REPORTS ON PROGRESS

Comprising the Regular Contributions of the Fortnightly Department Staff.

INTERNAL MEDICINE.

O. E. LADEMANN, M. D.

The Prognosis of Asthma.-Jack (Buffalo Medical Jour., August, 1905) contends that the prognosis of asthma, when uncomplicated, is positively favorable. He says the successful management is an art to be acquired only by study and clinical observation. The following rules are essential to the suc cessful management of a case: 1. Physio, logic measures are, when possible to be substituted for drugs. 2. Blood showing an excess of lymphocytes indicates the withhold. ing of lymphogenous foods, as milk and raw oysters.

3. Blood giving a pronounced idiophilia indicates the withholding of starches. 4. A lack of fibrin elements in the blood indicates the giving of gelatin. 5. A toxic cadaveric stool indicates withholding proteids or meats. 6. Urine containing indican, intestinal toxemia, indicates stricted diet.

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The Negative Value of Kernig's Sign.Wilson (Am. Jour. of Med. Sciences, Vol. 80, No. 2, 1905) studied this sign in 120 cases, 73 adults and 47 children under 10 years of age. He found it positive in 26.8 per cent of cases presenting no indication of a meningeal affection. Out of the 73 adults it it was present in 29, and of the 47 children, 3. Wilson concludes that Kernig's sign is by no means a positive indication of either an involvement of the meninges of the brain or cord, but may be regarded as a confirmatory sign, when associated with other symptoms of a meningitis. The sign as a rule persists far into convalescence and in certain cases it probably remains as a permanent indication of a former underlying lesion.

Diagnosis and Therapy of Nervous Stomach Affections.-Boas (Deutsche med. Wochenschrift, No. 33, 1905) discriminates between mono and poly symptomatic gastric neuroses, discussing in detail their diagnostic features. Characteristic of the monosymptomatic variety is as the designation implies, i.e., the predominance of a single symptom, which may either be of a depressive type, as anorexia, acoria, a heavy sensation in the epigastric region either before or after meals, or the exilarating, as bulimia, a sense of pain and burning in the epigastrium. The perspicacity of any one of the enumerated symptoms, together with the history and course of the disease usually clears the diagnosis. It is

readily apparent that a correct diagnosis of the polysymptomatic form offers greater difficulties owing to the fact that many somatic gastric lesions are intimately associated with nervous symptoms. The classic type of this variety of gastric neurosis is the well recognized "nervous dyspepsia," and as a matter of fact many individuals of this class usually diagnose their own malady. Suggestive influences in these cases aids materially in recognizing the true nature of the condition. As in the monosymptomatic form, the history is likewise of considerable significance. One of the most characteristic sign is that the symptoms are quite independent of the amount and kind of nourishment taken, and the inherent association between aggravation of symptoms and emotional influences. The test-breakfast, though naturally distressing to the patient, is a means of overcoming any obstacle in the diagnosis. It is to be remarked, however, that slight disturbances in the secretory, as well as the motor function does not exclude the possibility of a gastric neurosis. Regarding the treatment of the gastric as well as the intestinal forms, which Boas also discusses under the head of mono and polysymptomatic, it may be said that in no other condition does success depend on the physician himself rather than the agents he may prescribe. A rest cure in either a small hospital or sanatorium in combination with suitable diet (modified Weir Mitchell) offer the most promising results. The rest cure, however, is not always applicable and in the lighter forms is not indicated, the latter often yielding in changing to a high altitude, sea air, etc. Hydrotherapy, electrotherapy, massage and medical gymnastics are useful, acting in a twofold manner, physically and mentally. Among the local procedures which may be mentioned, though as a rule unsatisfactory, are gastric lavage, faradism and galvanism of the stomach and intestines. Drugs have no direct effect on the disease, but at times apparently seem to act beneficially. Those deserving mentioning are the bromides, small doses of opium derivatives, as codein and dionin, and the modern valerian preparations, validol and vallyl.

Stokes-Adams' Syndrome. -Foley (Boston Medical and Surgical Journal, August 31, 1905) gives a brief resume of the literature on the subject together with a detailed report of two cases. He says the condition may be one of either cardiac or nervous origin, characterized by vertigo, syncope, loss of consciousness, and low pulse- pseudo-apoplexy. Both of his cases exhibited a marked reduction in the pulse rate, the one varying from 16 to 42 beats per minute, and the other

Symptoms, Diagnosis and Prognosis of Uncomplicated Intestinal Amebeasis in the Tropics.-Musgrave (J. A. M. A., Sept. 16, 1905) discusses the subject of intestinal amebiasis under the following clinical divisions: 1. Latent masked infections. 2. Mild and moderately severe ones. 3. Severe cases, including gangrenous and diphtheritic ones. 4. Infection in children and in the aged. These clinical forms often change from one to the other, and may do so several times during the course of the disease in the same patient. The author says, the amebic process in all is essentially chronic, but acute symptoms from concurrent or secondary infection by other agents are frequently seen. He enters upon a detailed discussion of the various symptoms. As there are no classical symptoms in the diseases, an absolute diagnosis can only be made. by a microscopic examination of the feces. The following are the most important clinical manifestations in a question of diagnosis: 1. The bowel eyacuations, particularly their odor, and the presence or absence of blood. Their consistency, quantity, frequency, and . the presence or absence of mucus, are much less important. 2. Abdominal soreness,

which is increased on pressure and extends particularly along the colon is most common and, taken singly, is one of the most valuable symptoms. Its diagnostic importance is greatest when of maximum intensity over the cecum and ascending colon. 3. So-called "indigestion" headache, general lassitude, with nausea or pain below the stomach after treating, etc., is quite common, but is also prevalent at other times, so that but little importance must be attached to it alone. 4. Loss of weight, especially in the presence of a good appetite, is quite important and is the best guide to the progress being made by the infection. Neither one nor all of these symptoms taken together are sufficient for an absolute diagnosis; but when taken together in cases where careful palpation reveals a thickened, tender colon in places where it may be felt, they make the nearest approach to a sure diagnosis possible without microscopic examination of the feces. Several points should be considered in the prognosis

and the evidence in each individual case should be carefully weighed before an expression of opinion is justifiable. In general, under proper treatment recovery is the rule in young, well nourished adults, in whom the disease is not of too long duration. The principal determining factors in giving a fav. orable prognosis are the manner of treatment, age, nationality, general condition of the patient and duration of the disease at the time treament is instituted, reaction to treatment, the presence of complications and associated diseases, and, finally the location of the amebic lesion. In children and natives. of the tropics the disease is usually milder. The mortality among the aged is relatively high and its course more often a shorter duration. Alcoholics are apparently less frequently infected, but when the disease is once established the the prognosis is bad. Previous good health and a good general physical conditions are favorable factors. The more recent the infection at the time of treatment and the greater tolerance for enemas, the more favorable the prognosis. Complications, as abscess of the liver, severe hemorrhoids, fistula or fissure in ano and the like, materially decrease the chances of ultimate recovery. The locations of the lesions is prob ably the most important guide in making a prognosis. As a rule, the higher the intestinal lesions, the greater the mortality.

Trichinosis.-Stäubli (Korrespondenzblatt f. Schweizer Aerzte, No. 16, 1905) reports in detail five cases observed in the medical clinic of the University of Munich. Several of the cases presented the clinical picture closely resembling that of typhoid. He mentions the following as characteristic diagnostic data: 1. Hyperleucocytosis with a predominance of the esoinophiles (25 per cent). 2. Kernig's phenomena with an absence of the petallar reflexes. 3. A strongly positive diazoreaction.

Acid Intoxication and Late Poisonous Effects of Anesthetics.-Bevan and Favill's (Jour. A. M.A., Sept. 2 and 9, 1905) communication embraces a splendid study of the subject of hepatic toxemia as a remote effect of chioroform, suggesting the dangers of its prolonged administration which is evidently not generally recognized by the profession. They report in detail the case of a girl operated upon for a gangrenous ovarian cyst, who died four and a half days after the operation from symptoms of a profound toxemia. Although men of more than ordinary ability were called in as consultants, the diagnosis remained obscure until a review of 29 similar recorded cases served to clear up matters Their article is summarized as follows: 1

Anesthetics, especially chloroform (ether to a very limited degree) can produce a destructive effect on the cells of the liver and kidneys and 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. 2. The constant and most important injury done is that to the liver. 3. This injury to the liver cells is in direct proportion to the amount of anesthetic employed, and to the length of the anesthesia. 4. Certain individuals exhibit an idiosyncrasy or a susceptibility to this form of poisoning which it is difficult to explain. 5. There are certain predisposing causes which favor this destructive effect of chloroform, among which are (a) age-the younger, the more susceptible; (b) causes which lower the general vitality of the individual, and probably the vitality of the liver cells, such as diabetes, previous recent anesthesias, infections from pus germs, diphtheria, intoxications from a dead fetus in the uterus, a gangrenous mass in the abdominal cavity, etc.; (c) exhaustion due to hemorrhage; (d) exhaustion due to starvation; (e) exhaustion due to wasting diseases, such as carcinoma; (f) lesions which have resulted in extensive fatty degenerations, such as occur in the limbs in infantile paralysis; (g) chronic disease involving both liver and kidney, such as cirrhosis and nephritis. 6. As a result of this fatty degeneration and necrosis of the liver cells, toxines are produced either from the liver cells themselves, or as a result of the failure of these cells to eliminate substances which, under normal conditions they fail to do, and these substances therefore, may acummulate and produce toxic effects. These toxines produce a definite symptomcomplex which makes its appearance from ten to fifteen hours after the anesthesia. This symptom-complex consists of vomiting, restlessness, delirium, convulsions, coma, CheyneStokes respiration, cyanosis, icterus in varying degree, and usually terminates in death. 8. It is probable that milder degrees of this poisoning are recovered from, and that the transient icterus noticed after chloroform anesthesia without other evident cause is due to such poisoning and many cases which exhibit restlessness, fright, mild delirium, drowsiness, etc., after anesthesia may be due to the same cause. 9. This disease is an hepatic toxemia; the toxins producing it hepatic toxins; and possibly the previous condition making its development easily possible should be ascribed as liver insufficiency. Just as we have for a long time recognized a condition, uremia, in which we find arising from a variety of noxious agents, anesthetics, poisons, infectious, pregnancy, etc., affecting

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the secreting cells of the kidney and preventing their normal function, a pathologic condition, accompanied with a certain definite symptom-complex; so we must now, we believe, recognize, a condition involving the liver in which we find from a variety of noxious agents (anesthetics, poisons, infections, pregancy, etc.), affecting the secreting cells of the liver and preventing their normal function, a pathologic condition which we must describe as hepatic toxemia, accompanied with a certain symptom-complex, and showing certain changes post-mortem. believe that the condition of acute fatty degeneration of the liver with resulting hepatic toxemia is a denfiite pathologic entity as is acute pancreatitis with fat necrosis. As by products in this toxemia, but not as the essential poisons, are found acetone, diacetic acid and betaoxybutyric acid in the blood and urine. 11. Post-mortem reveals fatty degeneration of the liver, fatty degeneration and mild degree of inflammation of the kidneys, and in extreme cases, fatty degeneration of the heart and other muscles. The lesion of the liver, we believe, to be the over! shadowing and important one, and the one which is responsible for the symptoms and fatal result. The injury to the liver, in some cases, is so great as to result in practically a total destruction of the organ. 12. Somewhat similar hepatic toxemias resulting from fatty degeneration of the liver cells occur in other conditions, and are accompanied with very similar symptoms. In such conditions as phosphorus poisoning, diabetes, puerperal eclampsia, acute yellow atrophy of the liver. 13. This fatty degeneration of the liver with hepatic toxemia following anesthesia is almost invariably due to chloroform in fatal cases. Ether is seldom the cause of a death of this kind. 14. This serious and even fatal late effect of chloroform which has heretofore not been generally recognized must still further limit the use of this powerful and dangerous agent. 15. The possibility of the development development of hepatic toxemia makes chloroform distinctly contraindicated in those cases in which there exists the conditions which seem to favor its developmet, i. e., diabetes, sepsis, starvation, hemorrhage; the presence of intoxication from dead material; the presence of fatty degenerations, as already cited, after infantile paralysis and lesions of the liver. The susceptibility of children to this hepatic toxemia must be recognized. That chloroform is capable of producing these serious late poisonous effects is a strong argument in favor of the more general use of ether; and yet we are confronted at times with the Charybdis of ether pneumonia on the one hand, and the Scylla of chloroform

hepatic toxemia on the other. 16. The recognition of this danger of hepatic toxemia is a strong argument against the employ. ment of chloroform for long anesthesia, as it can be shown that a two-hour chloroform anesthesia is almost invariably fatal to rabbits and guinea-pigs, from fatty degeneration and necrosis of the liver cells; and a two-hour chloroform anesthesia in man is an exceedingly dangerous thing. 17. These facts in regard to the late poisonous effects of anesthetics, and the fact that the dangers increase with the amount of drug employed, employed, and with the length of the anesthesia form a strong argument in favor of rapid operating and in favor of limiting in every way possible the length of the anesthesia and the dose of the anesthetic. For example time consuming preparations of the patient should be made before, not after, anesthesia. In the light of this present knowledge, no geon can claim, as some have in the past, that after the patient is once asleep, that it makes no difference whether it requires one or two hours for the doing of an operation. 18. The problem seems a very important one, and worthy of the most careful study and research. At present we are practically limited to chloroform and ether as general anesthetics. Each has its danger; each has its special field in which one is safer than the other. We have, as a rule, heretofore, employed chloroform in cases in which there was a previous lung or kidney lesion, and in children, with the idea that it was less likely to produce nephritis and pneumonia, and have used ether in the bulk of our work and felt that it was especially to be selected in heart lesions. We must now add new limitations, and attempt to determine by previous examination whether there is what might be called hepatic insufficiency, the conditions present which favor the development of the late poisonous effect of chloroform on the liver. Another

way of solving this problem would be the discovery of new anesthetic agents, which do not carry with them the poisonous effects, or the employment of the present anesthetic in such a way as to avoid these dangers. For instance, it has been suggested that chloroform and oxygen combined would prevent the poisonous effects of chloroform alone, and there is some evidence to support tuis view. This should be determined by special research.

AN UNFORTUNATE MOVE.-The daily press has lately contained announcements of the opening, by the Health Officer in Cleveland, of a Tuberculosis Dispensary in the City Infirmary office at the City Hall. The plan of dispensary routine is copied after Dr. Rus

sell's clinic, which is run in connection with the Post-Graduate Hospital in New York City, and includes morning and evening dispensary hours, and as a prominent feature the dispensing of Russell's Vegetable Compound, a concentrated form of nourishment for tuberculous patients. That municipal patronage should be extended to any movement against tuberculosis is certainly gratifying and most appropriate, but that the city of Cleveland should be committed to the exploitation of the methods of one man and the use of his product in the treatment of tuberculosis seems to us not only unwise, but it also puts the city in the unethical position of booming a method which savors of quackery.-Cleveland Med. Jour.

LARYNGOLOGY AND RHINOLOGY.

HERMAN STOLTE, M. D.

The Etiology and Treatment of Hay Fever. (Prof. Dr. Wm. Dunbar, Hamburg, Annals of Otologie and Rhinologie, Vol. XIV, No. 2.)-It has been proved now beyond any doubt by Professor Dunbar's scientific experimental work, that the cause of all diseases, that fall under the conception of hay fever, as June cold, rose fever, autumnal catarrh, are produced by the affect of pollen, or its constituents, of different plants on the conjunctiva or mucous membrane of the nose and upper air passages. While the European and Australian hay fever is commonly produced by the pollen of graminaceae, as rye, or different kinds of grasses, etc. The North American hay fever is produced by the pollen of solidago and artemizia plants (especially golden rod and rag weed). It is not the mechanical irritation of the pollen itself that produces the hay fever, but it is the very strong, poisonous action of a toxalbumin in the pollen which produces already in a strength of 1-500,000 grain a reaction in the mucous membrane of a predisposed person. Dunbar established the absolute non-toxicity of the pollen or its toxalbumins for predisposed persons, whilst he always could produce artificial hay fever at any time in predisposed individuals, also a violent reaction by subcutaneous injection of pollen toxin. In hay fever the amount of pollen in the air influences considerably the seriousness of the attacks. Liefman calculated that during the blooming of the hay fever plants about 4,000,000 pollen grains fall upon a surface of one square meter in twentyfour hours. According to Dunbar the American fall catarrh is a disease of a single etiology, as it is produced only by the toxins of

the pollen of golden rod and rag weed. Nearly all who suffer from fall catarrh, are absolutely unaffected by the toxins of the grasses or similar plants, that produce the European hay fever. But there are persons who react to both toxins, the graminae as well as the toxin of the fall catarrh. Dunbar now gained by treating predisposed animals, as horses with pollen toxin gradually a serum, which showed antitoxic qualities. This serum he used for treament of hay fever, by blowing the dried serum as powder into the nose or conjunctiva. Here it develops antitoxic qualties, not by destroying at once the entire disposition for hay fever, and curing in that way the disease at once, but by locally neutralizing so long it is applied, the continually developed toxin. Dunbar demands that the antitoxin called pollantin, is applied only, in very small doses, as otherwise an irritation and increase of the hay fever condition is produced. Every patient should therefore carefully study and follow the directions given with every bottle of pollantin powder. He has to blow the small amount of a lenticel of pollantin into his nares, either in the evening two hours before or upon going to bed, or in the moment of awakening, or upon going the first time in the open air, according to his individual need, established by various trials. In that way he will succeed in overcoming the first morning attack of the poison, and as the nose is in the morning, especially receptive for the poison, accumulated during night, and quickly assimilated by the increase of the morning secretion, he will in the case of success be relatively free from further attacks during the day, if he repeats now and then the inflation of pollantin. The results are by correct and painstaking use of the pollantin very satisafctory (complete success in 60%) and far better than with any other known remedy.

Deflections of the Nasal Septum.-A critical review of the method of their correction and by the window resection, with a report of 116 operations, by Dr. Otto Freer, Chicago (Annals of Otologie and Rhinologie, Vol. XV, No. 2). In this very valuable paper, embracing fully the modern methods of correcting nasal septum deformities, Dr. Otto Freer, Chicago, continues to advocate his method of the submucous resection of the deflected septum, as he has done it since 1902. He was the first in this country to give up the old method of resecting parts of the septum, sacrificing the mucous membrane of one side. His method, to make the mucous membrane incision, is quite different from Killian's, Hayek or Ballenger's incision, who make one curved incision in the foremost

part of the septum in front of the deflection, forming a buttonhole, from which they try to resect all deflected parts cartilaginous as well as bony. Freer uses an angular incision in the shape of a capital L, looking backward, making the vertical incision on the summit of the angular deflection, the horizontal along the crest of the deflection, or along the floor of the nose. Thus he creates flaps that make the deepest parts of the deflected vomer readily accessible, while in all other methods the operator works from a point of the greatest distance from the vomer, resecting under a long sac of mucous membrane under ever increasing difficulties. Freer uses his special by himself constructed instruments to make the incisions to detach the mucous membrane and perichondrium from cartilage and bone, to circumcize the cartilaginous part of the septum, and finally to resect the deflected vomer. This latter is done by means of a very useful, strong bone forceps. Freer does not sew the flaps, but fixes both walls (mucous membrane and perichondrium) by firmly packing both nares with lint strips, saturated with bismuth subnitrate powder. In six days the healing is complete, and the patient has a new, plain and straight septum from front til to the posterior openings. The writer, who used Freer's method, in about twenty cases, is of the opinion that in far backwards resecting, difficult vomer deflections, Freer's method is superior to all other methods.

EGG MEMBRANES IN SURGERY.-At a recent session of the Therapeutical Association of Paris, Dr. Amat stated that he has observed for some time the good results of placing egg membranes upon the surface of wounds, and reports two new cases, that of a young girl suffering from a burn on her foot, and a man of 40, with a large ulcer on his leg. Both wounds were in process of healing, and were covered with healthy granulations. He overspread them with six or eight pieces of the membrane of eggs, which was covered with tin-foil and fastened with dry antispetic bandages. After four days the bandages and tin-foil were removed, and it was shown that the membrane of the egg had partly grown into the tissues and had caused the growing of a good skin. That the egg membrane had contributed much to the healing process was demonstrated in the future course of treatment. It seems, however, that the membrane does not always adhere. The process of cicatrization is not only hastened, but the wound heals exceptionally well and leaves but few perceptible traces. -Army and Navy Register.