REPORTS ON PROGRESS

Comprising the Regular Contributions of the Fortnightly Department Staff.

INTERNAL MEDICINE.

O. E. LADEMANN, M. D.

Observations upon Amebas Infecting the Human Intestine, with a Description of Two Spe

cies, Entameba Coli and Entameba Dysenteriae. Charles Graig (American Medicine, June 3 and 10, 1905) discusses the subject at length, summarizing his observations as follows: 1. The intestine of man may be infected with two varieties of amebas, one pathogenic (entameba dysenteriae), and the other non-pathogenic (entameba coli). 2. Entameba coli, the non-pathogenic variety, 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. 3. These organisms can be easily distinguished in both fresh and stained specimens. 4. They differ widely in their method of reproduction, and this is the most important method of distinguishing them. 5. Entameba dysenteriae. whether fed in milk or injected through the rectum, produces in kittens the typic lesions of amebic dysentery

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as observed in man. 6. In kittens, entameba coli, whether fed on milk or injected through the rectum, is absolutely harmless. Neither feeding experiments nor rectal injec tions of fecal material or the bacteria occur

ring in such material produce any lesions of amebic dysentery, unless entameba dysenteriae is present.

Report on Early Diagnosis of Tuberculosis. Klebs, Musser, Billings, Wilson and Landis (Boston Medical and Surgical Jour., June 1, 1904) recommend for a more general introduction, the adoption of the term "closed," designating the stage in which there is an absence of bacilli in the sputum, in opposition to the "open, "i.e., with bacilli found in the sputum. They particularly emphasize the paramount importance of making a diagnosis in the "closed" stage. The physician who hesitates to make a positive diagnosis of pulmonary tuberculosis on account of the absence of bacilli in the sputum assumes a very grave responsibility, as the chances of a permanent recovery diminish proportionally with the postponement of rational therapeu tic measures. The sypmtoms in the incipient stage are rarely typical. Cough may or may not be present. Hemoptysis, in the absence of other causes among all the symptoms which may be found in the history, is

of the greatest significance. Length and weight of body, circumference and degree of expansion of the chest, are data of importance, and in their correlation give indication of the bodily condition and state of nutri tion. The temperature is of great importance. Even a slight rise of temperature in the afternoon, if other factors can be elim. inated, ought invariably to arouse suspicion. A two hourly record should be taken for sevonly after exercise, in women before and dureral days. In some patients the rise appears ing menstruation. On inspection there is often a retardation of respiratory movements over the effected area. Vocal fremitus in the

incipiency gives little information. It may be increased or decreased over areas of pleural thickening; over pleuritic exudations it is always diminished. Percussion will sometimes elicit a significant retraction of one apex as compared with the other. Marked dullness is but rarely found over portions of the lungs in the early stage. Marking the border lines and determining the excursions of the lungs cannot be urged too strongly. Rales which can easily be discovered in the morning or on damp days, will regularly be absent during the afternoon or in dryer weather. In women the pulmonary signs are accentuated at the time of menstruation.

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Although every portion of the lung should be examined with the stethoscope, particular attention should be directed to the upper portions, and the lower borders and to the axillary regions. "Impure and roughened" (Sahli), and slightly diminished respiratory murmur may be regarded as the earliest auscultatory sign in early pulmonary tuberculosis, preceding the appearance of rales. The rough murmur is produced by slight inflammatory changes in the bronchioles, the air passing over an uneven surface and slightly narrowed lumen. The rales are usually fine crackling, and can often only be heard directly after the patient has coughed. Bronchial breathing is heard but rarely in early tuberculosis, and when it appears is an expression of a more extensive process. Pleuritic friction sound, on the other hand, is often heard at an early period, most frequently in or near the axillary line, between the sixth and eighth ribs. culin and the administration of iodine salts, the latter to increase the catarrhal symptoms, are important diagnostic methods, but great care is necesasry in their application, and on the whole are not to be advocated. The various other methods recommended for the early detection of tuberculosis-inoscopy, syphgmograph, syphgmomanometry serum test, etc., offer no practical advantage in the every day diagnosis of so frequent a disease.

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Further Remarks on Ischochymia and Its Treatment. Einhorn (American Medicine, June 3, 1905) offers a third contribution on the subject of gastric dilation. Among 74 cases of motor insufficiency of the stomach there were twenty-three of the benign type (17 men, 6 women), twenty-one malignant (13 men, 8 women), and three undetermined (2 men, 1 woman). He describes two cases of benign ischochymia with severe peristaltic restlessness of the stomach which were cured by medical treatment. Two cases of benign ischochymia with a history of short duration; two cases in which the tumors were seen and palpated during operation and were clinically recognized as cancerous, which, according to their future course were certainly not malignant. The indications for medical and surgical treatment of ischochymia may be placed as follows: 1. Benign ischochymia requires first medical treatment; if this be unsuccessful, i.e., if after a longer period of treatment, the fasting stomach, on a fluid diet, is not empty, but contains food remnants, an operation is advisable. 2. Surgical intervention is also indicated in benign ischochymia which has developed subsequent to a condition of continuous hypersection of the gastric juice (preceded by hemorrhage or not). 3. Malignant ischochymia or one of dubious nature in which, however, a thickening of the pylorus is found, should also be treated surgically (gastroenterostomy, and if possible, resection of the pylorus).

A Very Simple Method to Locate the Stomach.-(Knapp, Medical News, June 10, 1905.) -The method is described by the author consists in the patient drinking a cold glass of water, wait about half a minute, and then put a hand on the bare abdomen. The abdomen must not be exposed, as this soon chills the surface, and the examiner's hand must not be cold. Although this simple procedure does not give the exact size of the stomach, it will enable one to determine its location.

Widal Reaction.-Andrade (Medical News, May 27, 1905) deducts the following conclusions from a careful comparison of the results obtained from the examination of 300 specimens of typhoid blood with both living and dead cultures of typhoid bacilli: 1. Living and dead cultures are about equally sensitive to the action of the agglutinous of typhoid fever, though in dead cultures the reaction may require a longer time to take effect, and it is, therefore, necessary to keep the specimen under observation for two hours. In some cases, the reaction is quicker with the dead than with the living cultures. 2. The dried blood method is equally effective with dead

as with living cultures. 3. The reaction, when it takes place, is more characteristic with dead than with living cultures. There are no pseudoreactions with dead cultures. 4. Dead cultures do not seem to lose their sensibility to the agglutinous of typhoid fever for a long time. The author still uses a dead culture prepared six months ago, and it reacts just as typically as when first used.

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The Heart and Circulation in the Prognosis and Management of Pulmonary Tuberculosis. -Von Ruck (Medical Record, June 3, 1905) directs attention to the importance of studying the relation of the heart and circulation to the course of chronic pulmonary tuberculosis, stating that it is a factor both in the prognosis and management of such cases. He suggests the analogy between the relation of the heart and circulation to the local disease in acute pneumonia and in chronic pulmonary tuberculosis. According to his conception, this relation differs chiefly in that the pulmonary obstruction develops rapidly in the one and more slowly in the other. reason of this difference more can be done to conserve or increase the power of the heart in tuberculosis than is possible in acute pneumonia. It follows that close observation of the circulation in the course of pulmonary tuberculosis is imperative, and that a weak second pulmonic sound is to be regarded as a danger signal just as in acute pneumonia. Ruck considers over-exercise a potent factor in the production of tachycardia in consumptives. He consequently urges restriction of exercise in consumptives with a weak heart. He describes in detail the physical management of such patients, together with a regulation of the diet, bathing, etc.

Observations on Urine After Anesthesia.— Goodwin (Therapeutic Gazette, May, 1905) following anesthesia. made an exhaustive series of urinary analyses In 65 instances of

chloroform narcosis, the urine either showed albumin or casts (or both) induced or increased in 40% of the cases. Sugar occurred in one case. In 16 cases of nitrous oxide anesthesia followed by ether, albumin and casts occurred or were increased in the urine in 12%, sugar occurring in one instance. In 41 cases of chloroform narcosis followed by ether, albumin and casts were induced or increased in 41.5% of the cases. Thirty-nine per cent of 28 ether anesthesias showed the presence of albumin and casts in the urine. Sugar evidenced itself in small quantities in two cases. In all the cases the albumin and casts usually disappeared in a few days, though rarely they persisted for ten days. The sugar in all the cases disappeared after the first day.

A Case of "Splenomegalic" or "Myelopathic" Polycythemia with True Plethora and Arterial Hypertonia without Cyanosis. Weber (Lancet, May 13, 1905) reports an interesting case of polycythemia which differs markedly from the hitherto recorded cases in that there was an absence of cyanosis. The patient had suffered from erythromelalgia, but recovered from this affection before a discovery of the polycythemia. Although cyanosis was missing, the cutaneous vessels were somewhat dilated and overfilled, and the tongue was a bright red with a bluish tinge. The complaints of the patient were tinnitus aurium, slight vertigo and occasional headache. The spleen was moderately enlarged. The hematologic examination was complete, including a determination of its viscosity, the amount of albuminous substance in the blood plasma, the estimation of the salts, and a thorough cryoscopic examination. The blood count showed an enormous increase in the erythrocytes and a leucopenia with a high percentage of the polymorphonuclear cells. The specific gravity was 1072, and the estimation of the blood volume by Haldane's carbon monoxide method showed it to be considerably increased. Weber believes that the development of these cases are due to: 1. Increased erythroblastic activity involving a great part, but not necessarily the whole, of the bone marrow. 2. Increased viscosity of the blood resulting from the polychythemia. 3 Dilation of the small blood vessels, partly to lessen resistance to the abnormally viscus blood, partly to make room for dilution of the blood. 4. The "plethora vera" or "polycythemia" is probably to be regarded as an attempt to compensate for the increased viscosity of the blood and for the excessive percentage of the total blood volume occupied by the cells. In fact, it is necessary, first, that there should be sufficient blood plasma to nourish the tissues and to make metabolism possible; and, second, that the viscosity may not become so great as to render sufficient circulation impossible. 5. The arterial hypertonia is to be regarded as a result of the greater strain thrown on the circulatory mechanism. Cyanosis, when this occurs, is probably due to inadequacy of the series of compensatory changes which, according to this view, precedes it.

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The Influence of Smallpox on Vaccination. -Hibbert (Lancet, May 20, 1905) made a study of twenty cases of smallpox in which the patients were vaccinated or revaccinated after the appearance of the eruption. Of these, eleven vaccinations proved successful. No second attempt of vaccination or revac

cination was made in the unsuccessful cases. In the majority of successful cases well marked "takes" appeared at the site of the vaccination, the vesicles appearing from the fourth to the sixth day after the inoculation and ran the usual course. In some cases merely an indurated papule presented itself instead of the typical vesicle. Ten of the

successful cases had been vaccinated within the first four days of the eruption. The eleventh case was not inoculated with the vaccine virus until the fourteenth day of the smallpox rash. These observations prove the fact that a successful vaccination in cases with a rash of doubtful character is no argument that the eruption is not one of smallpox. The author was unable to note that vaccination or revaccination, after the smallpox eruption had appeared, had any material modifying influence on either rash or course of the disease.

Muller's Modification of Donne's Pus Test.

(Goldberg Centralblatt f. innere Medizin, No. 20, 1905.)-The original Donnè reaction consists in adding a solution of potassium hydrate to the urine. The presence of pus is signified by the formation of small transparent gelatinous bubbles arising to the surface of the urine which are the result of the action of the potassium hydrate on the pus corpuscles. Müller modifies the test by adding the potassium hydrate solution in drop quantities shaking the urine after the addition of each drop. In this manner the bubbles which form remain in the urine, or only ascend very slowly to the surface. Müller

suggests that an excess of potassium hydrate should not be added, as this causes the mucous to dissolve. It is also necessary to agitate the urine immediately after the addition of each drop of KOH, as the phenomena disappears in a short time. Goldberg has tried this modification in 50 cases and found it to be a reliable test, although a negative reaction in an alkaline urine does not disprove the presence of pus. A negative reaction in an acid urine, however, excludes the presence of pus in any quantity. The author recommends the test wherever a microscope is not at hand.

The Value of a Tremor as a Sign of Alcoholism.-Fürbringer (Berliner klinische Wochenschrift, No. 21, 1905) analyzed 500 cases in order to ascertain the diagnostic significance of a tremor in connection with inebriatism. The results of his observations may be briefly given as follows: In about onetenth of the alcoholic cases a tremor of the hands and fingers was absent. A trenior of moderate degree does not warrant a supposition of acloholism. A markedly pronounced

tremor, although not absolutely characteristic, is strongly suggestive of alcohol abuse and is, therefore, a diagnosticum of some value. Over one-half of the examined cases presented a more or less tremor of the hands which is not to be confounded with the true alcoholic tremor. A slight tremor was more frequently observed among the total abstainers and moderate users of alcohol than among the intemperate.

The Effect of Electricity on the Gastric Secretion. Freund (Virchow's Archiv, Bd. 180, Heft 2, 1905) made a study of the effect of electric current on gastric secretion, and found that electric stimulation of the stomach had absolutely no effect on the flow of the gastric juice, the only result was the production of a small amount of a mucoid secretion strongly alkaline in reaction. He concludes that food is the only stimulus which cause the gastric glands to react. Therefore, nothing is to be expected of the electric treatment in gastric glandular stimulation.

Atheroma of the Aorta Following Tobacco. -Boveri (Gazz. d. aspedli, No. 6, 1905) reports an interesting observation in a rabbit which had been fed a daily amount of 10 to 40 c. c. of a 10 per cent tobacco infusion for a period of fourteen days. At the autopsy the aorta presented a dilation, a diminished elasticity, and white areas in both thoracic and abdominal aorta.

OBSTETRICS AND GYNECOLOGY

W. H. VOGT, M. D.

Late Results of Bossi's Method of Dilatation.-F. Lichtenstein (Archiv f. Gynaekologie, Vol. 75, No. 1) reports on 18 cases on whom the Bossi dilator was used for various purposes. In 11 cases he found no tear, in four a small tear of the portio, in two cases larger tears of the portio, and in one case a double-sided cervical tear. In two of these cases he attributes the tear to the forceps operation. The article is accompanied by excellent plates showing the various tears. Lichtenstein is better pleased with the Bossi method than with the incisions of Duehrsen. Since these results are the opposite of those obtained by von Bardeleben in Gusserow's clinic, the author expresses the opinion that von Bardeleben uses a less appropriate instrument, or does not follow closely the directions for its use. The most important points to observe are: 1. Positive indication. 2. Patience and time. 3. The proper instruments and the proper application of the same. The instruments giving best satisfaction are

the original of Bossi with its new screw, and that of Seigneux.

Accouchement Force. Boyd (Medicine, May 10, 1905) in his paper comes to the following conclusions regarding this subject: 1. Each case must be a study in itself; 2, forced delivery by whatever method must be considered a major operation, and should be performed by one trained in obstetric surgery, (3) manual dilatation is successful in the majority of cases; 4, in a few cases in which the cervix is long and unobliterated it will be necessary to use Dührsen's Cesarean section; 5, as a method of checking hemorrhage rapidly, or in cases in which delay is accompanied with exhaustion of the delivery were accomplished per vias naturales, it would be well to consider the conservative Cesarean section.

A New Plan of Procedure in Retro-Uterine Displacements.-(E. E. Montgomery, Philadelphia, Surgery, Gynecology and Obstetrics, Vol. I, No. 1.)-The mere existence of uterine displacement must not be considered an indication for treatment. In recent cases of subinvolution where the displacement arises merely from increased weight and requires only to be supported in its normal position until the process of involution can be completed, when the ligaments will be capable of maintaining it, the mechanical measures should be employed. The author describes his method as follows: 1. Through an abdominal incision a temporary ligature is passed beneath each round ligament about 13 inches from the uterine cornu, and secured by a hemostate. 2. The two ends of one of these ligatures are threaded into the eye of a pedicle needle, the round ligament seized with pressure forceps just external to the ligature and drawn toward the median line to render the external portion of the ligament tense. The peritoneum of the anterior portion of the broad ligament is picked up and snipped with scissors, affording a trap door through which the pedicle needle carrying the ligature is introduced. The ligature is thus carried between the layers of the broad ligament until the abdominal wall is reached, when it is thrust through the muscular structure and is withdrawn from the needle external to the aponeurosis. A similar course follows with the second ligature. 3. Having drawn the superficial fascia away from the point made by the opening in the aponeurosis, the ligature is rendered tense while pointed scissors are introduced closed alongside the ligature and their blades slightly separated as they are withdrawn. Their withdrawal is generally followed by a loop of the round ligament which is drawn up by the tempor

ary ligature. Loops of both round ligaments having been thus brought out upon the aponeurosis, they are secured by catgut sutures to the aponeurotic layer. The advantages claimed for this operation are: 1. It closely imitates the normal conditions and employes natural ligaments for its support. 2. It employs the strongest part of the round ligament and leaves no lesions within the abdomen for the formation of unfortunate adhesions. 3. It permits of a careful exploration of the abdomen and pelvis, and affords an opportunity for the proper treatinent of diseased conditions present. Several other operations are mentioned in the article, and brief objections are made to each one.

Is Craniotomy on the Living Child Ever Justifiable? J. Marx (Medical Record, June 10, 1905) says that other things being equal the life of the mother deserves much more consideration than that of the fetus. Only in rare cases is a Cesarean section on a woman many hours in labor after several efforts to deliver, to be considered as more conservative than a skillfully performed craniotomy. The author says: "When from an early rupture of the waters a version is impossible, the tentative use of typical or atypi cal forceps might be of value. The application must not be persisted in too long, or be too powerful, for fear of doing injury to the fetus. If this be unsuccessful, the woman and child in good condition, and the patient in such environment that the outcome of an operation is reasonably certain, then and then only would a Cesarean section be allowable." The positive contraindication to perforation is furnished by absolute contraction of the pelvis, either from bone approximation, or through obstruction by a tumor. Here the early induction of labor should be performed, or elective Cesarean section at or near term.

Fibroid Tumors of the Uterus; Their Surgical Treatment.- Franklin H. Martin, Chicago (New York Med. Jour., June 17, 1905) bases his conclusions on the analysis of the last 200 conservative cases of fibroids of the uterus operated upon by him, by hysterectomy or myomectomy up to December 1, 1904, on the analysis of 1188 cases reported by Dr. Charles P. Noble before the American Gynecological Society, and on knowledge gained by the different forms of less radical operative procedures and on the non-operative method of treatment employed by himself during a period of over eighteen years in caring for more than 400 cases not submitted to radical operation. The complications may be divided into (a) those arising

in the tumor itself, and (b) those arising as accessory complications to the growth. The conclusion arrived at from this large material are as follows: 1. The routine treatment for fibroids of the uterus, presenting symptoms, in women 45 years of age, should be supra-vaginal hysterectomy, except as herein after stated. The exception to this rule should be (a) in subperitoneal tumors either pedunculated or not, in which only one or more distinct developments 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 hemorrhagic tendencies; in which the hemoglobin is reduced below 25 per cent, or in which serious vascular cardiac or kidney com. plications exist, which greatly increase the risk of the operation, when a preliminary operation of vaginal ligation of the uterine arteries should be resorted to. (c) In cases where a radical operation will not be accepted. a curettement 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 galvanism scientifically applied may be depended upon to relieve the patient materially, and occasionally tide them over the menopause to a complete symptomatic cure. 2. The treatment for large, complicated tumors without regard to age, or large apparently uncompli cated tumors in which symptoms of hemor rhage or pressure exist, should be supravaginal hysterectomy. 3. 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 tumos are of the symmetrical developed type, enlarging uniformly the uterus. and the principal symptom is an exaggerated menstrual flow, the case may almost invariably 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, cu rettement, and, if considerable flowing is a symptom, vaginal ligation of the uterine ar teries, with the idea of obtaining a sympto matic cure over the menopause. 4. The ex tremely small class of tumors coming under the head of "inoperable" cases must be managed on general principles-rest in bed, general tonics, treatment of the cardiovascular and kidney complications when they exist. curetting and irrigating for septic endome tritis, electricity for pain and hemorrhage, ligation of the uterine blood supply practi cable for intractable hemorrhage, and vaginal incision impacted cysts or pus accumulations.