The Rapid Dilatation of the Os Uteri-Bounaire's Method (By R. J. Th. Meurer, Monatsschrift fur Geburtshuelfe und Gynaekologie, June, 1903). The author reports 29 cases in which dilatation was performed by the above-mentioned method. A number of them were cases of placenta praevia, others cases of eclampsia and various other conditions where rapid dilatation was indicated. Dilatation was completed in from three to seven minutes without any cervical tear occurring. He believes the method safer and more rapid than dilating with the Champetier de Relies bag or with the Bossi instrument. The latter he would reserve for such cases that offer an unusual amount of resistance, in other words, when the os is extremely rigid. The indication for the use of Bounaire's method he formulates as follows: 1. In transverse presentations when the os uteri is only slightly dilated, the bag of waters not ruptured, when external version has been unsuccessful and the awaiting would not be practical. And in cases in which the contraction ring has appeared early. 2. In cases of a rigid os (scars, etc). 3. In cases where the pains are extremely strong. In this indication he advises careful section of the cases, and claims one should be guided by the effect which the pains may have on the general condition of the patient. 4. In cases where a forceps delivery will probably become necessary he advises the use of this method for it may be possible in this way to have the labor end spontaneously.

A Few Infrequent Cases of Uterine Tears with Special Consideration of the Mechanism of the Lacerations.-(By E. Knauer, Monatsschrift fur Gebsurtshuelfe und Gynaekologie, June, 1903.)-Knauer reports a case of rupture of the uterus caused by a large mass of Imyph glands, situated in the right side of the pelvis in the region of the acetabulum and extending obliquely downward and backward to the rectum. He believes since the head of the fetus could not enter the pelvis, owing to this glandular tumor, the cervix became fixed by the fetal head, or through its natural attachments and during the strong pains the lower uterine segment became greatly distended, and finally ruptured. The tear in this case occurred in the muscular part of the uterus at first, later through the formation of a large hematoma the serous coat tore, but the laceration did not extend in the uterine cavity. He mentions cases of death following premature separation of the placenta, three observed by himself and one of Kouwer's, in which at the post mortem examination fissures of greater or less extent were found in the uterus, the same causing hemorrhage into the abdomen. He believes

that some connection exists between premature separation of the placenta and these lacerations, and that the accident occurs more often than it is recognized. He emphasizes the sentence of Saenger, viz.: Where we have signs of internal hemorrhage, with increasing collapse and no external bleeding after labor, or after traumatism, or during pregnancy we should think of the possibility of these fissure uteri, as he calls them. Not only in cases of premature separation of the placenta, but also in other cases where the uterus is suddenly distended should we think of this condition and act accordingly, especially when increasing anemia without external hemorrhage is present.

The Diagnosis of Pregnancy.-(By W. S. A. Griffith, British Medical Journal, April 11, 1903.)-The author lays great stress on the history, also on the condition of the breasts; the same showing signs of increased activity very early in pregnancy, viz., plainly visible vessels, increased pigmentation and secretion. The size of the uterus plays an important roll, but on the contractions of uterus he lays less stress since the same may occur in myoma.

Habitual Abortion. (By John W. Taylor, British Medical Journal, April 11, 1903.)-The author complains that this important subject is so superficially dealt within most of the text-books. Only those cases does he recognize as cases of habitual abortion, in which the woman has aborted regularly since the beginning of her married life. As causes he gives syphilis, then intra-peritoneal adhesions of the uterus, especially following appendicitis, chronic albuminuria, and deep cervical tears. He describes 12 cases, all of which had a so-called scrofulous family history, these he claims form a large part of the cases of habitual abortion, and favorable results are obtained in such cases through proper treatment, viz. Fresh air, rest and good nourishment.

Shortening of the Round Ligaments.- (By W. Alexander, Medical Press and Circular. April 29, 1903.)—The author who first performed and published this operation in 1881 now gives a short description of the method, which he now practices. The difficulty of finding the bands of which so many operators complain is not so very great. At first the aponeurosis of the ext. oblique must be exposed external to the inguinal ring, and not until the aponeurosis has been positively found is the ring exposed. It is necessary to use very gentle traction, since the lower part of the band is very thin and may easily tear. Only in 3 to 4 per cent were cases found where the bands were so thin that no traction could at all be used, and the operation had to be given up. In order to get good results it is advisable to place an intra-uterine and a Hodge's pessary, and in this way keep the uterus in place after the operation, especially is the intrauterine pessary necessary, this remains in place as long as the patient is confined to bed. The Hodge's pessary remains in place two months. The patient is then kept under observation for a short time, and in case the uterus should show any inclination to fall backward a pessary is again introduced. If care is taken in the after-treatment returns should not occur. In case of adhesions the same are separated through a vaginal celiotomy and the ligaments then shortened in one sitting.

DEPARTMENT OF OTOLOGY.

BY A. F. KOETTER, M. D.

ST. LOUIS

Local Anesthetics in Aural Work. In a compilation on local anesthetics in operations on the ear, Dr. Hugo Frey, Vienna (Internationales Centralblatt fuer Ohrenheilkunde) claims they were used soon after the introduction into general surgery, but the results have not been as gratifying as in rhinology, laryngology and ophthalmology. He also speaks of the vain attempts to discover an efficient substitute for cocaine. In operations on the membrane Kuchner recommends a 10-20 per cent sol. of cocainum hydrochloricum applied at intervals of five to ten minutes, causing partial anesthesia after fifteen minutes. For paracentesis in acute catarrh Hedinger uses a 15 per cent, in acute otitis a 20 per cent solution, but even this causes only a partial anesthesia. Hume and Yeasley report good results with 5-8 per cent eucaine sol., doing away with the unpleasant affects of cocaine. Bonain recommends the following: acidi carbolici crystallisata 2.0, cocain hydrochlorici, menthol aa 0.5; carbolic acid causing a blanching of membrane, after which paracentesis will be painless, but the large amount of carbolic acid speaks against frequent use of this formula. Gray uses the following: R Cocain muriate 5.0, olei anilini, spiritus vini diluti aa 15.0, causing complete anesthesia in 3 to 5 minutes and disappearance of reflex cough. In order to overcome bad effects of anilin Gray proposes having a 20 per cent alcoholic cocain sol. and 15 to 20 per cent eucain sol. in anilin oil mixing equal quantities of both and applying same to membrane with cotton tampon, but even with this formula a pale violet discoloration of membrane takes place. Ethyl chloride spray to the membrane, according to Bloch, is not to be recommended, the application to membrane being painful and necrosis sometimes following the freezing. McAuliffe proposes the injection of cocain sol. through eustachian catheter, the nerves of membrana tympani being situated in middle and inner layer, but catheterization is not to be recommended in acute otitis.

In operations of tympanic cavity, as removal of polyps, Frey recommends injections of 1 to 3 per cent cocain sol. into polyps, causing anesthesia in from 2 to 3 minutes. The best results are obtained from the use of adrenalin chloride, combined with cocain, making the operation a bloodless one. Moure and Brindel use a solution of adrenalin 1:5000 (10.0), cocain 1:10 (5.0). In operations on the auricle Schleich's method of local anesthesia gives uniformly satisfactory results. In operations on the mastoid where general anesthesia is not advisable ethyl chloride spray and Schleich's infiltration method, preceded by an injection of morphine, are highly recommended. All authors claim that the most painful part of the operation is the incision of the soft parts and detaching the periostium. Of the methods recommended for local anesthesia Schleich's has taken foremost rank. Braun recommends the substitution of eucain B for cocain in Schleich's formula and uses the following: Eucain B 1.0, Saline sol. 8.0, Aqua 1000; solution must be of body temperature. Eucain is

less poisonous and irritating than cocain. Alexander reports eleven cases in which the mastoid was opened under administration of Schleich's local anesthesia, in six of the cases slight headache and vomiting followed the operation, but it is doubtful whether these symptoms were due to Schleich's solution or the result of the concussion. The operation is considerably prolonged by the use of local anesthesia. Whenever possible general anesthesia should be used.

DEPARTMENT OF INTERNAL MEDICINE.

BY O. E. LADEMANN, M. D.

ST. LOUIS.

A Case of Acute Miliary Tuberculosis Following an Abortion. (M. Westenhoeffer, Deutsche Med. Wochenschrift, 1903, M. 13.) — A women with a chronic apex tuberculosis, otherwise healthy, a condition resulted simulating the sepsis following an abortion. Post mortem revealed a diffuse tuberculosis of the general organism.

A Supra-phrenic Abscess.-(H. Nothnagel, Gesellschaft fur innere Medizin in Wien Mai 14, 1903.)-Demonstration of an interesting anatomical preparation of a supra-phrenic abscess resulting from a case of tonsillitis with the following explanation. The formation of a secondary abscess near the base of the right lung terminating in a large supra-diaphragmatic abscess with pulmonary emboli; the latter by means of the vena azygos, vena cava superior, through the heart into the pulmonary arteries.

Paralysis of the Recurrent Laryngeal Nerve in a Mitral Stenosis. (Hofbauer, Wiener klin. Wochenschrift, 1902, M. 41.)-Although such cases have been reported, it is disputed as to the cause. Ortner being of the opinion that the paralysis is due to pressure on the nerve by the dilated left auricle, where as Krauss describes it as being due to the ligamentum Botalli crossing the nerve exerting a pressure on it. The case of the author speaks in favor of the latter, as the husky voice manifested itself with the other early symptoms of a cardiac lesion. The alteration in the voice being most pronounced when the patient leaned forward or lying on the left side.

Aneurism of the Arch of the Aorta in a Child.-(A. C. Jordan, Lancet, February, 1903.)-A boy 6 years old, who since his earliest days had a double otitis media. The boy suddenly died during an attack of some febrile disease, the symptoms of which were headache, vomiting and a swelling of one knee, the latter disappearing spontaneously before death. The necropsy revealed a saccular aneurism of the ascending portion of the arch of the aorta which had perforated into the pericardial sac with otherwise perfectly intact arterial walls and valves of the heart. As etiology the author gives a localized septic aortitis, possibly the result of a small septic embolus which had lodged in one of the vasa vasorum.

Decapsulation of the Kidneys.-(Johnson, Annals of Surgery, April, 1903.) From experiments conducted on dogs the author concludes that decapsulating the kidneys does not influence the circulation of those organs any, as claimed by Edeboles. Johnson is very skeptical as to the published results of the mentioned author, as among them are cases of floating kidney otherwise in a healthy condition. Edeboles in his publication also speaks of unilateral occurrence of Bright's disease, which has never satisfactorily been proven to exist and, finally there is not a single case where a cure has lasted any length of time.

Paroxysmal Hematoporphyrinurie. (Pal, Centralblatt fur innere Med. 1903 M. 25.)—An individual, age 66, with a luetic history, a dilated and hypertrophied left ventricle with an accentuated second aortic sound and a slight blowing systolic murmur, after every prolonged exposure or chilling of the body experienced pain in the abdomen and right lumbar region. The urine for the next twelve to twenty-four hours was of a black color, containing serum albumin, casts and a large quantity of hematoporphyrin. As hemaglobin and blood corpuscles were absent, the color of the urine was due to the increased hemato-porphyrin. The clinical picture resembled that of a paroxysmal hemoglobinurie. It is possible that syphilis played a role.

The Widal Reaction in an Abscess of the Liver.- (Megele, Meunchner Med. Wochenschrift, 1903, M. 14.)-Though the symptoms did not speak in favor of typhoid, and the autopsy absolutely negative, the Widal serum reaction was positive in a dilution of 1:40 and 1:100 with a twelvehour bouillon culture. Shortly before death the patient became icteric, suggesting a hepatic lesion, the clinical picture being one of sepsis. Necropsy a large abscess of the liver, spleen enlarged, lymphatic glands swollen, intestines negative. The intestinal lesions in typhoid fever may be absent, as Chiari has shown in five cases, but was able in each case to cultivate the typhoid bacillus from the spleen and mesenterial glands. Cultures in the author's cases were made from the abscess and mesenterial glands, showing staphylococcus pyogenes aurens in pure cultures.

Two Cases of Aneurism of the Hepatic Artery.-(A. Sommers, Prager med. Wochenschrift, 1902, page 469.)-In addition to the eight cases of this rare occurrence found in literature. Sommers reports two cases which he observed in the Grazer clinic. In one case the patient had severe attacks of pain in the abdomen, intestinal hemorrhages and a continuous icterus. The aneurism was found to compress the bile ducts with a perforation into the ductus choledochus. The other case presenting intestinal hemorrhages and abdominal pain, but no icterus. In this case there was an aneurism of the gastro-duodenal artery pressing on the pancreas and duodenum with a perforation into the latter. Although the diagnosis of an aneurism of the hepatic artery has never been made during life, the writer lays importance on pain in the right hypochondriac and epigastric region, with intermittent icterus and hemorrhages of the upper portion of the intestinal tract.