meningitis and luetic affections of the central nervous system. (b) Therapeutic: It has beneficial effects in a serous meningitis, in the severe headaches of chlorotics and old syphilitics. The writer asserts that no evil consequences follow the procedure if strict asepsis be adhered to and only a few cubic centimeters of the fluid allowed to escape slowly. In cases of suspected brain tumor lumbar puncture should not be practiced.

Acute Dilatation of the Stomach. Ernst Hoffmann (Muenchner med. Wochenscrift, No. 45, 1904) states that this condition may result either from a paralysis of the motor nerve supply of the stomach following an injury to the head, as in Erdmann's reported case, or through some failure in the diet, "dilatatio ab ingestis.' The author narrates in detail a case of the latter group in an 18year-old individual demonstrating that it is possible for an acute, fatal dilation of the stomach to occur without any previous notable gastric manifestations. The case is also

instructive, as it shows the difficulties entailed in concluding an accurate diagnosis. In the case described the man was suffering from extreme thirst and incessant vomiting of dark brown matter. A presumptive diagnosis of a circumscribed peritonitis with encapsulated exudate was made, but at the immediate laparotomy the stomach was found greatly distended, measuring 18 x 25 x 34 cm. and containing six quarts of fluid and large undigested pieces of cucumbers. Death shortly followed. The necropsy, in addition to the immensely enlarged stomach, revealed an enlarged and abnormally hard head of the pancreas with multiple necrotic islands. Doubtless an atony of the stomach had existed for some time and the large ingestion of cucumbers induced the acute dilation. It is proba

ble that death resulted from heart muscular insufficiency, though it might have resulted from shock which followed the acute distension of the organ.

Three Recent Cases of Croup Due to Staphylococcus and Requiring Tracheotomy.Anzinsger (Am. Jour. of Med. So., Nov., 1904) reports three cases of sore throats with laryngeal obstructive symptoms requiring tracheotomy. In neither case was there evidence of a psuedo-membrane, although the clinical symptoms suggested a local infectious process with the elaboration of toxines. Diphtheria was entertained in two cases, but antitoxin had negative results. The bacteriologic examination showed pure cultures of staphylococci in the larynx and trachea. The author summarizes the results of his investigations as follows: 1. The winter epidemics of tonsillitis and sore throat in children at

times gives rise to laryngeal complications. 2. This condition is always serious owing to the ease with which the juvenile throat may be obstructed. 3. Individual predisposition to laryngeal complication is quite probable. 4. Staphylococcus, a common denizen of the throat, may, under favorable conditions, give rise to grave symptoms, as exemplified in the cases reported. 5. The rapidity of onset and severity of symptoms may at times suggest diphtheria. 6. A reliable examination of the throat is prerequisite. 7. Antitoxin, although to be used in doubtful cases, will be of no service in cases in which the KlebsLoeffler organism is not the causative factor. 8. The failures of antitoxin are often credited to such cases. 9. A careful analysis should be made of each case, basing the diagnosis on both clinical and bacteriologic evidence.

The Etiology and Pathology of Gout.Futcher (J.A.M.A., November 26 and December 3, 1904) discusses the etiology and pathology of this condition in a most thorough and splendid manner. His paper is summarized as follows: Heredity, overindulgence in malt liquors, pure food with bad hy gienic surroundings, or overeating with inundoubtedly important predisposing etiologic sufficient exercise, and lead intoxication are factors in the production of gout. An analysis of 544 cases treated in the medical wards of the Johns Hopkins Hospital shows that the overuse of fermented beverages seems to be the most potent factor in this country. Gout in the United States appears, therefore, in the majority of cases to be acquired or "free-hold," rather than "copy hold" or inherited.

Studies in the metabolism in gout have as yet afforded no satisfactory explanation for the causation of the disease. There seems very little doubt but that it is due to disturbance in the metabolism of the endogenous and exogenous purins. As yet there is not sufficient experimental evidence to warrant us in abandoning the theory that the manifestations are in large part due to disturbances in uric-acid metabolism. Practically all researches agree in showing that the blood in gout contains a marked excess of uric acid, and the balance of opinion is in favor of the view that this excess is due to deficient excretion on the part of the kidneys. The alkalinity of the blood apparently is not diminished, as Garrod supposed.

The joint manifestations are essentially due to the deposition of the uric-acid combinations of the blood in the form of the crystal line sodium biurate. Whether a local tissue necrosis is primary or secondary to this de

position is a question still in dispute. Nephritis, usually a chronic interstitial type, arteriosclerosis myocarditis, pericarditis and emphysema are the mosty frequent pathologic findings.

A New Symptom in Exophthalmic Goiter. -Jellinck (Wiener klin Wochenschrift, No. 43, 1904) describes a symptom, which he claims belongs to the early symptoms of a Graves' disease and is absent only in rare cases. The symptom consists of a brown pigmentation of the upper and lower eyelids. The pigmentation extends upward to the eyebrow, the lower limit is the infraorbital margin. The conjunctiva is not effected.

The Differential Diagnosis and Treatment of So-Called Rheumatoid Diseases.-Goldthwait (Boston Medical and Surgical Journal, November 17, 1904) bases his paper on the experience gained during the past twelve years at the orthopedic department of the Carney Hospital. He divides rheumatoid affectious into five types: 1. Chronic villous arthritis, or dry joint is common and not a general disease, but represents a local process with a tendency to progression. The characteristics are chiefly crepitation on motion with pain and tenderness in varying degree. The knee is the most common joint affected, and is apt to be associated with flat-foot and a lack of muscular tone in the calf and thigh muscles. The treatment is directed in essentially improving the tonus of the joint structures by baths, massage, etc., 2. Atrophic arthritis. This is commonly called rheumatoid arthritis, and is a progressive disease resulting in marked distortion and crippling with the pathologic feature of atrophy in which the joint membranes, cartilages, bones and even the skin show the change. The first signs are swelling of the joint, increase in the synovial fluid and infiltrations of the membranes and periarticular structures The joint structures show signs of atrophy and the cartilages soon begin to disappear, as evidenced by the radiograph. The disease progresses for years. In this variety, tonics, freshair, alkaline drinks, stimulating baths, forced feeding and massage are indicated. 3. Hypertrophic arthritis, commonly called osteoarthritis, may be a general or local process and is characterized by thickening at the edges of the articular cartilages, or at the attachments of ligaments, forming ridges or nodes which become ossified and interfere with joint motion. The essential feature is hypertrophy of the cartilage and bone. In the finger joints Heberden's nodes are the type. The etiology is unknown, and treatment rests in fixation or at least protection of the affected parts during the action or

painful stage. Ankylosis may proceed so far that operative interference may be necessary. 4. Infectious arthritis includes cases commonly called acute or chronic rheumatism as well as many cases formerly spoken of as arthritis deformans and is the most common of the joint affections. The condition is the result of infection, either local or general, and the infecting agent is apparently any one or more of several germs. The treatment is directed to the general as well as the local condition. The salicylates frequently do no good, and if they afford relief at all it is quickly noted after their administration. 5. Chronic gout is less understood than the other types because much less common. The chief characteristics are the deposits of sodium urates in the soft structures about the joints with some bone absorption adjacent to the deposits. The disease is usually slowly progressive.

OBSTETRICS AND GYNECOLOGY

W. H. VOGT, M. D.

The Effect of Hysterectomy on the Sexual Function. (Hiram N. Vineberg (Med. News, December 31, 1904).-According to the author the effect on the sexual function of hysterectomy performed on the adult woman, is nil. He concludes, from his own experience and from a study of the literature on the subject, that whatever other effects the removal of the uterus and ovaries may have upon the female human economy, it has little or none upon her sexual feelings.

Chorea in Pregnancy.-J. M. Semple (Northwest Medicine, December, 1904) em. phasizes the dangers of chorea in pregnancy and advises the induction of premature labor as offering the only chance of recovery in those cases where the symptoms increase in spite of medical and moral treatment, and the sleep is becoming disturbed.

Vomiting of M. H. Martin British Medical Journal, London, December 10, 1904) states that vomiting may be due to phthisis or gastric ulcer coincident with preg. nancy. He gives the following classification of vomiting of pregnancy: (1) Where the nausea or sickness is light, with, at the most, retching, occurring usually in the forenoon and passing away just before or when quickening takes place, without producing any constitutional disturbance. (2) Where vomiting as well as nausea is of frequent occurrence, not confined to any period of the day, and resulting in appreciable failure of health and emaciation. (3) Where vomiting is so con

stant and persistent that all food is rejected, rapid emaciation follows, with febrile disturbance, circulatory troubles, jaundice, dry tongue, quick pulse, delirium and threatened death. (4) Where organic disease is present and it is difficult or impossible to say what share it has, in producing a dangerous or fatal result. He claims, that malposition of the uterus, if the cause of so many troubles in ordinary conditions of health must be of graver trouble in the pregnant woman and thus increases the vomiting of pregnancy and consequent malnutrition and emaciation. That hysteria, in the absence of uterine troubles and organic disease, plays an important role and usually defies all therapeutic meas

ures.

In such cases as come under the third and fourth divisions of his classification, the induction of abortion should be considered but the responsibility should be divided with another physician. There should be no long waiting under the hope that the vomiting may suddenly subside, but the patient should have the benefit of it before it is too late.

Frank

Obliteratio Uteri Totalio. Fr. (Muench. Med. Wochenschrift Nos. 46 and 47) cites a number of cases with good results. He considers it a simple and harmless procedure. It might be called the "extraperitoneal uterus extirpation." The indications for the total removal of the lining membrane according to the author are about the same as those for atmokausis of Pincus, viz: (1) In persistent climacteric hemorrhage especially when associated with small submucous fibroma. (2) In severe neuroses which have their origin in the endometrium. (3) In chronic endometritis complicated with retroflexions in advanced age. He has been condemned by many for this, but believes the results warrant a continuation of this operation. He does not wish to be understood as

advising it in malignant conditions, but thinks it often prevents the occurrence of a carcin

oma.

The Remote Results of Anterior Vaginal Hysterotomy. Heinrich v. Bardeleben (Zentralblatt fuer Gynaek., No. 46) briefly goes over the histories of eight cases which were later examined. Only in one case did the portio show any signs of the previous operation; here there was a cleft reaching to the vaginal attachment. He found similar clefts but laterally in women who had had normal confinements 22 times out of 447, viz., about 5% and 13 cases which had considerably larger tears. In his 8 cases examined he found the scar in the anterior vaginal wall not sensitive and not adherent to the underlying structures. There was never any hem

orrhage nor any vaginal discharge, nor even a retroflexion. In one case there was an ante-position found, and in two cases a retroversion with anteflexion. The advantage of this operation is that one can control the evacuation of the uterus in a given time and produce a wound which is in the best possible condition for repair. The disadvantage of the dilating methods consist in the fact that one has not always control of the dilatation since in unyielding tissues there is great danger of laceration, after which the prospects for repair are much less favorable than with the anterior utero-vaginal incision.

Hebotomy.-G. Leopold (Zentralblatt fuer Gynaek., No. 46) found occasion to perform this operation five times in the course of a few weeks. He found the same to be very simple, and the lying-in period was normal in every respect. The women were able to be up and about on the sixteenth to the twentieth day. He gives a complete history of each

case.

Symptomatology of Retroflexio Uteri Mobilis. (W. Nacke, Zentralblatt fuer Gynaek., No. 47). Out of 265 cases he found but 37 not complaining of symptoms due to the back displacement. He believes that movable retroflexions cause disturbances only then. when physiologic or pathologic processes that place that cause on enlargement of the organ or an irritation. The symptoms are probably due to slight changes in the tissues or in the nervous apparatus of this region.

Removal of a Stone from the Bladder.— -(Paul von Kubinyi, Zentralblatt fuer Gynaek., No. 47.)-During an attempt at self-catheterization with a goose quill a piece of the quili broke off in the bladder and a stone formed about the same. The patient complained of considerable trouble in passing her urine. After dilating the urethra with a pair of forceps the stone was extracted, during this operation the bladder and urethra proved to be completely anesthetized. Kubinyi believes an affection of the cauda equina or the conus medullaris to be the cause of the urinary troubles, and this anesthetic condition of the urethra and bladder.

Mastitis of Both Breasts in Pregnancy, Following an Eczema of the Nipple.-(A. Colmann, Zentralblatt fuer Gynaek., No. 47).This affection was observed in a I para 20 years of age, six months pregnant. She was suffering from an eczema of both mammae; only after several incisions were made was a cure effected. As other causes for mastitis gravidarum, aside from eczema, the author mentions trauma and syphilis.

Dangerous Hemorrhage from Varices During Pregnancy.--(Paul v. Kubinyi, Zentralblatt fuer Gynaek., No. 48.)-A woman 32 years of age, in her eighth month of pregnancy began to pass bloody urine after having lifted a heavy object. Following this there was no further spontaneous urination and the bladder became constantly larger and more distended. After dilating the urethra and introducing the finger a thick blood clot was removed and the bladder irrigated. Recovery followed and there was no further hemorrhage into the bladder. The author believes the cause of the hemorrhage to have been due to a ruptured varix in the mucous membrane of the bladder.

The Detection of a Child in Utero by Means of the X-Ray. (Albers-Schoenberg, Zentralblatt fuer Gynaek., No. 49.)-By means of the compression diaphragm attached to an X-Ray machine, the author succeeded in outlining the fetus in two cases. One case а woman eight months pregnant was brought on her side and examined. The skull, orbits, jaw and also the upper arm of the child could be distinctly seen. In the second case also a woman eight months pregnant, the extremities, ribs and parts of the vertebral column could be recognized. He believes it possible to be able to diagnose twin pregnancies with this apparatus, since extrauterine pregnancies and lithopedian have been shown by other authorities. His findings should His findings should be considered as an interesting advancement in Roentgen technic.

OTOLOGY.

ALBERT F. KOETTER, M. D.

The Involvement of the Ear in Acute Infectious Diseases. -(Compilation by Dr. Franz Kobrak, Breslau, Internationales Centralblatt fuer Ohrenheilkunde.) The study of the process of diseases which develop within the reach of the ear during the course of acute infectious diseases is oftentimes aggravated by the fact that the general clinician and the specialist do not work in harmony with one another. The activity of the otologist commences too late, the observations especially in the initial stage must necessarily be incomplete. Exact clinical observations of the local process from the very beginning at a time in which only the general infection is manifest and signs of the local process cannot be recognized can only help us to understand the anatomical picture thoroughly which we possess, of these processes, in increasing completeness. All claims with re

gard to equal consideration of the clinical conduct as well as the anatomical condition will be met by the work of Lewins from the Habermann clinic, viz.: On the clinical and pathologic-anatomical conduct of the ear genuine diphtheria. Lewins found that the middle ear conditions appearing in pharyngeal diphtheria seldom show a tendency to change for the worse or to spread, on the other hand they recover very slowly and late. Severe is the course of those rare cases of pathologic-anatomically true middle ear diphtheria in genuine pharyngeal diphtheria. The external canal is often involved in the specific disease, even with intact drum membrane. Many authors deny the frequency of ear complications in diphtheria. Spangenberg agrees with Lewins in that the ear is more often involved than is generally believed. In 1000 cases of diphtheria Spangenberg found 24.3% with pathological conditions in the ear. There are cases with partially mild inflammatory symptoms on the part of the ear, where only the bacteriolog ical examination can prove the specific condition of the ear secretion. The cases reported were in part mild suppurative cases without casting off a pseudomembrane through the rather large perforation. In one case the attention was called to the ear by a facial paralysis existing on the same side as the ear trouble. The membrane was lusterless and upper posterior portion flattened. To the great surprise of every one the smear made after the paracentesis showed a pure culture of suspicious diphtheria bacillus which were then identified as the true Loeffler bacillus. An important supplement to the clinical data

are

had,

the pathologic-anatomical results of Lewins. Macroscopially and anatomially the cases were in part benign mucous or serous middle ear inflammations, but in the more severe cases, where an autopsy was showed intense purulent inflammation. Lewins considers the following changes characteristic from a histological standpoint. In the vascular system of the inner ear a marked stasis occurs, so that in some case the rami cochleae et vestibuli are run through with a mesh work of congested blood vessels. Besides the thrombosis there are hemorrhages, stronger in the periostium of the meatus and the epineurium, weaker in the nerve trunks between and n the bundles. The nerve substance shows a high degree of degeneration. More often than the auditory nerve, the nerve cells of the ganglion Scarpae and spirale were changed. In the course of the facial, the nerve itself did not show such exquisite degenerative changes as the acoustic nerve, or as the ganglion geniculi. The result as to the staining for fibrin and bacilli

was negative. The acoustic proved to be, according to Lewins, the part of the ear, most often and severely affected. This fact which may be traced to the peculiar affinity of the acoustic nerve to the diphtheria virus as well as to the circumstance that the changes in the nerve are not in proportion to the other condiitons of the ear. The explanation for the severe functional disturbance of the genuine diphtheria, in otherwise negative results will not be hard to find. From the etiological standpoint Lewins is of the opinion that the diphtheria otitis in the predominant number of cases is through the emanation of the diphtheria poison circulating in the blood and not by the pharyngeal process, by the tube. Lewins came to this conclusion because of the peculiar condition demonstrated in the blood vessels and on account of the epithelium which is oftentimes found intact in severe inflammations in the internal ear. As illustration and supplementary to the anatomical conditions, found by Lewins in diphtheria, are Witmaack's researches of the toxic acoustic neuritis and the participation of the ganglion belonging to it. Witmaack's clinical and pathological findings concern us because perhaps the acute infectious diseases of which provisionally sufficient observations are lacking, offer analogous results to those of Witmaack and other observers. Clinically we are dealing with an acoustic neuritis which develops as a progressive bilateral disease, and is characterized by the presence of intense continuous subjective noises throughout the whole course, or at least at the beginning of the disease. Of importance to Witmaack is the total absence of severe attacks of vertigo referred to the semi-circular canals, or rather their occurrence a long time after the beginning of the disease. Therapeutically, in the neuritis occurring in the course of an acute infectious disease, a specific, eventually a serum treatment, might be considered. Pathologic-anatomically the frequent involvement of the cochleae nerve with the spiral ganglion, found by many observers is remarkable. The imbedding of the nerve fibres and ganglion cells in the spiral ganglion, in a rigid, for compensation of the lymph, unfavorable surrounding is given, by Witmaack, as an explanation for the predisposition of the cochleae nerve to pathological processes.

the

Alt describes an acoustic neuritis following influenza. On the second day of the dis ease facial paralysis set in, and on the third day tinnitus aurium, vertigo and deafness occurred on the same side as facial paralysis. The tests showed a labyrinthian affection, high notes were perceived better than low tones. For the cerebral form of influneza

:

Sugar introduces a peculiar ear complication, viz. Sudden disturbance of hearing, severe vertigo, pain in the temporal region. Sugar surmises either a hemorrhage in the fourth ventricle in the sense of a polioencephalitis superior hemorrhagica acuta, or still more is he inclined to the supposition of a hemorrhage in the labyrinth, especially in unilateral ear affections. As illustration of the malignancy of the influenza otitis a case each from Knapp and Scheibe is given. Whereas the case of Knapp was characterized by frequent, stubborn recurrences and a very extended suppurative area, Scheibe reports a case of acute bulbus thrombosis which often follows suppuration of influenza otitis. The influ enza bacillus dangerous because it attacks blood-vessels and causes necrosis. A singular symptom complex has been observed by Goldstein. Intense deep-seated pain radiating from the ear to the temple, rapid swelling of mastoid process, profuse serous secretion from tympanum, vertigo and hemicrania. To this he adds deafness occurring early in the disease and involvement of the labyrinth. The property attributed to the influenza bacillus by Scheibe, that of causing necrosis, Koller found on a large scale in a case of post-diphtheritic otitis. Twenty-four hours after the beginning of the earache deafness occurred, eight weeks later operation removal of sequestrium of the superior and horizontal semi-circular canals.

Bi.

At the head of the infectious diseases, according to the latest reports, is scarlet fever, that is as regards the destruction caused by the intensity and extension of the disease virus. A rapid disintegration in acute scarlet fever otitis was shown by Scheibe at the meeting of the German Otological Society. Death in the fifth week of the disease, in the right ear which was affected three weeks destruction of the membrane and the internal muscles, ossicles necrotic, labyrinth normal. Total deafness. Of prognostic value Bezold emphasizes the fetid nature of the discharge at the beginning of the disease. lateral labyrinth necrosis with bilateral facial paralysis is described by Herzfeld following scarlet fever. On the fourth day bilateral deafness and facial paralysis. On one side, in operating, the necrotic disintegrated cochlea was opened and on the other side only a caries of the lateral semi-circular canal was found. Hermann describes two types of scarlet fever otitis complications: one, which by primary bacterial process in the bone leads to rapid necrosis of large portions of the petrous part of the temporal bone; the suppurtive otitis leading to antrum empyema. The latter usually runs a benign course. Those cases examined and reported by Gaessler evi