know whether the inventor or abstracter is to blame for this oversight in giving credit, but it is certain that it represents a crab-like advance in the construction of instruments. Extra-Amniotic Development of the Fetus. In the same column we find an abstract of a paper by Wiemar, "Hydrorrhea Gravidarum with Extra-Amniotic Development of the Fetus." Early rupture of the membranes with subsequent growth of the child is not an unheard-of thing, but upon what hypothesis do they consider this a growth outside the membranes? If a case was recorded where the child had been extruded from the uterus into the vagina and there continued to grow, or where the ruptured membrane had retracted over the fetus, it would be worthy of record and the term would apply. Under the circumstances set forth it is nonsense, and only noticed to call attention to the fact that the value of a journal depends more upon the care and judgment exercised in abstracting for its pages than upon the volume of reading matter furnished. Telling the Time of Labor. QUERY NO. 23.-What do you think of the doctrine, which seems to be growing popular in some quarters, that the physician should, by examining the patient, be able to foretell with certainty the time of labor? Genito-Urinary Diseases. BY E. O. SMITH, M. D., Lecturer on Genito-Urinary Diseases, Medical College of Ohio. Permanent Drainage of the Kidney. By the substitution of comfortable permanent drainage of the kidney through a renal fistula in the loin, Watson (Annals of Surgery, September) believes that we should be enabled to save many kidneys which are now sacrificed in order to save the patient the distress arising from the presence of a renal fistula. He proposes the simultaneous performance of bilateral nephrostomy, tying off both ureters at the same time and establishing permanent renal fiistulæ, thus diverting the urine from entrance into the bladder, for the following purposes: 1. As a palliative measure: (a) in cases of inoperable vesical tumor; (b) in cases of vesical tuberculosis originating in descending infection in which both kidneys are involved in the tubercular process, and when the tuberculous lesions of the bladder are causing suffering. 2. As a step preliminary to the total extirpation of the bladder in certain cases of vesical tumor. The success of these measures must de When a boy I heard one in whose judg-pend in a large degree upon the possibility of ment I had full confidence, but who had devoted much more time to formulating opinions than to acquiring the art of tempering his expressions to sensitive ears, enunciate the following opinion: "The man who attempts to prophesy the exact time of labor is an ass. A vaginal examination will reveal facts tending to assist us in arriving at an opinion on this point. If the cervix is beginning to shorten the time of labor is usually near at hand, but in women who have previously borne children the infra-vaginal portion may be entirely taken up long before the onset of labor. Indeed, I have had women come to the office for examination in whom the os was as large as a quarter, and the edge thin, and have found a few hours later, with corsets removed, that the dilatation had entirely disappeared. On the other hand, the infravaginal cervix is frequently not shortened until after the onset of real labor. Personal experience has led me to qualify the opinion expressed above. He who attempts an exact prophecy as to the time of delivery may not be an ass, but he certainly acts like one. A child is nourished not by what it swallows, but by what it digests. arranging the drainage in such a manner that will be comfortable to the patient, thus avoiding a condition as intolerable in its way as that for the relief of which it had been undertaken. He believes that he has overcome this objection by a simple contrivance he has devised which keeps the patient perfectly dry, and can be worn without attracting attention, and with absolute comfort to the patient. It consists of (1) a hard rubber cupshaped shield through which the tube that enters and drains the kidney is passed; and (2) a light metal receptacle which receives. the urine from the cup. These are held in place by two elastic belts which pass around the body. The capacity of the receptacle is about ten ounces, and can be emptied through a tube attached without removal of any part of the apparatus from the body. Of course, this contrivance can be equally well applied to fistulous openings of transplanted ureters and other similar conditions connected with different organs of the body with which fistula is connected. The operative mortality for nephrostomy is far less than that for ureteral implantation, and with this device, by which the patient can be made comfortable, much can be hoped Mr. W., aged twenty-seven, of German parentage, woodworker in a piano factory. Never been sick, and denies all venereal diseases. Family history negative, except that his mother died at the age of fifty-seven years from carcinoma of the stomach and liver. Three years ago the patient noticed that his urine was very dark at times. He consulted a physician at that time, but the cause of the dark urine was not located. After about two months of this dark urine at intervals the patient noticed nothing more until April of this year, when he observed that his urine was again at times "like strong coffee in color." His general health was not affected, and he continued at his work the same as usual. He consulted the writer June 25, 1907, for this dark urine, which was the only symptom he presented. Urine passed in the office showed a slight reddish tinge. Microscopic examination of the centrifuged sediment showed no abnormality except a few red blood cells. Examination of urine passed in the office on several different occasions always revealed a few red cells, but never in large quantities. He would report having passed very dark urine every two or three days, but it did not seem to have any relation to exercise, as it was sometimes present in the first urine passed early in the morning, and again it would occur late in the afternoon. Never any clots in the urine. Palpation of the kidneys brought out nothing abnormal. Three careful and thorough cystoscopic examinations revealed an absolutely normal bladder wall. I was never able to make an examination when the active hemorrhage was on, hence I could not determine from which kidney the blood was coming, thinking it not advisable to make a ureteral examination with the ureteral catheter until X-ray examination had failed to throw any light on the case. Radiographic examination was made by Dr. Kennon Dunham, who assured me there was a soft calculus in the pelvis of the right kidney. On August 7 I removed, extraperitoneally, a stone larger than an almond from the pelvis of the right kidney. The stone was held fast to the posterior wall of the pelvis and probably never attempted to enter the ureter, which no doubt accounts for the absence of pain. The kidney was replaced, the incision closed without drainage. The patient made an uneventful recovery, and the urine is now entirely free from red blood cells. The points of especial interest in this case are: (1) The atypical hematuria, bearing no relation to exercise; (2) the total absence of pain; and (3) the value of the X-ray in locating the offending object. The most perfect type of an albumenoid is the white of an egg. Otology. C. R. HOLMES, M. D. Mastoiditis in Diabetic Subjects. John D. Richards, New York (Archives of Otology, Vol. xxxvi, Nos. 1 and 2), read to the Section on Otology of the New York Academy of Medicine a paper on mastoiditis occurring in diabetic subjects based study of nine cases. Following a detailed report of four cases he comes to the following conclusions: 1. The mastoid invasion is characteristic -acute otitis, frequently without pain; persistently bulging drum membrane; gradual narrowing of the cartilaginous canal; mastoid tenderness develops later; low temperature; absence of acute inflammatory phenomena in mastoid region; later, post-mastoid tenderness and edema develops, which, with headache, indicate extensive destruction of bone and epidural abscess. 2. The slow march of the mastoid symptoms argues a low vitality of the tissues. 3. The good effect of a proper diet and increasing doses of codeine is sometimes striking. 4. The mortality of these cases is high; six of the nine cases died. Death occurs, as a rule, within the first few days following operation in diabetic coma. 5. In plethoric adults of advanced years chloroform is the safer anesthetic. 6. Following the administration of the anesthetic there may be an increase, a decrease or a temporary disappearance of the sugar in the urine. 7. Following anesthesia dyspnea may develop, and is of particular ill omen. Dyspnea is the one symptom of the greatest prognostic value. It points almost certainly to a fatal termination. 8. A successful issue depends largely upon the rapidity of operation and the short duration of the anesthesia. Richards has seen no case recover in which the operation lasted thirty minutes. 9. The bone should be removed well beyond the apparent limit of involvement. It is bad surgery to sew up in these cases, even to .the slightest extent, the soft tissues over bone pockets. Richards has seen secondary operation necessary and death follow from this trifling error. 10. Diabetes seems to predispose to or be accompanied by vascular changes, such as sinus thrombosis and subcortical cerebral hemorrhage. In sinus thrombosis, in the absence of septic absorption it is safer not to disturb the clot further than to open the vessel and remove the main portion of the thrombus and the corresponding external sinus wall, without establishing return flows. 11. The claim that those cases showing 3 per cent. of sugar, if operated upon, always terminate fatally, is unfounded; and that if diacetic acid and acetone are present the cases have a fatal termination, is also untrue. One case illustrated the facts that neither the amount of urine passed in twenty-four hours, the percentage of sugar, the presence at once of diacetic acid and acetone, together with the severest general symptoms of the diabetes and of the mastoiditis, are of definite prognostic value. The case recovered. Embryology of the Ductus Cochlearis. George E. Shambaugh, Chicago (Archives of Otology, Vol. xxxvi, No. 3), describes the origin of the cells found in the deeper layer of the stria vascularis of the ductus cochlearis. His observations were made upon embryo pigs 34, 6, 8, 12, 15, 18 and 25 cm. long. The selection of a suitable stain was a most important problem, for while both the eosin hematoxylin and the Van Giesen stains would show the well-developed basement membrane found in the first stage, neither of these stains were found capable of differentiating the attenuated basement membrane which was present when the development of the reticular layer began. The stain that was found particularly suitable for the demonstration desired was the reticulum stain of Mallory. This stain, when carefully applied, was found capable of selecting out the finest thread of basement membrane, which it stained a bright hue in the midst of cellular elements taking largely a reddish stain. The development of the reticular layer is a process which proceeds with great rapidity when once it has begun. The development of the reticulum was often well advanced before the basement membrane had completely disappeared. After a historical review and a detailed description of the evolution of the stria and surrounding structures, his résumé of the subject is as follows: 1. Two views exist regarding the origin of the cells found in the deeper layer of the stria vascularis; one is that these cells are derived from the surface layer of epithelium, the other is that they are of connective tissue origin. 2. In the development of the stria vascularis three distinct stages are found: First, where a single row of epithelium is found along the outer wall of the ductus cochlearis, having a distinct basement membrane which separates it from the underlying connective tissue; second, where a broad reticular layer has formed beneath the surface layer of epithelium. In this stage the basement membrane has completely disappeared and the blood-vessels of the reticulum have formed; third, condition found in the adult stria vascularis; here the stria represents a narrower band than is found in the second stage, protoplasmic processes from the surface layer of epithelium have penetrated the entire stria, the reticulum has become completely obliterated. 3. A study of the transition from the first to the second stage brings out the fact that the basement membrane separating the epithelium from the connective tissue persists until the formation of the reticulum of the second stage is well advanced. The position occupied by this basement membrane is not directly beneath the surface layer of epithelium, as it would be in case the reticulum was derived from the underlying connective tissue. The basement membrane is found passing through the midst of the cells forming the reticular layer and at a considerable distance from the surface layer of epithelium. This position of the membrane proves definitely that the cells forming the reticulum are derived in part from the surface layer of epithelium and in part from the underlying connective tissue. 4. The blood-vessels of the stria are placed directly beneath the surface layer of epithelium, and as soon as formed are enveloped in protoplasmic processes from the surface layer. In addition, the cells immediately around the blood-vessels are clearly derived from the surface layer of epithelium, so that while the cells found in the deeper layer of the stria are in part epithelial and in part connective tissue, we are justified in assuming that the stria vascularis represents a true vascular epithelium. Transillumination of the Mastoid. A. H. Andrews, Chicago (Journal of Ophthalmology and Oto-Laryngology, p. 26, 1907), describes a new lamp for transillumination of the mastoid. The test is made by means of a small cylindrical twelve-candle power incandescent electric lamp covered with a soft rubber hood having a five-sixteenth inch aperture at the end for contact with the mastoid. The examination is conducted in a darkened room. An ordinary ear speculum is placed in the meatus and directed backward so as to oppose the posterior wall of the auditory canal. The lamp is placed with the aperture against the back part of the mastoid and the light directed slightly forward. When the mastoid is normal light can be seen in the auditory canal. When the mastoid is filled with pus or granulations no light is perceptible in the canal. In These statements are based upon the examination of several hundred mastoids. more than fifty cases in which light was not transmitted pathological changes were demonstrated by operation. In all the cases in which Andrews used the lamp before operating the findings have been in accordance with the indications as shown by transillumination. The cases which have demonstrated the value of this method of examination are: 1. Acute cases which in the early stage showed good transillumination, but as the case developed light ceased to pass through the mastoid, while after the mastoiditis subsided light was again transmitted. 2. Acute cases which transmitted light in the beginning, but failed to transmit light as mastoiditis developed, and later operation showed the mastoid necrotic or the cells filled with pus and granulation tissue. 3. Chronic cases with obstruction to light transmission in which operation showed the presence of necrosis, pus or granulation tissue. 4. Intractable chronic cases with good transillumination in which operation revealed open mastoid cells, with the cause of the suppuration in the antrum or attic. 5. Cases in which the lateral sinus was superficial and situated close to the auditory canal. In these cases the sinus obstructed the light, but both above and below the sinus trunsillumination was good. V. Stein's Symptoms in the Diagnosis of Labyrinthine Suppuration. W. P. Eagleton, Newark (Archives of Otology, Vol. xxxvi, No. 3), read to the Section on Otology of the New York Academy of Medicine a paper on the value of v. Stein's symptoms in the diagnosis of labyrinthine suppuration. At the Newark Eye and Ear Infirmary, out of seventeen consecutive cases of tympanic exenteration for chronic suppuration, seven, or 41 per cent., were found to have fistula leading into the labyrinth, while three more which have not as yet been operated upon, present symptoms warranting such a diagnosis. Of the seven cases, two had disease of the cochlea and semi-circular canals, the remaining five being of the semi-circular canals alone. In the seven cases, in five it was unsuspected prior to the operation, while in the sixth it was tentatively diagnosed, and only positively diagnosed in the seventh. In two at least of the other five cases it would have been possible to have diagnosed the condition prior to the operation, as they still exhibited disturbances of orientation, notwithstanding that the labyrinth had been exposed and drained several months previously. From his observations, including between two hundred and three hundred persons, Eugleton draws the following conclusions: 1. A normal person not suffering from disease of the labyrinth, suppurative or otherwise, jumps with his eyes closed with a degree of assurance on the second or third attempt. 2. In applying this test age must be considered, as normal persons past middle life soon tire. 3. The symptom has a value in chronic non-suppurative aural disease in which the labyrinth has become affected. 4. The symptom is very valuable in chronic suppuration of the semi-circular canals, and in such may be the only symptom of the condition. 5. The symptom is probably more marked in the early involvement of the labyrinth. It would appear that as suppuration goes on the patient gradually regains to a large degree the ability to perform the co-ordinate movements at first lost. 6. The symptom persists in some cases after the drainage of the labyrinth, but disappears in others. Symptoms of suppuration of the labyrinth where the semi-circular canals at least are involved may be divided into three stages: An active stage or stage of irritation with dizziness, with a great impairment of co-ordinate dynamic movements, associated perhaps with nausea, vomiting and nystagmus; second, a paralytic or latent stage, in which all symptoms are absent excepting the ability to perform with closed eyes certain delicate co-ordinate movements requiring both a correct orientation and accurate co-ordination; and third, even this may disappear, especially in young persons, after drainage of the labyrinth, and perhaps without it. Therapeutics. E. S. M'KEE, M.D. Apocodeine Hydrochloride. Having mentioned this as a hypodermic remedy to produce a prompt evacuation of the bowels in a recent writing, I have since been the recipient of various letters of inquiry about the drug. To answer these letters and furnish some concise information about this remedy and its therapeutic action, the following is presented: A yellow, gray to greenish-gray, hygroscopic powder. It is soluble in water, expectorant, sedative, hypnotic and laxative. Uses: Chronic bronchitis and other bronchial affections. Acts like codeine but weaker, producing large secretions of saliva, and accelerating the peristaltic action of the bowels. Dose: Sedative, subcutaneously or per os, 0.02 to 0.06. Best used hypodermically in a 1 to 2 per cent. aqueous solution. It should be kept free from air and light. Apocodeine hypodermically as a laxative is discussed by Dr. W. E. Dixon, of Cambridge, England, in the British Med. Journal, 1902, No. 2128. After experimentation on animals he was led to recommend its use on human beings. He found that the drug does not produce vomiting or give rise to any other ill effect. It lowers blood pressure, produces vaso-dilatation and increases peristaltic movements. This he thinks is all due to its sedative action on the sympathetic inhibitory ganglia. The author suggests that a 1 or 2 per cent. solution be used, which should be neutral and filtered before used. Two or three cubic centimetres (30 to 45 minims) may be injected. Lyon has also reported favorable results with apocodeine, both as a sedative and a laxative. He administered it per os or hypodermically in doses of one-third to one grain. Prof. Combemale, of Lille University, has experimented extensively with the drug with especial reference to its value as a laxative. He has administered it hypodermically to a large number of patients suffering from constipation. He injected thirty minims of a 1 per cent. solution of apocodeine hydrochloride, which was followed in almost every case within a half-hour by one or two loose stools. He considers the remedy as worthy of special attention, because the number of remedies which will produce an evacuation of the bowels when administered hypodermically is extremely limited. The author found some pain and redness occurring at the site of the injection, which he was able to avoid by injecting directly into the muscle instead of under the skin. In none of the cases did the apocodeine produce any bad effects. Podophyllin contains podophyllotoxin. One-half grain doses produce liquid stools in from twenty minutes to one hour if injected under the skin. For Dressing Wounds. The following powder is employed in place of iodoform by Genevrier, as described in Archives de medicine militaire: Boracic acid, bismuth subnitrate, powdered camphor, equal parts. He also finds very valuable sodium perborate, previously pulverized as fine as possible and preserved in a flask closed with a piece of sterile gauze through which an impalpable powder can be shaken. This acts like oxygenated water, equally as a disinfectant, a derodorizer and a perfect detergent which sweeps away all impurities by its production of gas. It is inodorus, not painful, toxic or irritating, and can consequently be placed in any hands for use; further, by its alkaline action it favors the cicatrization of wounds, and can be employed upon mucous membranes and the most sensitive epidermal tissue. It arrests capillary hemorrhage and blanches and decolorizes. Its action is proportional to the requirements and is exercised only when the wound suppurates or secretes. Although used in excess, it never forms crusts on the wounds.. Sodium perborate may be used to prepare extemporaneously an oxygenated water of any strength, of alkaline reaction, and consequently not at all irritant-at any rate up to a volume of 1 to 4-which fact renders it practically useful to keep on hand. |