or reddish in color, with moderate induration, are quite characteristic, but often the microscope has to decide. Differential Diagnosis.-The polypoid variety from: 1. Papillary tuberculosis may be made by careful inspection, finding the millet seed nodules or tubercle in the neighborhood. For example, the tubes, peritoneum or a focus in other organs. Inspection 2. From mucous polyps. shows the surface mucous membrane intact, and the sound that they originate in the cervix. Cervical fibroids with the pedicle is distinguished by its intact mucous membrane and nonfriability, unless gangrenous. 4. Follicular hypertrophy of the vaginal surface. Here the surface is not rough, the tumor is not friable, and it is covered by intact mucous membrane through which the follicles may be seen. 5. Condylomata acuminata. Here there is only a papillary surface with thick epithelium, no ulceration or infiltration. The color is a whitish red. Further condylomata may be found also in the vagina or vulva. Infiltrating Variety. The differential diagnosis from: I. Inflammatory infections metritis colli, but inflammation usually affects the whole vaginal portion uniformly. The consistency is not so hard, the mucous membrane is intact and follicles are seen. For example, a case in hospital the microscope. decided. Flat Cancerous Ulcerations.-Flat cancerous ulcerations have to be distinguished from: 1. Erosions, if developed upon a hard inflammatory base, 0** associated with ectropion, or the surface becomes rough on account of thick papillary erosions. Inspection decides; an erosion surrounds the external os evenly and has a glistening shiny appearance and bright red color, as it is covered by columnar epithelium, whilst a cancer is duller in color and rougher, even if ulceration is quite superficial. The erosion has no sharp border, but merges gradually into the squamous epithelium of the vaginal portion outline irregular and pits or follicular ulcers are often seen on the surface. But if the erosion has lost its epithelum the microscope decides. 2. Simple ulcers: Due to prolapse or a pessory or cauterization or croupous processes, lack induration and at the borders healing is often seen. 3. A tubercular ulcer is similar to cancer but is very rare. It surrounds the external os. ternal os. Its edges are undermined, the floor is granular but not indurated, yellow miliary tubercles may be seen. Also the disease is found elsewhere or the microscope shows a tubercle structure. 4. Chancroids (soft sore): Are usually small scres, becoming larger by confluence, have elevated borders, the floor has a croupous membrane but is not indurated. Ulcers are multiple and contact ulcers are found. Also ulcers on the vagina or vulva. 5. Syphilitic Ulcers: (a) Initial lesion. (b) Degenerative papule. Degenerative papule is a solitary indurated and shallow ulcer, with indistinct border and dirty copper red color, with greasy exudate on its floor. The anterior lip is the favorite site. 6. Condylomata lata, or papulous ulcers, are elevated slightly and covered by a yellowish debris. They are multiple and other papules may be found on the vulva. 7. Gummata-are rare. The ulcers are elliptical, well-defined, shallow, and the floor covered by a pus-like exudate, which on separation leaves bleeding granulations. It is situated usually to one side of the external os, and extends by serpiginous border. One may demonstrate the lesion elsewhere, also the Wasserman reaction or the presence of spirochaete may be shown. Diagnosis of Cervical Cancer. This more difficult, especially if the os is closed, but otherwise when the os is patulous. Then ulceration, the absence of epithelium and especially friability on scraping with the curette is diagnostic. is Infiltrating Cancer.-Here diagnosis depends on change in shape of the cervix. and its consistency. The surface becomes distended on one side, perhaps, and the canal displaced. Its consistency is cartilaginous. If infiltration is high up in the cervix a rectal examination may help, but , 1910 , Vol. V., No. the best plan is to remove a piece of tissue with the curette and examine histologically, or even to curette the body as well as the cervix and vice versa. Differential Diagnosis.-1. Metritis or endocervitis, but here the condition is uniform and the mucous membrane is intact. 2. Follicular hypertrophy, but here the mucous membrane is intact and the follicles shining through may be punctured. are more 3. Interstitial myomata, rounded; that is, better outlined and surrounded by soft tissue, while cancer owing to inflammatory reaction is not. Ulceration favors cancer. 4. Chronic cervical catarrh, in old females. Here the mucous membrane feels rough, uneven and nodular owing to the granular depression and the surrounding fibrosis, but the mucous membrane is intact and the curette gets no tissue. The microscope decides. Cancer of the Uterine Body.-Cancer occurs here about one-fifteenth as often as in the cervix, but is very important to diagnose, since most corporeal cancers arise. after the menopause. Hence, there are two important signs: I. 1. Hemorrhages. 2. Simpson's pains, regular labor-like pains, lasting several hours and recurring at definite times of the day. But there are no characteristic bi-manual palpatory findings in cancer of the body. The size of the uterus may be normal or even atrophic. Later it may resemble a fibroid or metritic uterus. Diagnosis is made by exploring the cavity. I. By the sound which distinguishes from retained desidua or fungus endometritis, by presence of hard nodules or depressions when cancer is present. If the interior seems smooth cancer may be excluded, but if there are irregularities of the surface the microscope is necessary. The microscope is the proper method of diagnosing early cancer of the body. Digital exploration may be employed if the os is open plus curettage, but if the cervix is closed curettage is employed, and if negative digital exploration is then used, but the latter is more dangerous, besides palpation is not so sure as the microscope. But cancer is distinguished by the two signs of neoplasm and degeneration. about one-fifteenth as often as the other Although corporeal cancer occurs only varieties, still it is more insidious in its mode of onset. It is more frequent in spinsters and in barren wives than in multipara. This corresponds with the clinical experience that it is frequently associated with fibroids, and fibroids are a result of the barren or the celebate state. It is interesting to note that cancer of the body of the uterus has been found to follow double ovariotomy, and since this is practiced occasionally for bleeding fibroids near the menopause is worth remembering. Again, sub-mucous fibroids are often associated with changes in the endometrium which not only cause excessive bleeding but set up also inflammatory conditions, giving rise to salpingitis, leucorrhoea, etc., but also render the mucous membrane more susceptible to cancer. Bland-Sutton (Burghard's System of Surgery, Vol. 4. p. 52) states that in patients submitted to hysterectomy for fibroids, over the age of fifty years, about ten per cent. will be found to have cancer of the corporeal endometrium. Hence, one may sum up the early diagnosis of uterine cancer by stating that: 1. The family history is important in discovering a predisposition. 2. The personal history is important in deciding a predisposition. For example, cervical cancer is almost exclusively a disease of women who have borne children, or at least been pregnant. Hence, there seems good reason to suppose that injuries and their sequelæ are predisposing factors. Again, corporeal cancer is chiefly the disease of spinsters and barren wives, and these are the patients who suffer from endometritis and fibroids. , 1910 Series, Vol. V. 3. Chronic irritations are important etiological factors. For example, lacerations in multipara, fibroids, and endometritis in nullipara. 4. The warnings or prodromes are: I. 1. The red flag of metrorrhagia after the menopause and the Simpson pains in corporeal cancer. 2. The unusual discharge in cervical cancer. 3. The bleeding after coitus in the vaginal variety. A rapid and delicate method of detecting bile pigment in urine. The best known methods of detecting bile pigments in the urine depend upon the fact that oxidation leads to the production of pigments of different colors; the commonest is that with fuming nitric acid-Gmelin's test. It is well enough known, however, that even in cases of distinct jaundice it may be difficult to get a positive reaction for bile pigments in the urine, and if this is so in patients who are already known to be jaundiced it is still more likely to be so in those slighter cases in which incipient jaundice is suspected but in which there is some doubt. Macadie has described a method of detecting them which is both rapid and more delicate than most other tests. It depends, like most others, on the extraction of bilirubin, and the production of a series of colors. It has the advantage that the amount of oxidation may be regulated and prevented from going so far as to pass through the green stage of biliverdin to the yellow or indeterminate stage of choletelin. About 10 c. c. of urine is acidulated with acetic acid, shaken up well, and to it is added enough of a clear saturated solution of calcium chloride to precipitate the bulk of the urates. The specimen is centrifugalised well, the supernatant liquid is decanted from the sediment, the latter is rinsed with a few drops of water, which is again decanted off and the precipitate left as well drained as possible. The greater part of the bile pigment that was present in the 10 cubic centimetres of urine has been carried down by the precipitated urates. To the latter 5 or 6 cubic centimetres of Macadie's reagent are now added; this consists of one part of hydro 'The Hospital, Sept. 10, 1910. chloric acid of specific gravity 1.16 and three parts of rectified spirit of wine. On stirring with a glass rod the urate precipitate dissolves to a more or less clear solution on to the surface of which five or six drops of nitric acid of specific gravity 1.12 are allowed to trickle down the side of the tube. The liquid rapidly assumes a series of colors precisely similar to that of Gmelin's test. At the bottom of the liquid and next to the nitric acid is a yellow layer, above that a wine-red layer, above that a blue layer, above that a bluish-green layer, and above that a green layer. Care should be taken not to shake up the liquid. When bile pigment is almost like that of a spectrum. The layers present in any quantity the appearance is of different colors are not in such close proximity as they are in Gmelin's test, and Macadie states they are therefore much more easily recognised. In doubtful cases, especially when the urine is being tested in a laboratory, the traces of bile pigment from a pint of urine can be collected in quite a small urate precipitate, and this makes the centrifugal machine the procedure can be test a very delicate one. With the aid of a carried out in less than five minutes, and it is not influenced by urobilin, blood pigments, or indican. The danger of misinterpreting the brown color produced when the nitric acid is employed is considerable in practice, and the importance of avoiding this source of error is great. The only difficulty that might arise in connection with Macadie's test would be if calcium chloride did not give a precipitate of urates. This must be a rare occurrence, but when it arises one drop of caustic soda solution may be added to the mixture of calcium chloride and urine so as to get a phosphatic instead of a uratic precipitate. The process may then be continued in precisely the same manner as above and the reaction obtained as before. TREATMENT. The Treatment of Wounds with Alcohol1.- The treatment recommended by Bahnson is very simple and embraces only two principles. "First, absolute rest of the 'H. T. Bahnson, M. D., Winston-Salem, N. C., Int. Jour. of Surgery, Sept., 1910. Series, affected limb, which includes the scrupulous avoidance of all manipulation, palpation or prodding of infiltrated areas by the surgeon's fingers, and second, the enveloping of the whole limb in a loose, voluminous dressing of gauze and absorbent cotton, which is kept constantly wet with a fluid consisting of one part of alcohol to four or six parts of a saturated solution of boric acid, to which Dr. Ochsner adds one part of 5 per cent, carbolic acid solution. This dressing is covered carefully with some impervious material to retain warmth and prevent evaporation. The warm fluid. is poured on as often as necessary to keep the whole dressing wet-not merely damp -and the dressing is renewed in fortyeight hours. This second dressing is usually sufficient to entirely overcome the sepsis. Under this treatment the position of the limb can be shifted as desired, and the comfort of the patient leaves a comparison with any other plan entirely out of the question. A word as to the strength of alcohol used. In the above you will note it is only 15 to 20 per cent. Ordinarily I employ it half strength, but where I think the case demands it I use pure alcohol, and always with good results. For the preparation of the operative field in my hospital work I conform strictly to the standard technic, although I doubt the necessity or efficacy of the ten minutes scrubbing with green soap, which leaves the skin soggy and waterlogged-a condition which is fortunately corrected to a great extent by the final douching with alcohol. Very recently Grossich and Walther have demonstrated that the field of operation is made perfectly sterile by dry-shaving and painting with tincture of iodine. It is also proved by experiment that alcohol penetrates the deeper layers of the skin and destroys, or permanently inhibits, saprophytic and pathogenic bacteria." The Treatment of Varicose Ulcer.1 According to Coplan, rest for the limb is essential; if possible place the patient in the recumbent position and elevate the affected 'M. Coplan, M. D., Cleveland Med. Jour., Sept., 1910. limb, not only until the ulcer is closed but until the scar becomes sufficiently resistant. If the patient cannot afford so much time, the recumbent posture for even a short period will decrease the severity of the case, diminish the ulcerated surface and make it yield to treatment more readily. An elastic stocking should be ordered at once and the patient made to wear it whenever he is on his feet. Those who cannot remain in bed all the time on account of their work should be advised to stand as little as possible and to stay in bed on Sundays, holidays, or whenever possible. This advice is readily accepted and it has proved very beneficial in many cases. Rubber or any other kind of bandages are much inferior to the elastic stocking, and Coplan has never seen a patient who could apply the bandage properly, it is either too tight, or too loose and it does not accomplish much. The treatment of the ulcer itself consists in thorough antisepsis of the wound and surrounding skin, procured by first washing the entire leg with soap and water and then with 1-1000 bichlorid solution, or a saturated solution of boric acid; brushing the ulcer with carbolic acid, then covering it with cotton dipped in alcohol, drying it carefully and dusting on quite thickly bismuth subnitrate and starch powder, in equal amounts, and a dressing consisting of a small pad is held by a gauze bandage or by small strips of adhesive plaster. The elastic stocking is then put on. The powder is changed every morning by the patient, the wound is washed once every two or three days as stated above, inspected, and if necessary, the carbolic acid and alcohol application is again made and the powder reapplied. The indications for the carbolic acid and alcohol applications are when the retrograde changes equal the reparative, or when the former exceed the latter. When the surface of the ulcer is covered with a layer of healthy granulation tissue composed of round cells closely packed together and supplied with a rich capillary network of blood vessels, the above treatment is all that is necessary. If the granulations are irregular, unhealthy, protruding above the edges of the wound, with ill smelling, purulent or sero 1 purulent discharges, the surface should be curetted thoroughly before the above applications are made. GENERAL TOPICS. The Difference Between a Sanitarium and a Sanatorium.- The words "sanitarium" and "sanatorium" are popularly understood to have the same meaning and are generally used interchangeably, says the Scientific American, when designating (or describing) places of refuge for sick people, but there is, in fact, quite a distinction between the meaning of the two words. In answer to a correspondent on this subject the Literary Digest says: "The distinction between these words lies in the fact that they are derived from two different Latin roots. 'Sanatorium' is derived from the late Latin sanatorius, meaning health-giving. The term relates specially to an institution for treatment of disease or care of invalids; especially an establishment employing natural therapeutic agents or conditions peculiar to the locality, or some specific treatment, or treating particular diseases.' On the other hand, 'sanitarium' is derived from the Latin sanitas, from sanus, meaning whole, or sound. 'Sanitarium' relates more specifically to 'a place where the hygienic conditions are preservative of health, as distinguished from one where therapeutic agencies are employed.' Hence it is the province of a 'sanitarium' to prserve health, that of a 'sanatorium' to restore it. Care should be exercised in combining the proper vowels in these two . words, in order to indicate correctly the derivation." Pipe, Cigarette and Cigar.1- The question as to which of the three forms of smoking, the pipe, the cigarette, or the cigar, introduces the greatest proportion of nicotine into the smoker's system has never obtained a completely decisive answer, although it has received considerable discussion from time to time. At one time it was freely asserted that the tobacco which contained the highest amount of nicotine necessarily tended to be the most injurious, no matter in what form it was smoked, but 'London Lancet. now we know that the form of smoking plays an important part. There was a theory that not in all three cases was the original nicotine in the tobacco conveyed as such to the mouth; sometimes it was destroyed by effective combustion, while at other times pyridine was responsible for toxic effects. According to this theory, which was all on the right track, the cigarette was least harmful, because the tobacco along the thin paper wrapper was exposed freely to the air, and as a consequence the tobacco was well burnt and all nicotine was destroyed. Against this it was held that in such a case one poison disappeared only for another one to be elaborated, and carbon monoxide was found in marked quantity as a poisonous constituent of cigarette smoke. As a matter of fact, carbon monoxide is invariably found in all tobacco smoke, and that circumstance should be sufficient to warn all smokers against inhaling it persistently. Theories as to what happens in the combustion of tobacco in the various ways it is smoked next took into account the extent to which condensation products were formed and retained in the tobacco. The most effective condenser, of course, is the pipe, and there can be little doubt that owing to the length of the stem a comparatively small proportion of these condensation products reaches the mouth. In the cigar, on the contrary, the condensing process has a tendency to travel throughout the cigar; at all events, as the cigar gets shorter the condensed product area gradually reaches the mouth and eventually the products are conveyed there by the heat of the burning end. It has been said by connoisseurs that no cigar is worth smoking after one-half of it has been consumed, which seems to be a practical realization of theoretical considerations very suitable for application by millionaires. Again, a cigar that has been partially smoked and then allowed to go out is decidedly unpleasant when re-lit, owing doubtless to the spread of condensation products to the mouth end. In the case of the pipe, the burning area is always in the same place; it never comes nearer the mouth, and therefore the probability is that the condensation products do not reach the mouth in, at any rate, appreciable quantities. In the cigarette the condensation products eventually reach the mouth, but there is in this case less chance |