Uric acid contains more nitrogen than does urea. Many observers have proved that the amount of nitrogen eliminated during work or exercise was in direct relation to the amount of work. Probably this fact accounts for there being less urates deposited in persons having healthful exercise. Another more likely explanation of the beneficial influence of exercise, is the fact that muscular fluids after moderate exercise become alkaline thus causing a condition more favorable to a dissolution of uric acid. It has been shown by HAIG that exercise keeps down the acidity of the urine and at the same time increases the excretion of uric acid. HAIG* found that in the cold months of the year, the acidity of the blood tends to be high, because of little loss of acid in the perspiration and through the urine, each being excreted to a less amount during colder months. HAIG has also pointed out a constant relation between acidity of the urine and the retention of the uric acid, both tending to rise and fall together. Any condition which tends to diminish the solubility of uric acid, tends to retain and accumulate it in the body. As the uric acid tends to remain in the body when the urine is highly acid, and the perspiration of summer tends to reduce the acidity of the urine, then the summer tends to reduce the retention of uric acid. It is well known that gouty and rheumatic patients have less trouble in the summer than in the winter. And it is also undoubtedly true that if sufficient exercise were to be had in the winter, the cold months would not be attended with so much rheumatic trouble. While according to HAIG exercise keeps down acidity of the urine, and increases the excretion of uric acid, it must be borne in mind that the reason of less acidity in the summer is due to the excretory function of the skin and kidneys during that season of the year. Here again it is shown the necessity of out-door exercise, where oxygen can and is more freely taken into the system through the lungs. The action of the lungs and heart increase under muscular exercise, and the blood receives more oxygen which is sent rushing through the arteries to every tissue of the human system. Oxygen stimulates the blood, and in connection with muscular exercise increases the quantity of blood. If rheumatism is caused by a germ as is claimed by some authorities, the beneficial results experienced after moderate exercise has probably a direct relation to METSCHNIKOFF's theory of phagocytosis. A stimulation of the blood's activity may render such a condition favorable to throwing off the poisons that may be excreted by the germs. This same argument may also hold true as regards the ability of the blood to throw off or dissolve the urates deposited in the various tissues. Exercise certainly stimulates every fibre and tissue in the body by a stimulation of its blood supply. It is important that exercise be regular and even in order to produce the most beneficial results in rheumatic trouble. Make the exercise regular, increasing the amount slowly in order not to cause exhaustion; especial attention should be given the regularity of exercise in persons past the prime of life, because as age advances the muscular activity tends to decrease and requires greater effort to keep the muscles in active working condition. Over exercise might be the cause of a rheumatic attack especially if an abnormal condition like chill, et cetera, were encountered after violent exercise. Then again it is equally as important that during a long ride sufficient water shall be taken into the system at the proper time, in order that perspiration may go freely on, and that the human body may receive the amount of water required to carry on the combustion and extra work devolved upon it during exercise, and cause a thorough flushing of the system thus aiding in eliminating waste material. The fatigue after violent exercise, HAIG attributes to the excess of uric acid formed that would have been carried off by a preceding continued exercise. Hence the importance of being in training and taking regular, not excessive, exercise. *HAIG: "Uric Acid in the Causation of Disease," second edition, and British Medical Journal, 1896. [TO BE CONTINUED.] A REPORT OF A CASE OF SARCOMA.* BY THEODORE A. FELCH, M. D., ISHPEMING, MICHIGAN. [PUBLISHED IN The Physician and Surgeon EXCLUSIVELY] THE patient was first shown me eleven years ago, when ten years of age, having a rather small well-defined soft tumor on his breast whose centre was just above and to the right of the left nipple. His appearance was somewhat anemic but he did not complain of pain or discomfort except a slight tenderness when the parts were handled. In the course of two weeks the overlying integument became of dusky hue and the tumor seemed about to suppurate when, the patient accidentally falling down stairs, the skin was broken and quite a profuse hemorrhage from the parts took place. There then commenced a slowly progressing necrosis of the skin from centre to periphery, and as the skin FIGURE 1. disappeared its place was filled by masses of exuberant granulations which bled easily on touch and from which constantly exuded a sero-sanguineous fluid. The illustrations, made from photographs taken at the time, show the condition very well. After a while these granulations disappeared, the ulcer took on a healthier appearance, and in one year's time the surface was entirely covered with cicatricial tissue and so remains to this day. Patient's health remained good and he went to school and engaged in all the sports of boyhood. Later he learned the butcher trade and worked hard in many ways. About the first of this year he began to feel debilitated and called my attention to a swelling on the upper outer aspect of his right thigh. This tumor repeated the course pursued by the first and now looks exactly as the one in the engraving and I believe it to be of the same nature. I have called this a case of sarcoma. That was the diagnosis at the time by more than one medical gentleman and the diagnosis was confirmed by no less an authority than DOCTOR CHRISTIAN FENGER, of Chicago, who twice submitted portions of the tumor to microscopic tests and also saw the patient in person, giving a very unfavorable prognosis. A sarcoma has been called a semimalignant growth, but it is a well-known clinical fact that the round-celled sarcoma is one of the most malignant of growths. On the other hand there are growths corresponding to the embryonic elements of sarcoma which are benign in character. VIRCHOW calls attention to the melano-sarcoma in horses. It is a well-known fact that white and gray horses are especially subject to these tumors, which appear principally on the *Read before the UPPER PENINSULA (Michigan) MEDICAL SOCIETY. tail or around the anus. These tumors have not the malignant course that similar tumors have in man and ordinarily do not reappear after complete excision. A tendency to the development of these tumors is transmissible to a high degree, especially by the stallion, the offspring, both male and female, especially those of a whitish color, being liable to it. VIRCHOW sees in the absence of color in such horses a weakness or lack of resistance in the skin. ("Reference Handbook"). The spindle-celled and myxo-sarcomata are in general only malignant locally. But we know clinically that the site of the growth aside from its histological elements exercises a most important influence in the prognosis. In our case the growth sprung from the pectoralis major, which I find is one of its favorite locations. After attaining its maximum growth the granulations disappeared and cicatrization commenced. The theory of CоHNHEIM supposes that more embryonic tissue is supplied to a part than the subsequent development of the parts require and this unused tissue may take on a sarcomatous or carcinomatous growth. Possibly the excess of embryonic tissue at this point exhausted itself in excessive growth and the neighboring parts were not infected. Why should this secondary ulcer occur on the thigh? Sarcomata extend most frequently by direct extension, next by the blood-vessels, and sometimes by the lymphatics. COUNCILMAN says that the cells not only have an extreme degree of proliferative energy but the tissue of the sarcoma . . . favors this outward growth of the cells. In addition to this direct outward growth of cells into the tissue, it is very probable that the cells of many sarcomata have the power of ameboid. movement. This would FIGURE II. explain the presence of small foci separated by a greater or less interval from the parent tumor. VIRCHOW advances the view that the sarcomatous cells can excite the cells of the tissues with which they come in contact to a similar growth. This can take place both about the original tumor and in those places where the cells may be carried by the blood and lymph currents. Most of the recent authors do not accept this view as to the mode of formation of secondary tumors but believe that these result from a direct growth of the cells or collection of cells which have been carried from the tumors and deposited in distant organs. ("Reference Handbook"). Now, as to treatment. In this case the conditions precluded operation. Arsenic was recommended but little of it was taken. About this time my patient was persuaded by friends to take a certain patent medicine which is reputed to contain large doses of potassium iodide. He took many bottles. Concerning the use of iodides in sarcomata we are reminded of a remark attributed to BILLROTH that in his earlier experience he knew of and practiced but one method-total extirpation, but seeing cases which refused operation get better under the iodide treatment he had modified his practice materially. Therefore, we must admit that either iodide and arsenic have some influence on growths classed as sarcomata or that our methods of making a diagnosis admit of errors. But one more means of treatment need be spoken of—that by the use of toxins. Upon the benefit accruing from the use of toxins there is great diversity of opinion. SHIRELY says notwithstanding its possible dangers, and the uncertainty of its action, the toxin treatment constitutes at present our only therapeutic resource for inoperable malignant disease, having well authenticated cases of recovery to its credit. On the other hand the committee from the New York Surgical Society says, finally and most important, that if the method is to be resorted to at all it should be confined to absolutely inoperable cases. TRANSACTIONS. DETROIT ACADEMY OF MEDICINE. STATED MEETING, FEBRUARY 8, 1898. THE PRESIDENT, DAVID INGLIS, M. D., IN THE CHAIR. DISCUSSION OF PAPERS. DOCTOR W. P. MANTON read a paper entitled "Two Obstetric Lesions." (See page 394.) DOCTOR MAIRE: I am always interested in subjects along this line. Years ago little attention was paid to cervical operations, and the early operations were novelties. A headache in a married woman, especialiy if located in the top of the head, or in the occiput, is frequently a case for the gynecologist instead of the eye specialist, while a pain over the eyebrows is more likely to be connected with eye strain. DOCTOR CAMPBELL: Some thoughts have occurred to me with regard to the academy. It makes us often think along unusual lines, and the eye man does not often think along this line. The eye man handles cases of neurasthenia and the gynecologist does so as well. Nervous prostration requires not the correction of eye refraction alone, or of cervical and perineal tears, but the correction of all. Correction of eye trouble may relieve for a while, but frequently the patient needs further patching up. The great mass of physicians allow the defects to go too long uncorrected before repair is made. DOCTOR HITCHCOCK: It is refreshing to hear a gynecologist take the position that departure from mental state is not due to trouble with the genital tract. Neurotic women have been said to get their nervous trouble from reflex trouble in the ovary, the cervix and the perineum. There are some well-known irritations from these organs. I should like to ask how early DoCTOR MANTON repairs. tears. DOCTOR BIGG: From the standpoint of the general practitioner I recognize valuable hints. These troubles often result from ignorance and neglect of the physician. It is next to impossible to deliver women without damage to cervix in cases of rigid os. In some cases, even after a wait of twenty-four hours, we get more or less damage to the cervix. The subject, however much discussed, is ever new and practical. DOCTOR WINTER: I agree that every woman receives more or less injury to R the cervix. There is only one rule to follow in tears, namely, leave the cervix alone at the time of delivery and repair it in a few months, but repair the perineum at once, within twenty-four hours. I have had no perineum that has not healed satisfactorily. I never leave to nature to heal what will take but a few moments to repair. While some claim that the parts are numbed, and stitches can be taken without causing much pain, I have never seen such cases, and I usually have to give chloroform. DOCTOR ROBBINS: I have two questions-(1) What is a laceration of the perineum? When it goes through the skin of course it needs a stitch. (2) Does an erosion of the cervix always mean a previous mechanical injury? Can a nullipara have a cervical erosion? DOCTOR WILSON: There is no question as to the importance of these lesions. I have repaired many lacerations of the cervix and have failed to get bad results. I agree with DOCTOR WINTER that primary repair of the perineum cannot be done as it should be without chloroform. I have never repaired a cervix directly after delivery, for in examining the cervix after confinement I have been bothered to find what seemed large after the birth of the child. Yet I repair months afterward, and even a few weeks afterward. Many cases have had extensive laceration, yet I have always regarded them as well. Some were in women who were aborting all the time. While unskillful manipulation causes tears, the worst I have seen have been in those who have had no attendant, hence if the doctor had been there he might have been credited with the tear. We should, therefore, always be considerate about what we say of a tear when accrediting it to other doctors. DOCTOR DUFFIELD: In the paper a year ago by DOCTOR MANTON he recommended some aseptic suppositories. I have used them, and since then I have had better recoveries. Yet prolonged lying in bed after confinement-longer than two weeks-is extremely useful. I insist on this in all cases wherein I can do so. DOCTOR H. D. JENKS: In a series of one hundred consecutive cases examined the thirteenth day after delivery, one case only showed no cervix tear, the remainder all showing more or less extensive unilateral or bilateral tears. About twenty per cent. of the cases were low forceps deliveries, the remainder being more or less simple ones. A large proportion of these cases were primiparæ. Almost the same proportion was found in a second one hundred which I helped examine in the same way, but did not deliver. DOCTOR CONNOR: The relation of one organ to another is interesting. A patient of mine after reading one half hour will develop intense tinnitus aurium in the right ear, but she is of a nervous make-up. Cases of middle ear trouble are always helped by correction of ocular defects. There is likely to be a disturbance at the next weakest point when one irritation is removed. DOCTOR INGLIS: DOCTOR MANTON's attitude is conservative and just. I am convinced that if all obstetricians put in practice the best obstetrical practice of today, as, I believe, DOCTOR MANTON has outlined it, many women would be spared years of suffering. The careful and courageous obstetrician habitually lives up to this standard, yet we must be equally careful in forming harsh judgments of our brother physicians when we find bad lacerations. In the first place such accidents occur in the practice of the most careful obstetricians. It is not a question of the physician's skill alone, but one of anatomical structure and relations. So, too, an unrepaired laceration is not always an evidence of neglect on the part of the attending physician. Before condemning some preceding doctor, let us be certain that he did not advise the wise treatment; patients frequently are quite as culpable in refusal as doctors in neglect. Furthermore, while it is true that a bad tear may set up severe nervous disturbances, it is also true that multitudes of women go through life absolutely free from nervous troubles with equally bad tears. And it is true, too, that when a woman has nervous troubles and a bad laceration it by no means follows that one is the cause of the other. Indeed it is often a very grave error to operate for a lacera |