the distribution of malaria. The insects are plentiful in localities where malaria had never existed or disappeared entirely. Celli mentions districts in which malaria is prevalent and the anopheles plentiful, but new comers are not infected. Francesco refers to regions where malaria is rife, but no anopheles have been seen. The author states that malaria can be propagated without the anopheles or any other mosquito species. In Algeria epidemics have followed heavy rains. Malaria in Posen and Eastern Prussia is general from the onset of spring when mosquito bites are rare. During July and August the soldiers in these districts are most discomforted by the bites of mosquitoes, although the disease suddenly decreases. Malaria in Bessarabia, in May, 1901, was twice as severe as the previous year, which was particularly infested with mosquitoes. Meteorlogic or Meteorlogic or telluric influences seem to correspond with the prevalence of the disease. At Tomsk, Siberia, malaria begins when the temperature registers 10 deg. C. below zero. Such a low temperature would hardly be favorably for mosquitoes. Concerning yellow fever, the author claims that its amelioration or disappearance in Havana cannot be attributed to a destruction of the mosquitoes, contending that the disease usually dies out spontaneously in from two to four years unless fresh cases are imported. The writer also cites cases of infection from fomites in his article.

Phosphaturia and Hypoacidity of the Urine. Compani (Riforma med., No. 51, 1904) from a number of personal observations, concludes that in the far majority of instances of so-called phosphaturia are not the result of an actual increase of the phosphates, but a diminution in the acidity of the urine. He advocates the name of hypoacidity in cases of an apparent increase of the phosphates in the urine, limiting the term phosphaturia or diabetes phosphaticus to those cases in which an actual increase of the phosphates really occurs. Urinary hypoacidity very frequently occurs in the male sex at the age of puberty, and is aggravated by excessive sexual intercourse. This can only be attributed to the diet, as no relation exists between urinary hypoacidty, in the sense of Compani, and genito-urinary disorders. In none of his cases did any signs of a gastric disturbance manifest themselves. Mineral acids, particularly hydrochloric acid had decided therapeutic effects.

Examinations of the Urine and Urinary

Sediments in Normal Persons, Rheumatic Individuals with the Effect of Salicylic Acid Preparations. Klieneberger and Oxenius (Deutsches Archiv f. klinische Medizin, Bd.

LXXX, Heft 3 and 4) made a series of urinary examinations in Treupel's clinic, Frankfort. They found in the urine of normal individuals, albumin in 58 per cent of the examined specimens; casts in 89 per cent, kid. ney epithelium in 24 per cent. In afebrile cases of articular rheumatism the urinary findings did not differ materially from the normal. In articular rheumatism associated with fever, 94 per cent of the cases contained albumin, casts in 67 per cent, and renal epithelium in 35 per cent. Both albumin and the form elements increased with the internal administration of salicylic acid, thus substantiating the views of Lüthje, who asserts that the internal use of the salicylates quite regularly causes a nephritis. The writers farther observed that a continuation of salicylic acid caused the nephritis to disappear. They also observed that a renewal of the salicylic acid, after a few days discontinuation, caused a reappearance of the nephritis. The salicylic acid nephritis as well as the slight nephritis frequently produced by the toxins of the agent of acute articular rheumatism are of a favorable kind, rapidly leading to a complete recovery.

Two Attacks of Tubercular Meningitis in the Same Individual with Recovery.-Jirasek (Revue v. neurologii, psychiatrii, etc, p. 369, 1904) reports an 11 year old girl of tubercular parentage who four years ago suddenly became ill with an intense headache, a peculiar swinging gait, vomiting, constipation and psychic disturbances. Her pupils were widely dilated with a retarded reaction to both light and motion. The facial expression was a painful one, pain upon motion of the head, retraction of the head, tenderness of head and back of neck, retraction of the abdomen, exaggerated knee reflexes, dermographism, "Parrot's reflex," cutaneous hyperesthesia. A complete loss of consciousness soon set in, with a temperature of 38 deg. C. and a pulse rate of 60. Somnolens and Cheyne-Stokes breathing were prominent features, together with a left-sided facial paralyiss, and a rightsided hemiplegia. In addition to these symptoms and signs the patient showed an infiltration in both lungs, justifying the assumption that the primary seat of the infection was in the lungs with a secondary and unFive mistakable tubercular meningitis. months after the onset of the meningeal trouble a complete recovery set in. Two years later the described clinical picture repeated itself in the exact manner, but in a

milder form and of a shorter duration.

The Symptomatology of Sclerosis of the Aorta. Bittorf (Deutsches Archiv f. klinische Medizin, Bd. 81, Heft 1 and 2, 1904)

tabulates 54 cases of sclerosis of the aorta dividing them into circumscribed or insular sclerosis and a diffuse disease of the aortic wall. Out of this number there were 34 cases of the diffuse form and 20 of the circumscribed: The distinction between the two varieties is by the character of the heart sounds over the aorta; the first heart sound is muffled and soft, or it may be inaudible, while the second sound is accentuated and of a ringing character; in the circumscribed or insular form there is a systolic murmur, while the second sound may be either normal or accentuated. With reference to the objective symptoms, the author calls attention to a peculiar ashen-grey pallor of the face which most of his cases presented. Pupilar inequality was frequently observed, due to probably some obscure influence on the sympathetics. Pulsations were often noted in the carotids, subclavians, and jugulars, while the superficial veins on the anterior portion of the chest were often dilated, together with a slight edema on the upper part of the sternum. The most constant pulmonary symptoms was an emphysema. A cardiac hypertrophy was demonstrable in 24 cases, doubtful in 22, with no evidence in 8. In 9 per cent with a diffuse form of the disease a cardiac musculature weakness was evident, while 50 per cent of the insular variety showed signs of this weakness. In 49 of the cases an enlargement of the ascending portion and arch of the aorta could be demonstrated. Signs of perpheral sclerosis was present in 42 cases, while 35 of these showed an increased arterial tension. The subjective symptoms consisted mainly of palpitation and shortness of breath on exertion, together with such manifestations resulting from impoverished blood or a defective supply, as dizziness, ringing in the ears, general weakness, etc. No single sign or symptom is characteristic of this condition, but a careful consideration of the symptoms in their aggregate will enable one to make a diagnosis.

The Pathogensis of Uremia and Eclampsia. -Robert Willson (J.A.M.A., October 8, 1904) briefly discusses some of the advanced theories concerning the production of these conditions. He offers nothing new, but states that many symptoms of uremia and eclampsia resemble brain pressure symptoms, reporting three cases illustrating the pressure theory and the results of therapeusis based on the same. He concludes as follows: That it is probable there are at work in the cerebrum, as well as throughout the system of uremic subjects, at least one, and probably several toxic substances which exert their influence more or less locally on the cortex.

1.

2. That it is equally certain that other portions of the brain than the cortex are also acted on, as in the production of coma, etc.

3. That no small part in the production of uremic and eclamptic condition is played by intracranial pressure, due to a temporary excess of fluid, whether acting independently of or in conjunction with the toxic substances already mentioned.

4. That lumbar puncture will at least temporarily relieve certain of the symptoms most readily ascribed to localized intracranial pressure, and that in cases in which the pressure is the main factor, drainage of the spinal canal may save life. The procedure, together with free bleeding, purging and diuresis should be added to our routine treatment of the condition.

5. That transfusion of normal salt solution by intravenous injection or hypodermoclysis, except in cases presenting anuria, or a greatly diminished urinary secretion, is contraindicated as tending to increase the liability to saturation of the tissues.

6. That the lumbar puncture in the three cases cited in this paper will not warrant the assumption that relief of intraspinal or intracrainal pressure can alone be depended on to cure the uremic or eclamptic condition, provided the toxic influence is the prominent one in the particular case.

SURGERY.

JOHN MCHALE DEAN, M. D.

Remarks on Appendicitis. The favorite and much exploited subject of appendicitis receives a valuable contribution in Annals of He diSurgery written by Parker Syms. vides the cases into three classes, viz: 1. Chronic recurrent, relapsing; 2, acute, perforative, gangrenous, suppurative, local, with more or less diffuse peritonitis; 3, fulminating and those with general septic peritonitis. Of the first class forty-three operated on in the interval between recurrent attacks all recovered. In the second class of cases operated on at the time of an attack 157 out of 164 cases recovered and seven died. In the third class of cases 19 operated on and 19 died.

The conclusion from the above is that interval operation is safe, rational and accompanied by practically no mortality. The acute form not fulminating furnishes a mortality of 4.4 per cent while the fulminating variety with septic general peritonitis are nearly always fatal.

Ochsner maintains that cases seen after the twelfth to the twentieth hour after the

onset should not be operated until resolution. takes place, and then treated as an interval case. The author does not favor this mode of treatment, for the simple reason that the gravity of the condition cannot always be diagnosticated prior to an operation.

Procrastination and the employment of rectal feeding with rest appeals more or less as a dangerous procedure in appendicitis. The reviewer would deem that all cases of appendicitis be operated on as soon as the diagnosis is made. The appendix is very often found during an operation to he on the verge of perforating, often decidedly gangrenous and would be unsafe to leave to nature and rest alone.

In cases of appendicitis of several days duration where no pus can be made out, it seems rational to tide such cases over and perform an interval operation. When pus is evident by finding a fluctuating tumefaction by rectal examination it appears as folly to leave it unmolested. It would be the wiser practice to leave to the inevitable cases, with well marked signs of general fulminating septic peritonitis, especially when seen in a semimoribund state.

The

The

Injurious After-effects of Chloroform.-Vorderbrugge (Deutshe Zeitschrift f. Chirurgie) reports two serious after-effects from chloroform. The patients were 10 and 5 years respectively, and the amount of chloroform used varied from three drams to one ounce. one case went into collapse and died. post-mortem showing fatty changes in the heart, liver and kidneys. The other showed albmuminuria and hemoglobinuria for some time, but finally recovered. The author is of the opinion that the hemoglobinuria was due to destructive changes on the red blood corpuscles due to the chloroform. Persistent vomiting. icterus cerebral symptoms with albuminuria and other indications of acute parenchymatous nephritis are found in cases where the pulse is progressively becoming more rapid and the outcome can be considered extremely grave.

Enterostomy in the Treatment and Prophylaxis in Peritonitis. Enterostomy has been performed with good results upon eight cases in peritonitis as reported by Gebhart in Deutsche Zeitschrift. The author strongly, commends the procedure for it offers a natural and most efficient drainage. In perforation the author also in very extreme cases uses this method by way of forming a fecal fistula by sewing the edges of the perforation to the external wound.

Another advantage of enterostomy is attained by causing an expulsion of the intestinal flatus, thereby collapsing the bowel.

Treatment of Fractures.-Lurman (Deutsche Med. Wochenschrift) advocates mobilization and early masssage in the treatment of fractures. The fracture is at first immobilized and then examined by the X-ray to ascertain the accuracy of approximation. It is then left alone for a short time, a week or so, when active massage is daily used. After massage it is again immobilized. That massage is not a novel procedure in these cases is evident to all, but unfortunately it is often practiced too late. Early massage causes rapid absorption of extravasation and exercises the adjacent muscles in such a way as to cause them to hold the ends of the fragments in place. Fractures in the aged, no matter what the location may be, should be subjected early and often to massage by the "surgical hand." Colles' fracture is best treated in this way, and in fact immobilization without massage in the aged, is sure to result in a permanent stiffness or anchylosis of the wrist. Massage in fractures of the neck of the femur should be commenced at the very beginning, especially in aged per

sons.

Turpentine a Cure for Traumatic Gangrene. -Christy (Iowa Med. Jour.) reports a case of traumatic gangrene of the forearm that was cured by the continuous application of a solution of equal parts of linseed oil and turpentine. The author claims that were it not for the turpentine amputation would certainly have been done. Turpentine is an astringent, diuretic and slightly antiseptic and undoubtedly exerts a beneficial effect in such cases Similar reports in medical and surgical literature mark turpentine as a remedy well worthy of a trial in these cases.

In

Injuries of the Rectum Caused by Gynecologic Examinations.-Howard Kelly reports in J.A.M.A. four cases of injury to the rectum during gynecologic examination. the four cases the fungi was pushed through the rectum into the abdomen. This is a very rare accident, and certainly emphasizes the fact that palpation should be gentle in the rectum, especially when an examination is made under general anesthesia. The author repaired the injuries immediately and no illeffects resulted. Kelly claims the precaution should be used not to invigorate the wall of the ampulla of the rectum on the end of the finger, but the finger should be carried up between the ampulla and the "third sphincter" of the rectum.

OBSTETRICS AND GYNECOLOGY

W. H. VOGT, M. D.

Case of Acute Inversion of the Uterus; Reduction by Taxis on the Seventh Day after Labor. (E. Octavius Croft, The Lancet, No. 4236, London).-The inversion occurred on the day following the confinement in a III para. After repeated unsuccessful attempts at replacement, Croft finally succeeded in the reposition seven days after confinement. He believes it is preferable to anethetize with chloroform than with ether since the uterine muscle is more easily relaxed with chloroform.

The First Spontaneous Rupture of the Gravid Uterus, at the Site of the Old Caesarean Section Scar Following the Transvers: Fundal Incision of Fritsch.-E. Eckstein (Zentralblatt fuer Gynekologie, No, 44) reports the case of a IV para, 33 years of age, who on account of a generally contracted flat rachitic pelvis was compelled to have two of her children perforated. At the third pregnancy Caesarean section was performed, the transverse fundal incision being made use of, and the opening again closed in three separate layers. Three years later she was brought to the clinic at the end of pregnancy and with the signs of a ruptured uterus. Laparotomy was immediately performed, the fetus placenta were free in the abdominal cavity and the uterus was found ruptured at the site of the previous Caesarean section scar extending the full length of the scar. After the child and placenta were removed and a toilet made the Paras operation was performed. woman died one and one-half hours after the operation. The pathologic examination showed in this case that the rupture was due to the proliferation of the placenta tissue in the region of the scar. He concludes therefore that the line of incision and likewise the method of suturing in conservative Caesarean section is immaterial, so far as rupture is concerned and believes that the insertion of the ovum in future pregnancies in the region of the old scar, forms the main cause for rupture. This possibility is certainly an objection to conservative Caesarean section. He suggests the use of lead for suturing the uterine muscle.

The

Positive Signs of Pregnancy in the First Months. v. Herff (Schweiz. Korresp. Blatt., No. 21) does not agree with Sarwey that fetal heart tones can be heard regularly before the eighteenth week of pregnancy. He asserts, however, that by careful auscultation certain fetal movements can be determined before the sixteenth week. A light rubbing or scraping sound, on the uterine wall, which rapidly disappears again he claims is characteristic.

Lumbar Puncture in Eclampsia. Max Henkle (Zentralblatt fuer Gynaekologie, No. 45) has used this mode of treatment in the clinic of Olshausen prior to B. Kronig, but has not published his results until recently. Sixteen cases are carefully reported. Four of these died; so the percentage of mortality in eclampsia which has usually been 20 per cent in their clinic has not been improved upon No case, however, died as a direct result of the lumbar puncture. The operation was performed with the patient lying on her side in the usual manner, the patient as a rule kept in this position except in a few cases the patient was brought in the sitting position to hasten, or rather improve the evacuation. He divides the cases into three groups:

1. Those in which there was no increase in the amount of spinal fluid:

2. Those in which the spinal fluid was not especially increased.

3. Those in which there was a great increase of the fluid.

He found the spinal fluid absent, or nearly so, in 7 of his cases, of which one died. A Two of these women died. small quantity only was found in five cases. The spinal fluid was increased markedly in four cases. The evacuation in these cases took place under very high pressure. He allowed, however, only 30 c.c. to flow off. Of these four cases

two women died. In all of the cases besides

withdrawing the spinal fluid, he injected 0.015 of cocain and 0.0003 of skopolamin.

A Short Remark Concerning the Lumbar Puncture in Eclampsia. (Ludwig Kleinwächter. Zentralblatt fuer Gynaekologie, No. 45.) -The priority of lumbar puncture in eclampsia, according to Kleinwächter, does not belong to B. Krönig, but to Thomas Arthur Helme of Manchester. His article concerning this mode of treatment appeared in the May number of the British Gynaecological Journal, 1904, on page 84. He reported a case of a woman who had had fifteen eclamptic attacks and had received chloral, diaphoretics, thyroid extract, croton oil and enemata of salt solution. In this case he performed the lumbar puncture and evacuated 1 drachms of spinal fluid under high pressure. The attacks ceased after this, but the albuminuria did not completely disappear until six weeks after.

Two Caesarean Sections in Eclampsia.(Dr. Warner, Zentralblatt fuer Gynaekologie, No. 45). In two very severe cases of eclampsia, eigth to fourteen days ante terminum, Caesarean section was performed. In the first case an abdominal section was done, there was complete anuria, and the patient died forty-eight hours after the operation.

In the second case_vaginal Caesarean section was performed. Four hours after confinement a severe hemorrhage took place which required tamponading of the uterus. The woman, however, made a good recovery and left the hospital with her living child nineteen days after confinement. The author believes that under ordinary circumstances the conservative methods suffice in cases of eclampsia and Caesarean section should be done only in very urgent cases, where there is an absence of pain with very little hopes of the pains coming on soon, and where the patient is in a comatose condition, and child and mother are clearly in danger. He prefers the vaginal to the abdominal method, and agrees with Kroemer that the emptying of the uterus in eclampsia is only a part of the general treatment, but adds that it undoubtedly remains the most important part.

Nephrotomy in Anuria of Eclampsia.-Prof. Albert Sippel (Zentralblatt fuer Gynaekologie, No. 45) after reviewing the case of Edebobl's in which a severe case of postpuerperal eclampsia recovered after having performed a decapsulation of the kidneys, the author comes to the following conclusions: That in every case of eclampsia, whose origin can be traced to a diseased condition of the kidneys, and which continues post partum, decapsulation of the kidneys should be performed in the hopes of relieving the acute ftension of the kidney and re-establishing its unction. Edebohls goes further than this, he not only advises in every case of eclampsia, which can be traced to a kidney condition, and which continues post partum, to decapsulate; but to perform this operation before labor has begun in the hopes of curing the disease and presenting a premature birth.

Digital Cervix Dilatation. (O. Koppe, Zentralblatt fuer Gynaekologie, No. 45.)-Instead of dilating with instruments, Koppe recommends dilatation with the fingers, first introducing the fingers one by one of the left hand, and then those of the right hand. (This method is the one which has long been practiced and known as Bannaire's method. -Ed.)

Induction of Premature Labor.-(Gallatia, Wien. klin. Wochenschr. No. 45.)-While the induction of premature labor was successful in the majority of cases as far as the mother was concerned, the mortality of the children varied according to the indication for which the operation was done. Where the induction was performed in the interest of the child the mortality was 30 per cent; when done in the interest of the mother it

reached 72 per cent. In half of the cases the introduction of the bougie into the uterus and tamponading the vagina, sufficed to bring on pains

Cholecystitis in the Puerperium.- Christiani (Petersburg med. Wochenschrift, No. 43) observed two such cases in which the attacks begun with a chill, high fever and vomiting and could have easily been mistaken for puerperal fever. According to statistics, cholecystitis as a complicating disease in the puerperium seems to be seldom,

Prevention of Blenorrhea Neonatorum.— Ernst (Zentralblatt fuer Gynaekologie, No. 41) thinks as good results can be obtained by the use of a 1 per cent solution of silver nitrate instead of a 2 per cent solution, as recommended by Credé, in the treatment of ophthalmia neonatorum. Irritation of the conjunctiva does not occur with the 1 per cent solution.

THE BERLIN CREMATION SOCIETY has sent to the Pope a petition to which are appended 950 signatures, praying that the last rites of the Roman Catholic Church shall no longer be denied to persons who wish their remains to be cremated.

THE United States government is preparing to spend $600,000 in improving the reserChickasaw Nation, I. T., for the purpose of vation and park at Sulphur Springs in the making a second Hot Springs similar to the famous Arkansas resort.

DR. MARTHA TRACY, a graduate of the Women's Medical College of Pennsylvania, obtained the highest mark among the candidates for licenses at the recent State examination. She had a mark of 91.07, while the College was but 80.39. best average of the graduates of any men's

HONORS FOR GAFFKY.-Professor Gaffky, until recently of Giessen, has now assumed charge of the Berlin University Institute for Infectious Diseases, in which he succeeds Koch. The city of Giessen has conferred honorary citizenship on Gaffky in token of his services in public health matters during his residence there.

IMPRISONED AND FINED.-Dr. Caleb E. Mathis, Kansas City, who pleaded guilty November 18 to the charge of sending through the mails matter prohibited by law, was fined $500 and sentenced to imprisonment for one year. This sentence was afterwards modified to six months' imprisonment and a fine of $750, and he commenced his term at. Clinton prison November 29.