diffuse,     septic:      drainage     in.      Von    Buren 

Knott    419 

General   septic.     1.   B.   Perkins 273 

Tubercular,  laparotomy  in.     P.  Y.  Eisenberg.  379 
Pernicious   anaemia,    etiology   and   pathogenesis 

of.     C.   H.   Bunting 400 

Pathology  of.    G.  L.  Gulland  and  A.  Goodall.  175 

Theory  of.     Liten  and  Michaelis 229 

Pertussis,    leucocytosis    in.     C.    G.    Grulee   and 

D.  B.   Phemister 471 

Treated  by  elastic  abdominal  belt.    T.  G.  Kil- 
mer         79 

Treatment   of.      L.    Itzkowitz 79 

J.    B.    Tyrrell 416 

Pharmacopoeia,  changes  in  the 429 

Phlebitis,  treatment  of.     H.  Vaquez 514 

Phlebosclerosis.     C.  F1.  Martin  and  J.  C.  Meak- 

ins    566 

Physiology  from  surgery,  lessons  in.    J.  Madi- 
son Taylor   545 

Placenta  praevia,  Caesarean  section  for.     R.  W. 

Holmes    372 

Pleural  and  cerebro-spinal  fluids,  cytodiagnosis 

of.     Edward  Turton 269 

Pleurisy.      N.    Moore 373 

And  tuberculosis.     Silvio  von   Ruck 567 

Pneumonia.     W.   J.   Galbraith 124 

Action  of  metal  ferments  on  metabolism  and 

in.     A.    Robin 79 

Acute  lobar,   treatment  of.     Beverley  Robin- 
son         38 

Alkaline  beverages  in.     C.   E.  de  M.   Sajous..  249 

And  pregnancy.     R.   C.  Ransdell 176 

Carbonate  of  creosote  in.     C.  P.  Stackhouse..  270 
Complicating     surgical     operations.       J.      L. 

Rothrock    516 

Freezing   points    of    blood    and    urine    in.      F. 

E.  Schmidt  515 

Is  it  increasing.     J.  S.  Fulton 79 

Lobar,  ice  applications  in.     P.  A.  Aurness....  416 

In   infancy.     J.   L.   Morse 17*6 

Infants  and  children.     II.   Koplik 417 

Pericarditis,  complicating.     J.   A.   Chatard..  566 

Prophylaxis  of.     J.   M.   Anders 368 

Some  irregular  features  of.     C.   K.  Law....  121 

Management  of.    O.  T.  Osborne 81 

Of  adults,  treatment  of.     M.  Manges 38 

Prevention  and  treatment  of  heart-failure  in. 

S.   Solis-Cohen   80 

Prognostic   value  of  phosphates  in   the  urine 

in.     Sicuriani    418 

Scrum  treatment  of.     J.  M.  Anders 39 

Treatment  of.    William  Ewart 125 

Postpartum  haemorrhage.     H.  H.  Loveland 229 


588 


INDEX. 


Potassium  iodide,   administration  of.     M.   Huh- 

ner     "3 

Permanganate  as  a  haemostatic.     Vomer 567 

Salts  or  sodium?     S.   Distefano 

Pott's  disease.     A.    Campini 326 

Treatment  of.     Arturo   Campani 270 

Practical  utility  of  thyroid  extract  in  puerperal 

eclampsia.     J.   Madison  Taylor 155 

Pregnancy,  toxaemia  of.     Ewing 177 

Prepuerperal    and  puerperal    haemorrhages.     C. 

J.    C.   O.    Hastings 178 

Presbyopia,  premature.     G.   M.   Gould 81 

Present  status  of  neurology.    Joseph  Collins 49 

Preventive    medicine:     how    can    the    physician 

profit  by  it?    J.  Madison  Taylor 179 

Problem  of  the  enlarged  prostate.     H.  M.  Chris- 
tian      4"8 

Prostate,   carcinoma  of  the.     H.   H.   Young 568 

Enlarged,  problem  of.     H.  M.  Christian 43S 

Prostatectomy.     M.  B.  Tinker S3 

Conservative  perineal.     H.   H.   Young 271 

Prostatic  enlargement,  pathological  changes  re- 
sulting from.     C.  E.   Barnett 126 

Hypertrophy,    obstructive,    pathology    of.      P. 

M.    Pilcher    230 

Surgical  treatment  of.     E.   G.   Ballenger 126 

Pruriginous  dermatoses,  x-rays  in  treatment  of. 

Belot    127 

Pruritus   ani,    cause   and    treatment   of.      F.    C. 

Wallis    374 

Inveterate,   treatment  of.     Charles  Ball 127 

Psoas  abscess  from  inguinal  or  femoral  hernia, 
valuable    sign    in    differentiation    of.      J. 

Torrance   Rugh    433 

Psoriasis,   treatment  of.     Dreuw 374 

Psychological  medicine.    Joseph  Jastrow 193 

Puerperae,  care  of.     J.  D.  Voorhees 83 

Puerperal    eclampsia,    practical    utility   of    thy- 
roid extract  in.    J.  Madison  Taylor 155 

Fever,  the  blood  in.    W.  D'Este  Emery 230 

Clinical  aspects  of.     Herman 271 

Prevention   of.     B.   Crede ISO 

Infection.     Lea    375 

Saline  infusion  in.     J.  Jaworski 84 

Infections,    treatment   of,    by   turpentine.      M. 

Fabre     516 

Septicaemia,  prevention  of.     Berry  Hart 272 

Pulmonary  haemorrhage,   treatment  of.     W.   A. 

Dickey     327 

Tuberculosis,    examination    cf    the    blood    in. 

J.  T.  Ullom  and  F.  A.  Craig 471 

Pupils,   inequality  of,   in   diseases  of  the  lungs 

and   pleura.      Dehrain 84 

Purgation  before  and  after  operation,  abuse  of. 

I.   S.    Stone 127 

Pyelitis,  treatment  of.     Howard  A.  Kelly 231 

Question  of  posture  in  cardio-vascular  disease 

Allen  J.  Smith   4 

Quinine,   administration  of.     Luca 375 

Rabies,  Negri's  bodies  and  their  significance  in. 

Luigi    D'Amato    39 

Raehicoeainization,    new   technique   of.      M.    Lc 

Filliatre    471 

Radiotherapeutic    technique,    variations    of.      R. 

H.   Boggs   40 

Radium   and   x-rays,   rdle   of   lecithin   in   action 

of.      R.    Werner 172 

Rectal  surgery,  anaesthesia  in.  J.  P.  Tuttle...  375 
Reflexes,    clinical    significance    of    the.      Philip 

Zenner     247 


Refraction  in  children,  nervous  symptoms  pro- 
duced by.     J.   H.   Claiborne 40 

Relation  which  hypertrophy  of  the  various  ton- 
sils   of    Waldeyer's    ring    bears    to    the 

etiology  of  disease.     J.  Price-Brown 489 

Remarks    on   muscular   rheumatism    and   allied 

painful   states.     J.   Madison  Taylor 394 

On  the  constitutional  treatment  of  rheumatic 

conditions.     J.    Madison    Taylor 494 

On    the    treatment    of    muscular    rheumatism 
and    allied    painful    states.      J.    Madison 

Taylor    440 

On    the    treatment    of    paralysis    agitans    and 
certain      forms      of      chronic      acquired 

tremor.     J.   Madison  Taylor 205 

Renal  and  ureteral  calculi,  diagnosis  of.     H.  A. 

Fowler     128 

Calculus,    diagnosis   of,    by    means   of   x-rays. 

A.    B.   Johnson 128 

Morton    Smart    517 

Capsule,   function  of.     I.   Levin 129 

Decapsulation.     J.   H.   Zaaijer 231 

Rheumatic  affections,  intravenous  injections  of 

salicylates   for.      Behr 40 

Conditions,     remarks     on     the     constitutional 

treatment  of.     J.    Madison   Taylor 494 

Poison.     F.   Le  Roy  Satterlee 517 

Rheumatism,  formic  acid  in.     L.  B.  Couch 376 

Of  the  feet.     L.  W.  Ely 418 

Rarer  forms  of.     J.   Schreiber 129 

Rheumatoid    arthritis    and    Raynaud's    disease. 

R.   L.   Jones 272 

Rickets  and  the  nervous  system.     James  Her- 
bert McKee    487 

Ringworm   of   the    scalp,    treatment   of.      T.    C. 

Fox    273 

Treatment  of.     J.  L.  Bunch 181 

Roentgen   ray   therapy   in    dermatology.     J.    H. 

Comroe    327 

And  sterility.    Brown  and  Osgood 273 

Influence  of,  on  internal  organs.    H.  Heineke.    85 
Therapy:    its  sphere  of  applicability.     Charles 

Lester  Leonard   99 

The   role   of  adrenoxin    (oxidase)    in   pathology. 

Charles  E.  de  M.  Sajous 10 

Rupture  of  intestines.     C.  P.  Flint 130 

Salicylates,  action  of,   on  kidneys.     Quenstedt..  472 

Salt  solution,  physiological  value  of,  in  circula- 
tory failure.     H.   C.  Wood 419 

Scabies.     J.   S.  Howe 376 

Scarlatina,  complications  of.     J.  H.  W.  Rhein..  328 

Scarlet   fever,    ear   complications   of.     Herman 

Jarecky     181 

Infection       with,       through       open       wounds. 

Charles   Haemann    ...". 568 

Infectivity    and    management    of.      W.    T.    G. 

Pugh     130 

Sciatica,   treatment  of.     Lange 131 

W.    M.    Leszynsky 518 

Scoliosis  in  children,  hypothesis  on  the  etiology 

of.     J.    Madison   Taylor 303 

Scopolamine-morpline   anaesthesia.     Ries 569 

As  an  adjuvant  in  the  administration  of  gen- 
eral   anaesthesia.      Seelig 472 

Self-education   of   the   general   practitioner.     J. 

Madison    Taylor    343 

Septic    peritonitis,    diffuse,    drainage    in.      Van 

Buren   Knott   .• 4'9 

General.     I.   B.  Perkins 273 

Serum     injections,     eff<  et     of,     on     the     blood. 

Kucharzewski     131 


IXDEX. 


589 


Shock,    condition    of    the    blood-vessels    during. 

J.    D.    Malcolm 518 

In  surgery.     G.  W.  Crile 328 

Sigmoid,  surgical  diseases  of  the.     H.  D.  Niles.    41 
Significance  of  so-called  "occult  haemorrhages" 
in  diagnosis  of  certain  gastric  affections. 

Julius    Friedenwald    199 

Skull   and   brain,    effect  of   direct   and   indirect 

violence  upon  the.     A.  E.  Sterne 41 

Birth-fracture  of  the.     James  H.  Nicoll 42 

Sleep,    biological   theory   of.     Claparede 132 

Sleeplessness  and  pain.     L.   Brunton 570 

Some    facts     about    artificial     drumheads     and 

other  aids  of  hearing.    B.  Alex.  Randall.  301 
Speech,    retarded    development    of,     in    young 

children.     G.   Hudson-Makuen 232 

Spina    bifida,    operative    treatment    of.,    E.    R. 

Secord      42 

Spinal  cord,  localization  of  the  motor  function 

in   the.      Lapinsky 472 

Spine,    tubercular  conditions  of  the.     DeForest 

Willard     570 

Spleen.     E.   T.Williams 329 

Indications  for  removal  of  the  pathologic.     B. 

B.     Davis 473 

Spondylose  Rhizomyelique.     D.  J.  McCarthy 274 

Sprains  of   the   knee   and   ankle   joints.     J.    T. 

Wilson    181 

Sprue,  use  of  cyllin  in.    W.  Hartigan 232 

Sterility,  treatment  of.     E.  Bumm 182 

Stomach    contents;     microscopical    examination 
during  fasting,  and  its  diagnostic  value. 

W.  Ackerman  and  L.  M.   Gompertz 329 

Diseases     of,     criticism     of     recent     surgical 

literature  on.     H.  W.  Bettmann 85 

Hydrochloric   acid  in   diseases   of  the.     R.    F. 

Chase     519 

Motor  insufficiency  of  the.    E.  O.  Adams 43 

Passage  of  foodstuffs  from.     W.  B.  Cannon...  132 
Ulcer      and     cancer     of     the.       Christopher 

Graham     474 

Stovaine.     C.   G.   Coakley 233 

Strabismus,  convergent.     Wendell  Reber.. 420 

Streptococci,    dissemination    of.      Alice    Hamil- 
ton       233 

Strictures      of      the      rectum,      non-malignant; 

treatment.     Howard  A.  Kelly 519 

Struma  and  cataract.    A.  Vossius 329 

Strychnine,  action  of  on  the  heart.    Gennari 263 

As  a  heart  stimulant.    Carlo  Gennari 234 

Subcutaneous  alimentation.     A.   E.  Barker 13 

Nourishment       after       surgical       operations. 

Friedrich    183 

Sudden  death.     William  S.  Wadsworth 201 

Sugar  in  urine,  detection  of.     E.  L.  McEwen...  329 
Summer    diarrhoeas    in    infancy,    etiology    and 

classification  of.     C.  H.   Dunn 377 

Suppuration,  temperature  as  a  guide  to  exist- 
ence of.     Lyman  Allen 133 

Suprarenal  extract  in  the  treatment  of  card  o- 

vascular  disease.     James  Tyson 53,  141 

Influence   of,    upon   absorption   and   transuda- 
tion.    S.  J.  Meltzer  and  John  Aucr 86 

Haemorrhage    of    the    new-born.      S.    Obern- 

derfer   5:0 

Insufficiency.      G.    Bossuet 86 

Preparations,  effect  of,  on   living  protopl;* 

Beaman     Douglass 133 

Glycosuria,    effect    of    fever,    Infection,    ami 

renal   injury  on.     Kllinger  and  Seellg. ...  274 
Surgery  during  the  Russo-Japanese  Naval  War. 

Surgeon-General    Suzuki 571 


Surgical  Anaesthesia,  Discovery  of.     James  Mc- 

Fadden     Gaston 481 

Cases,  treatment  of.    J.  E.  Cannaday 521 

Shock    and    collapse.     J.    P.    Lockhart   Mum- 
mery     224 

Suturing    the    heart   muscle.     Harry    M.    Sher- 
man    3S8 

Sweating  feet,  treatment  of.    Fischer 474 

Syphilis  and  longevity.     J.  N.  Hyde U71 

Fever  of  late  (visceral).    Arthur  Birt 572 

Prognosis  of.     N.  E.  Aronstam 43 

R.    W.   Taylor 474 

Scars     and     the     retrospective     diagnosis     of 

Arthur    Cooper 86 

Syphilitic      recrudescences,      pathogenesis      of. 

Medical  Record    133 

Tabes,    curability   of.     Faure 330 

Early    diagnosis    of.      Severino 572 

Pains  of.     W.  R.   Gowers 87 

Principles    of    physical    re-education    in.      H. 

S.    Frenkel    475 

Exercise  treatment  in.     Fraenkel 420 

Dorsalis,  mercury  in.     Maurice   Faure 521 

Tapeworn,    treatment  of.     I.    Boas 276 

Teaching   of   specialties    in   medicine.     Charles 

A.   Oliver  55 

Tendon    reflexes,    increased,    in    infections.      R. 

Massalongo     135 

Transplantation.     H.   A.    Wilson 276 

Tenotomy  of  the  tendo-Achillis.     J.  P.  Webster.    88 

Tetanus.    J.  M.  Anders  and  A.  C.  Morgan 421 

And  quinine.     E.  Vincent 276 

Blank  cartridge.     D.   H.   Dolley 88 

Thiersch's   skin   grafting,    modification   of.      Is- 

nardi    ^77 

Thrombosis    of    the    external    iliac    vein    after 

appendicectomy,  cause  of.     Witzel 521 

Thymectomy,    diminished    resistance    to    infec- 
tion after.     G.  A.    Pari 331 

Thyroid    and   pancreas,    relation   between.     Al- 
fonso  Pirera   183 

Gland,   elimination  of  iodine  and  its  relation 

to   the.     A.   Kocher 331 

Influence  of  diet  on  its  structure  and  func- 
tion.    Watson   :'77 

Iron  pigment  in  the.     G.  L.  Gulland  and  A. 

Goodall    476 

Thyroidism,    acute  post-operative.     S.    E.    San- 
derson      135 

Tonsil,  function  of.     G.   B.  Wood 8 

Growth  of  the  bone  in.     W.  \V.  Cart  r 136 

Tonsillitis  and  articular  rheumatism,   relations 

between.      Giirich    89 

Tourniquet,   dangers  of  the.     A.    Ahlberg. .. 
Toxaemia    of    intestinal    origin    as    a    condition 
predisposing  to  minor  Infections.     II.  A. 

Houghton     

Trachoma   treated   with    radium.     J.    V.    /..  Ii 

kovski    421 

Training  of  the  modern  surgeon.     X.  Senn 2 

Tubercular      cervical      lymph-nodes,      surgical 

treatment   of.     C.    N.    Dowd ill' 

Peritonitis,  laparotomy  In.  P.  Y.  EMsenberg.  379 
Tuberculin  test,  the  value  of  the.  I.  II  Neff. .  13 
Tuberculosis,  acid  salts  in  blood  in.     C.  Canter    im 

Adaptation    ami.     J.    G.    Adami 278 

And  mortality  in  childhood.     W.  P.  S.   Bran- 
son         90 

And  pregnane)-.     G.   E.   Malsbary 422 


590 


INDEX. 


Tuberculosis, 

Early  diagnosis  of.     A.  C.  Klebs,  J.  H.   Mus- 
ser,  F.  Billings,  J.  C.  Wilson,  H.  R.  M. 

Landis     332 

Effect  of   raw   meat   on    nitrogen    metabolism 

in.     J.    J.    Galbraith 279 

Healing  of.     H.   M.   King 90 

Heart  and  circulation  in  prognosis  and  man- 
agement of.     Von   Ruck 332 

In  the  United  States.     S.  A.  Knopf 91 

Mesenteric  glands  in  their  relation  to.     R.  C. 

Rosenberger     "69 

Of  caecum.     R.  A.  Stoney 424 

Of  larynx,  treatment  of,  with  sunlight.     Kun- 

wald     136 

Of  middle  ear,  bilateral.     Dunbar  Roy 44 

Pulmonary.     M.   Wassermann 91 

H.   P.   Loomis 476 

After-treatment  of.     J.   A.   Wilder 572 

Examination  of  the  blood  in.    J.  T.  Ullom  and 

F.   A.    Craig 471 

First   anatomical   changes   in.     A.    J.    Abri- 

kossoff   91 

Methods  of  infection  in.     J.  O.  Cobb 44 

Relation   of   human    and   bovine.      David    Bo- 

vaird,    Jr 236 

Stomach  function  in.     J.  E.   Munson 279 

Sugar  in.     R.  Massalongo  and  G.  Danio 137 

Transmission  of.     S.   Kitasato 92 

X-ray  in  deep-seated.     H.  K.  Pancoast 333 

Yeast  in.    W.  R.  Huggard  and  E.  C.  Morland  379 
Tuberculous    cervical    lymph    glands,    surgical 
treatment    of.      Editorial    in    Journal    of 

the  American  Medical  Association 522 

Deposits  in  the  tonsils,  significance  of.     G.  B. 

Wood    280 

Peritonitis,   recurrent,   after  incomplete  oper- 
ation.    J.    B.    Shober 476 

Ulceration  of  the  ascending  colon  simulating 

appendicitis.     G.  Grey  Turner 523 

Typhoid   and   colon   bacilli    in   water,    efficiency 
of    copper    foil    in    destroying.      Henry 

Kraemer    137 

Fever,  blood-pressure  in.     G.  Garriere  and  C. 

Dancourt    477 

Chloride  and   water   excretion   in,   with   co- 
pious diuresis.     Torald  Sollmann  and  J. 

A.    Hofmann    184 

Iodine   treatment  of.     A.    Ceriolo 379 

Perforation  in.     J.  A.  Scott 280 

Peritonitis   in.      Farquhar    Macrae 523 

Rupture  of  the  muscles  in.    Perochaud 93 

Treatment  of.     F.    F.   Caiger 45 

Medical    Record    137 

Water-drinking  in.     E.    F.   Cushing  and   T. 

W.    Clarke    140 

Typhus  fever.     F.  Robinson  and  E.  T.  Potts...  380 

Ulcer   of   the   stomach   and    duodenum.     C.    P. 

Howard     46 

Ulcerative  processes,  chloro-bromide  of  sodium 


in.     H.   W.   Mitchell 281 

Uraemic    hemiplegia,    intracranial    pressure    in. 

R.    N.    Willson 424 

Ureteral  stones,   diagnosis  of.     Harris 477 

Ureters,  operations  on  lower  ends  of.     John  A. 

Sampson    140 

Urethral   stricture,    treatment  of.     F.    S.   Wat- 
son       141 

Urethritis,  local  treatment  of.     Paul  Lebreton..  477 

Urethro-rectal  fistula.     W.   M.   Beach 425 

Uric  acid:    its  influence  in  gout.     C.   C.   Ran- 
som       185 

Urinalysis,     hints    for    the    interpretation    of. 

Nathaniel    Gildersleeve    537 

Urinary  tract,  early  diagnosis  of  surgical  dis- 
eases  of   the.     Benjamin   Tenney 478 

Urine  examination.     I.    R.    C.   Cabot 236 

Preservation    of.      J.    B.    Ogden 381 

Uterine   carcinoma,    early   detection   of.     D.    H. 

Craig    426 

Haemorrhage,    arteriosclerosis    of    the    uterus 

as  a  causal  factor  in.    Palmer  Findley..  426 

Myoma.     W.    M.    Thompson 282 

Myomata,  electric  treatment  of.     E.  Witte...    94 

Retrodeviations.      Lucy    Waite ^4 

Uterus,    fibroid   tumors  of,   surgical   treatment. 

F.     H.     Martin 41. 

Malpositions  of.     C.   G.   Child,   Jr 381 

Retrodisplacements  of  the.     Hayd 237 

Vaccination  during  smallpox.     J.  C.  Hibbert. ..  333 
Valuable    sign    in   the    differentiation    of   psoas 
abscess   from   inguinal   or   femoral   her- 
nia.     J.    Torrance    Rugh 433 

Varicose   ulcers.      P.    Leole 524 

Vertigo  of  aural  causation.     C.  J.  Blake 524 

Visceroptosis.     H.    A.   McCallum 185 

Vomiting  of  pregnancy.     J.  M.  H.   Martin 46 

J.   W.   Williams 573 

Recurrent.      B.    K.    Rachford 94 

Vulva,  epithelioma  of  the.     Howard  Dittrick...  478 

Water  cures,    errors   in.     Winternitz 28" 

Water-drinking,  influence  of.    P.  B.  Hawk 186 

Whooping-cough,   treatment  of.     H.   Stepp 187 

Widal    reaction.      E.    Andrade 333 

Wounds,  influence  of  pneumococci  on  the  heal- 
ing of.     J.  Wirt  Robinson 525 

X-ray  in  malignant  disease.     W.  B.  Coley 574 

Injuries,  protection  from.     C.   L.   Leonard 3.°2 

Treatment  of  cancer.     William  B.  Coley 4<.o 

X-rays,   dangers  of  the.     Milton  Franklin 1C3 

Method  of  measuring.     M.   Franklin 283 

Yeast  cells,   action  of.     Walter  Maiden 428 

Yellow  fever,   treatment  of.     A.   M.    Fernandez 

de  Ybarra  283 

Zinc  chloride,  cauterization  by.     L.   Brose 188 


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BINDING  LIST    NOV  1     W^ 


University  of  Toronto 
Bid       Li[>rary