REPORTS ON PROGRESS

Comprising the Regular Contributions of the Fortnightly Department Staff.

INTERNAL MEDICINE.

O. E. LADEMANN, M. D.

The Detection of Diacetic Acid in the Urine. -Lindermann (Muenchner Med. Wochenschrift, No. 29, 1905) suggests a modification of Riegler's diacetic test as more delicate and reliable than Gerhardt's iron reaction and better suitable in general practice than the cumbersome Lipliawsky modification of von Arnold's method. The test is carried out as follows: Ten c.c. of the urine is first acidified with five drops of dilute acetic acid (about a 30 per cent solution). Five drops of Lugol's solution (iodine 1 gram, potassium iodide 2 grams, water 100 grams) are then added and the mixture thoroughly

shaken with 2 c.c. of chloroform. The chloroform will remain colorless if diacetic is present, whereas in urine, containing no diacetic acid the liberated iodine changes the color of the chloroform to red. It is to be remarked that too much acid added to the urine effects the delicacy of the reaction. That the potassium iodide test is considerably more delicate than Gerhardt's iron chloride reaction is shown by the fact thatc.c. of urine containing diacetic acid added to 94 c.c. of normal urine still gives a positive reaction with the former, whereas the latter is negative. Unlike the iron chloride reaction, urine containing salicylic acid, aspirin, antipyrin, etc., it does not effect the potassium iodide test. Formalin, when added in large quantities or repeated boiling of a positive reaction converts the potassium iodide test into a negative one. Lindermann also claims that his test serves as a rough guide in estimating the quantity of diacetic acid.

Essential Albumin u ri a.-Neukirch (Deutsch. Arch. f. klin. Medizin, d. 84, Heft 1-4) reports an observation of this condition in his own child having its origin in an attack of diphtheria. The albuminuria made its appearance about the eighth day of the disease, at which time the throat manifestations had completely subsided. The albumin in the urine alternately disappeared and reappeared for a duration of about five years. The amount of albumin varied at different times, ranging between 0.25 to 0.5 gm., but increased during subsequent anginal attacks. The urine never showed any other evidence of a nephritis. There was a complete absence of cardiovascular alterations. Diet did not influence the condition

The condition always offers a favorable prognosis, but the kidneys must be considered as a locus minoris resistentiae and treatment directed to the avoidance of all harmful influences during the existence of the disease.

The Effect of Alcohol on the Secretory and Motor Function of the Stomach. Meyer (Klinische Yahrbuch, Bd. 13, 1905) observed slightly increased the hydrochloric acid sethat alcoholic drinks in large quantities

cretion in the stomach.

In moderate quan

tities, however, the increase in the percentage of hydrochloric acid was inappreciable. Regarding the effect of alcohol on the motor activity, he noted a retarded function with amylaceous foods, no change with albuminous, and an accelerated action with fatty foods. He is unable to give a plausible explanation why one variety of food should cause aretarded, and another an increased motor activity.

Ehrlich's Diazoreaction in Diseases of Chil

dren. Kephallinos (Wiener med. Wochenschrift, No. 23, 1905) studied the reaction in 3000 cases treated at the children's clinic in Graz. He points out the diagnostic value of a positive reaction in cases of tubercular lymph adenitis simulating the picture of a pseudo-leukemia. The writer has never observed a positive diazoreaction in rickets, anemia, pseudoleukemia, hemorrhagic diathesis, organic and functional diseases of the nervous system, erysipelas, whooping-cough, malaria, German measles, mumps, acute articular rheumatism, sepsis, influenza and dysentery.

The Etiology and Constitutional Treatment of Bright's Disease.-Porter (Post-Graduate, April, 1905) summarizes his paper as follows: 1. The etiologic factors in nephritis are numerous and very complicated in their action; no single remedy or operation can be expected to reach all the indications for treatment. 2. Histologically, Bright's disease can never be cured, but physiologically, the etiologic factors can be modified and often removed, and the symptoms held in abeyance, while the renal glands perform their functions normally. 3. The disease is by nature oscilla

tory and remission must not be mistaken for cures. 4. Rational dietetics and therpeutics offer the largest possibility for a complete physiologic cure. 5. A well regulated mixed diet, especially if composed largely of the animal class, when it can be tolerated, yields the best results. 6. Rational therapeutics is not directed at the renal lesion, per se, but toward establishing more perfect digestion and metabolism and a decrease in the work imposed upon the renal glands.

He

Methylene Blue Urine Test.-Russo (Rif. Med., No. 19, 1905) introduces a methylene blue test which he believes is an advantageous substitute of Ehrlich's diazoreaction. adds four drops of a one per thousand water solution of methylene blue to a test tube containing four to five c. c. of urine. A pronounced emerald or mint green tinge indicates that the test is positive. A light or bluish green signifies a negative reaction. The author claims that the reaction affords more information in typhoid than the diazoreaction, indicating the exact stage of the disease. In many cases of typhoid the reaction occurred as early as the second or third day of the disease. The reaction paralleled the diazo in 41 cases of typhoid and 32 of measles. The urine of 10 smallpox patients gave a positive methylene blue reaction, while the diazo test was negative in two of this number. No reaction occurred in 10 cases of pulmonary tuberculosis in the first stage, while it was positive in 10 out of 30 cases in the second stage. In 25 cases in the third stage the test was invariably positive. It was also positive in 6 cases of tuberculous pleurisy, 5 of tuberculous empyema, 4 of tuberculous peritonitis and 3 out of 5 cases of tubercular adenitis. The test was invariably negative in scarlet fever, chicken-pox, varioloid, influenza, bronchitis, nephrolithiasis, articular rheumatism, hepatic abscess, mitral regurgitation, neurasthenia, epilepsy and malaria. The test is characterized by the appearance of a mint green at first changing in tone to an emerald as the disease reaches its height, while the test gradually assumes a more and more bluish more and more bluish tint as the disease progresses towards a favorable termination, or the emerald tint remains until death. Russo considers the reaction a valuable differential sign in distinguishing smallpox from chicken-pox and varioloid, as it is constantly positive in the former and negative in the latter diseases.

Examination of Human Semen for MedicoLegal Purposes.-Wederhake (Deutsche Med. Wochenschrift, No. 25, 1905) proposes a more efficient and simple method of determining the presence of semen on suspicious

articles of clothing, in cases of rape, than the Florence reaction. The test is as follows: Suspicious semen stains are removed from the clothing with either well water or a physiologic salt solution. The wash solution is then centrifugated or placed in a conical glass for sedimentation, after which the supernatant fluid is decanted to a volume of about one c.c. and the sediment treated with one drop of tincture of iodine and thoroughly agitated. One c. c. of a crocein scarlet solution is next added and the whole again placed in a centrifugal tube, filling the latter with water almost to the top. After a thorough centrifugalization, a small amount of the sediment is placed on a slide by means of a pipette, covered with a cover glass and examined microscopically. The heads of the spermatozoa are stained an intense red. The crocienscarlet solution is made by dissolving crocein-scarlet 7 B. (obtainable from the firm of Kalle & Co., Biebrich, Germany) in 70 per cent alcohol to the point of saturation.

Clinical Method for the Quantitative Estimation of Uric Acid in the Urine.-Surveyor (British Medical Jour., July 8, 1905) describes a very practical method of estimating uric acid in the urine. Albumin or pus, if present, should be removed by adding acetic acid and boiling the urine, and all other extraneous matter, as dirt, etc., by filtration. Render the urine slightly alkaline by adding minute drops of a strong sodium-hydrate solution. To five c. c. of the urine, two small drops of hydrochloric acid from a capillary pipette (each drop equal 0.02 c. c.) are added, shaking well. The mixture is placed in a graduated centrifugal tube and immersed in a freezing mixture consisting of salt and ice for a period of 15 to 20 minutes. This causes a deposition of the urates, uric acid and other salts. Centrifugalize until the whole has remelted and read off the percentage of deposit as soon as the temperature is about 25 deg. C. If the percentage is less than 0.5 it signifies less than 0.04 per cent uric acid; a reading of 0.75 per cent to 1.0 per cent correspond to 0.05% to 0.08% uric acid; readings of 15 per cent to 2.0 per cent indicate a higher percentage of uric acid. In case the urine originally contains a deposit of urates or uric acid it must be rendered slightly alkaline with a strong solution of sodium-hydrate, and then boiled after which the method as described is followed.

Cystodiagnosis in Pleural Exudates.-Van der Meer (Wieh bl. voor Geneesk., No. 3, 1905) made an analysis of pleural exudates in 23 cases. His results warrant him in concluding that cytodiagnostic examinations of pleu

ritic exudates are of limited value. In tuberculous pleurisy there is a predominance of lymphocytes providing the exudate has existed for some days, but not all lymphocytic exudates are of tuberculous origin. In four cases of tuberculous meningitis the cerebrospinal fluid showed a lymphocytosis; in one case of epidemic cerebrospinal meningitis the predominating were polymorphonuclear leucocytes.

The Effects of Ether Narcosis on the Kid

neys.-Gröndahl (Norsk Magazin for Lägevidenskaben, No. 5, 1905) noted a positive Heller's albumin reaction in 27 (36 per cent) out of 75 cases of ether narcosis. In about one-half the number of cases the albuminuria appeared within 24 hours after the anesthesia, in the remaining number on the second and third day. The albumin usually persisted but a few days, it may, however, continue longer; in one case it persisted for a period of over two months. Individuals with cardiac lesions and a pre-existing anemia offer an apparent predisposition to albuminuria. The age of the patient, manner and prolongation of the anesthetic are significant factors. The percentage of albuminuria in children is relatively large. It is not possiIt is not possible to determine the intensity of the morbid process in the kidneys; in one case of ether narcosis a hematuria followed. The albuminuria is in all probability the result of poisonous action of the anesthetic on the renal protoplasmic elements producing a toxic nephritis. The renal changes do not, however, remain permanent, unless the narcosis is often repeated at short intervals. Out of 6 chloroform anesthesias, the writer observed 2 cases of prolonged albuminuria associated with hematuria. The author gives preference to ether over chloroform as an anesthetic in general, as the toxic action on the kidneys, as well as the organs, is less with ether than with chloroform.

An Early Bacteriologic Diagnosis of Tuberculosis of the Lungs.- Blum (Hospitalsidende, No. 25, 1905) advocates, in doubtful cases of pulmonary tuberculosis where there is no expectoration, an examination of the mucous in the larynx. He cites several cases of this type in which he was able to demonstrate the tubercle bacillus harboring in the mucous taken from the larynx, thereby clinching the diagnosis.

curring once and a trifle over in every three deaths. 2. The most common time of perforation is between the fourteenth and twentyfirst days; now and then perforation may occur without evidence of previous illness. 3. Perforation occurs in cases of all grades of severity, from the ambulatory to the hemorrhagic type. It is most common in those with moderate and severe infection. 4. The ileum is the common site of perforation (86 per cent); the majority occur within twelve inches of the ileocecal valve; the appendix and colon respectively are the next most frequent sites of perforation in this series of cases. 5. Pain of some kind is present in 75 per cent of all cases. In 50 per cent of all cases the onset is sudden and severe and of increasing intensity, localizing itself to a pain is of slow onset, not localized, with genspecial zone. In 20 per cent of the cases the eal distribution. In some cases no pain is complained of, and the usual symptoms of perforation are absent. 6. Tenderness and rigidity are present from 75 to 65 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. 7. When perforation is suspected the temperature should be taken every hour; only by this means can the immediate rise and slow fall to normal or subnormal which often occurs be detected; in some cases, and especially those of extreme toxicity; no noteworthy change at all in the pulse, temperature or respiration can be detected when perforation occurs. Diagnosis is then only an inference. 8. Distention (if absent during the course of the disease and at times of suspected perforation) is a late symptom of perforation. The obliteration of liver dullness is not a reliable sign of perforation. 9 The study of the leucocytes is of little value. Differential counting is not of practical use. 10. Before being assured of our diagnosis, right sided pluerisy, pneu. monia (especially in the young), cholecysti tis, acute gastrointestinal digestion, femoral thrombosis, appendicitis, peritonitis without perforation, cystitis, rupture of a mesenteric gland, or even hemorrhagic exudation into the abdominal muscles (Zenker's degeneration) should be considered. Even then mistakes in diagnosis will be made. 11. While nature will infrequently close one, two, or even three perforations, the only rational procedure when perforation occurs is operative interference. No case is too desperate for the attempt. Not infrequently the socalled mild cases succumb, while very ill ones recover. 12. The diagnosis made, time for operation has arrived; its important point

is rapidity. Closure of the perforation and drainage is all that is needed; fifteen to twenty minutes should suffice.

The Prognostic Significance of Phosphates in the Urine in Pheumonia. Sicuriani (Gazzetta delgi Aspedali, No. 43, 1905)made a urinary analysis in 25 cases of pueumonia with reference to the alkaline phosphates. He observed that they disappear from the urine during the course of the disease and a reappearance is a sign of good omen and indicative of an approaching crisis.

Vicarious Action of the Bowels for the Kidneys in Tuberculosis.-Flick and Walsh (American Medicine, July 22, 1905) state it has long since been recognized that in certain cases of tuberculosis there is a looseness of bowels which is not due to ulceration.

This

looseness has been termed in the text-books as an irritative diarrhea and has been ascribed to dietary errors. When it has occurred in cases which have come to autopsy the bowels have been found free from ulceration and apparently in a healthy condition. The writers report in detail eleven such instances which have come under their observation and from the post mortem findings are led to believe that in these cases the looseness of the bowels is due to a vicarious action of the bowels for the kidneys, and that nature is really trying to protect the system by the vicarious action. The ileum in three cases was slightly congested, in all the others the intestines were normal with the exception of the appendix which showed structural changes in several instances. Besides a tubercular involvement of the lungs in each case, the kidneys were found to have undergone acute changes. In seven out of the eleven cases the kidneys presented tubercles interspersed throughout the organ.

Several forms of nephritis evidenced themselves toxic, parenchymatous, diffuse and interstitial nephritis. The author found magnesium sulphate and nitroglycerine of greatest use in the treatment of this complication. When the bowels are very loose, 0.78 gm. (12 gr.) doses of magnesium sulphate every hour will lessen the number of stools. When the bowels

are costive the magnesia will greatly improve the general condition. Sometimes patients begin to gain in weight under the use of magnesium sulphate who have done badly before. Opiates should never be used in these cases.

Some Phases of the Neurotic Heart.-Robinson (Am. Jour. of Med. Sciences, June, 1905) emphasizes the following facts regarding the symptomatology of the so-called neurotic heart: 1. An apparent or evident slight

cardiac enlargement with or without dilation, and it may be slight hypertrophy occasioned by a proceeding directly from a cardiac neurosis. 2. A condition of secondary anemia, as shown by careful microscopic blood examination, with count and differentiation of white corpuscles, which remain stationary for a long while, despite the use of chalybeates and most rational treatment from every standpoint. 3. The absolute or relative uselessness of digitalis, notably unless the heart muscle is involved, and even in these in stances of acute manifestations of weakness or failure, strophantus is more useful. 4. Impaired nutrition, at a given period of the muscular walls of the heart under the immediate dependence, probably of diminished dilation at times which subsequently under nervous energy, gives rise to slight cardiac judicious treatment remain stationary as to amount and becomes functionally compen

sated.

Clinical Suggestions From the Study of Five Hundred Cases of Pulmonary Tuberculosis. Loomis (Medical Record, July 29, losis.-Loomis 1905) bases his suggestions on a careful clinical study of 500 cases of pulmonary tuberculosis in all its phases. The number include patients seen in private practice, large hosIn 80 per cent of pitals and in sanitoria.

100 cases the first presumable evidence of the disease was as follows: 48 per cent presented a more or less protracted cough. In 20 per cent of these, the cough was not accompanied by any expectoration. In 18 per cent the first manifestation of the disease was loss in weight with a general run down condition. Fourteen per cent of the cases gave a history of having had a previous attack of pleurisy, from which they recovered. The average time between the first attack of pleurisy and the actual development of a pulmonary tuberculosis was three and a half years. In the remaining 20 per cent the condition followed grip, malaria, pneumonia, enlarged cervical glands and hemoptysis. The author believes that the great majority of persons who apparently develop pulmonary tuberculosis after the age of thirty had a previous attack of the disease, which was so slight as to be overlooked, or they recovered so rapidly, owing to climatic advantages, that they questioned whether they ever had it, and unless a careful inquiry is made the fact is overlooked, and the condition for which they come under observation is believed to be the beginning of their pulmonary trouble. An analysis shows that three and a half months was the average time that elapsed from the actual beginning of the disease to the appearance of tubercle bacilli

in the sputum. The features of value in estimating the prognosis are general vitality of the patient, personal and family history, age (between 25 and 30 is especially favorable), and the general condition of the digestive tract, whereas the extent of the process, whether one or more than one lobe is involved, is of less significance than is usually supposed. Fever, hemorrhage, expectoration and tubercle bacilli in the sputum are of little prognostic value An analysis of 55 cured sanatorium cases showed that the average age was high-29, and that the long-lived ancestry of the patient was of special importance, hut a tuberculosis family history was of less import. The average length of life among the poor, with no advantages, is somewhat less than two years.

How to Palpate a Movable Kidney. – Aaron (New York Medical Jour., July 29, 1905) points out the methods to be observed in palpating a floating kidney. He says that bimanual palpating is always necessary. Pressure of the band over the lumbar region forces the kidney forward, while the hand on the abdomen gently presses toward the hand on the back. A point to be observed is firm pressure with the posterior palpating hand. The abdomen should be as completely relaxed as possible. The author usually places the patients in four different positions: 1. Standing, while manipulator sits on a chair. 2. Standing, while manipulator stands. Lying on back, while manipulator sits on edge of couch. 4. Lying on either side, depending on kidney palpated, while manipulator is sitting.

OTOLOGY.

ALBERT F. KOETTER, M. D.

3.

Deafness in School. Hartmann, Centralblat fuer Ohrenheilkunde.)-It has taken a long time for the deaf mutes to reach their present state of development. The number of self-supporting deaf-mutes has constantly increased. The census of 1880 showed 43.6%, in 1900 70.2% capable of earning a living, these figures speak very highly for the deaf mute instruction. Since Bezold has proven that the remnants of hearing can be utilized, a meeting of instructors and otolo. gists was held in Munich where results were reported. Wanner reported that 86% of the pupils after leaving school were self-sustaining. Those individuals hard of hearing are in a similar position. As the speech redeems the mental development, deafness must necessarily interfere with the development of the intellect and the power of conception must

suffer. Hartmann found in his observations that those hard of hearing were retarded in their school work. This has prompted him to proceed against these conditions, and this brought the question of school physicians into discussion. In Hamburg and later on in Berlin he caused the foundation of special classes and individual instruction.

Everywhere preparation is made for the care of the infirm and feeble-minded, therefore the curable contingent must also be considered. Those not curable must be regarded in so far as they can educate themselves. For instance, a child with very marked deafness, educated in the normal class could barely read and write at the end of the school term. The child, which did not make the impres sion of an idiot lacked perception and many words. At the end of the term child was examined and large adenoid vegetations were found whicih had not been demonstrated before, because child had never been examined. Of the children examined by Ostmann and Bezold 50% showed retracted membranes.

Does the percentage of deafness increase from the time the child is of school age? Weylanswus in the affirmative, while Ostmann thinks the percentage increased in the first years, presumably due to the frequency of infectious diseases, and then a very perceptible decrease occurs.

At the school figures from 1-100 were used in testing the hearing, the eyes turned away during the test. In order to show the influ ence that deafness has on the intellectual development Bezold places the average of the deaf children, the average of the normal child being 50, as follows:

Both ears 6 feet or less... .. 77

This goes to demonstrate that these child. ren are wrongly counted with the imbeciles and those of poor intellectual endowment.

The most important practical question is: In what manner shall the deaf be separated? The cause of the deafness should be ascertained, and several examinations made to see if the hearing improves or remains stationary. According to Bezold 41.7% of deaf children have a chance of improvement, Ostmann thinks 50% can be brought to hearing distance of 26 feet. For this purpose phy sicians especially those in the country must have some knowledge of otology, which can be looked for when the subject of otology is introduced in the examination of candidates for the degree of doctor of medicine. Hartmann advocates the establishing of poly. clinics, respectively the examination of deaf persons by specialists. Since Hermann Cohn's energetic procedure the care of pa