The Pathology of Icterus Neonatorum.- formication, a sense of coldness, constriction or tickling Knoepfelmacher (Wien klin. Woch.; Brit. Med. Jour.) is very frequent in certain forms of neuritis. In hyteria, has studied this question from a new point of view. paresthesiæ are very commonly present, and their more The theories as to the pathology of icterus neonatorum aggravated forms are often seen in cases of neurasthemay be grouped under five headings. The first attri- nia That they may be present in individuals who have butes it to the absorption of bile from the intestine, the otherwise healthy nervous systems and who are in comsecond to the absorption of normal bile from obstructed parative good health, has long been noted. bile ducts, the third to increased destruction of red A case of this latter kind recently came under our corpuscles, leading to formation of an increased quantity observation, which is so far exceptional that it is deserv. of bile, which is altered in quality, and so escapes into ing of notice. L. F., by birth an American, and a farmer the blood, although the biliary passages are clear. In by occupation, complained of an abnormal and peculiar this case the bile gets into the blood in the liver, but the sensation in his hands, which he described as a sense of fourth group of theories maintains that the conversion fullness and constriction of the fingers. There was no of altered blood pigment arising from increased destruc actual pain, nor had there been at any time any distion of red corpuscles goes on in the circulation without coloration, swelling, or edema of the surface. The sen. the intervention of the liver, and the last holds that it sation was worse in the right hand, where it had been is effected either in the dilated cutaneous capillaries or present for three years, in the left hand it had only after extravasation of blood into the tissues. The last been noted for about a year. Prior to coming under ob three groups all presuppose increased destruction of red servation there had been no change in his general corpuscles, and with a view to elucidate this question health, which was excellent. He is 24 years of age, and Knoepfelmacher has investigated the blood of infants when a youth was employed in a bookbindery establishduring the first seven days of life in three directions-ment; later he learned the trade of fireman, but within the number of red corpuscles, their resistance to sodium chloride solutions, and their histological characters. The research was carried out upon 12 childreu, all of whom developed a greater or less degree of jaundice. The cord was tied as soon as it ceased to pulsate, the first estimation was made as soon after birth as possible, and the succeeding ones at the same time on the follow ing days. The resistance was measured by the strength of sodium chloride solution required to break up the red corpuscles within a given time. The author finds that the number of red corpuscles either falls steadily from birth, or else rises a little immediately after birth, and then falls again; these changes are, as regards the cor puscles, only apparent, being really due to alterations in the volume of the plasma. They also bear absolutely no relation to the development or disappearance of jaundice. The resisting power of the red corpuscles is found to be the same at birth as in adult life, nor is it increased in icterus neonatorum, although von Limbeck has shown it to be much above the normal in the jaundice of adults. The most intense jaundice during the first week of life does not affect the resisting power. Histologi- quence his thoughts are not so much fixed on the condi cally Knoepfelmacher was able to detect considerable variation in the size of the erythrocytes, some of which were pale throughout, and others pale in the center; deformed and "shadow" corpuscles were absent. There was hence evidence of rapid production of red corpuscles without any indication of increased destruction. The author hence concludes that the red corpuscles play no part in the etiology of icterus neonatorum. A Case of Paresthesia.-Harold N. Moyer, M.D. (Medicine.) Paresthesia or preverted sensations are frequent accompaniments of many forms of nervous disease, both organic and functional. Thus we have peculiar sensatious in the lower extremities as one of the earliest symptoms in some cases of tabes, while the past few years has been at work as a farm laborer. He is strong and robust, of an excellent color, his appetite is good, and he is able to do hard manual labor. With the exception that his sleep is somewhat broken by the distress which he experiences in his hands, he does not think that his general health has been affected in any degree by this trouble. The sensation as he describes it never amounts to pain, although he says it is very distressing and is associated with a heavy feeling. At times the fingers feel as if they were enormously in. creased in size, and when he looks at them he is surprised to find that they are small as usual. At times the sensation is much worse than at others. So far as he is aware he has always been free from it in the summer time. He says it leaves him in May and returns again late in September, augmenting as the weather becomes colder. The condition is not aggravated by exposure to cold, as when he is out of doors he is freer from it than at any other time in the twenty-four hours, although at no time is it wholly absent. This he attributes to the fact that his attention is attracted by his work, and in conse tion of his hands. The symptom is always worse at night, and he says he is almost invariably awakened by it and that it is only relieved by rapid movements of the arm-if it is severe, he has to sit up in bed and swing the arm He is satisfied that the condition is gradually growing worse, and now that it has invaded the left arm in addition to the right he has become seriously alarmed about it. He says he never sustained any serious injury or acci. dent, nor has he had an illness. Examination shows him to be entirely healthy in every respect. His heart and lungs functionate normally, and the urine is normal. He does not present the slightest trace of neurasthenia. There is no tremor of tongue or eyelids, and no undue sense of fatigue upon exertion. He says he is able to work all day in the fields at hard manuel labor without In three cases of intestinal perforation the temperature experiencing any especial fatigue. None of the stig fell below 35° C. It would be a mistake to suppose mata of hysteria are present, his fields of vision being that all such falls in temperature indicate perforation. normal and there being no areas of anesthesia. His In many cases the defervescence is as sudden as in station is good and the knee jerks are present. Exami- pneumonia, or, again, such falls follow copious hemor nation of his hands shows that they are roughened and rhages. In the latter case, however, the temperature calloused by toil, but there are no abnormal changes in rises again rapidly, while in perforation it remains low the skin or nails. There is no suggestion or peripheral or rises very gradually. Perforation peritonitis lasts neuritis. Sensation is absolutely intact Tactile sen- from three days to a week, during which time deceptive sation is fully equal to that of anyone whose epidermis remissions may occur. The end is almost invariably is as much thickened as this man's. Slight differences fatal. In rare cases protective adhesions form, and re of temperature are easily appreciated. He can pick up a pin readily and distinguish between objects which are held in his hand with his eyes closed. The rate of conduction seems to be about normal, and the pain sense is unimpaired. covery ensues. In the peritonitis due to the propaga tion of the infectious process through the ulcerated but not perforated intestine there is a lesion of the vermi form appendix, which may ulcerate and be perforated at the level of its abudant lymphoid tissue. The symp. toms are the same as those of other typhoid perfora tions. "Paratyphoid preitonitis" is due to the remnant of a typhoid leslon of the appendix, and is characterized by a rise of temperature. Surgical treatment of this We report the above case not with the hope of offering an explanation nor of giving a diagnosis. It is sim ply one of those peculiar disturbances of sensation which may have their origin in the psychical sphere or possibly may be associated with some obscure changes condition should be the same as in ordinary appedicitis. of the cutaneous nerves. It may be a precursor of serious organic disease, which will show itself after years have passed. Note on Two Cases of Infectious and Toxic Purpura in Children.-Claude. (Rev. Mens. des Mal. de l'Enfance; Archiv. of Pediatrics). The first case was that of a boy thirteen months old, who developed measles during a second attack of broncho pneu. monia. When the eruption was disappearing the purpura came on, characterized by an aggravation of the general condition, petechiæ, and nodosities with a ne crotic center. Virulent pneumococci were found in these dermic lesions, as well as in the lungs. The case illustrates the infectious form of purpura, and proved fatal. The toxic form is illustrated by the second case: A boy of 14, after eating of tainted meat, had an attack of vomiting and diarrhea, accompanied by great prosta tion and a general purpuric eruption, without necrosis. Bacteriological examinations gave negative results, and recovery was complete, there being several crops of the purpuric eruption during convalescence. The problem of when to operate in a perforative peritonitis is a much more serious one, owing to the diffi culty of determining that perforation has taken place, the necessity of speedy and opportune intervention, and the fact that there may be several coincident perforations. Operation, however, holds out some hope of success, and in spite of the ulceration suture may bring about healing. Diabetes and Cirrhosis of the Liver.-Pusinelli (Berl. klin. Woch.; Brit. Med. Jour.) records the case of a man, aged 48, who in 1887 had a slight attack of jaundice, and in the following year 1 to 2 per cent of sugar was present in the urine. The sugar subsequently disappeared, but was present again after 1892. In 1893 there was much ascites with edema of the legs. Both the liver and spleen were enlarged. Ten litres of fluid were drawn off, and subsequently the tapping was twice repeated. The puncture then remained open, and after its spontaneous closure there was no further accumulation of fluid. No unevenness of the surface of the liver was ever made out. The amount of finids taken by the mouth was at first greater than that eliminated; but eight weeks after the tapping the order was reversed, and the ascites and edema disappeared. The patient improved so much that he was able to resume his business; the jaundice also disappeared, and the liver became less in size. Later albuminuria supervened, and Peritonitis in Typhoid Fever, Dieulafoy now and then edema of the legs. The sugar disap(Sem. Med.; Brit. Med. Jour.) discusses the varieties of peared from the urine while the ascites was present, peritonitis in typhoid fever in relation to operative in coming back again as soon as the ascites was gone. terference. Peritonitis due to perforation usually super This fact is difficult of explanation. As regards the venes at the period of stasis or during recurrence of treatment, perhaps the last tapping with a large trocar typhoid fever, and any part of the intestine involved in and the escape of fluid for several days afterwards may the typhoid process may be its seat. It is met with in have been of some importance, but this alone hardly mild as well as in severe cases, and the diagnosis would amounted for the great improvement. Perhaps the large be a matter of great difficulty but for a constant and doses of cream of tartar taken produced this beneficial often solitary sign, namely, sudden fall of temperature. result. This remedy has been recommended by Sasaki The cases prove that purpura is not uniform in its manifestations, and that it is not due to any specific micro-organism, but may be caused by microbial toxines as well as by mineral or organic poisons. in daily doses of 8 to 40 g.; if the patient's general con dition is unsatisfactory, iron, quinine, etc. are given in addition. The author discusses the relation of the liver affection to the diabetes. The cirrhosis was certainly first in point of time, jaundice appearing a year before the glycosuria. As regards the form of the cirrhosis, syphilis, alcohol, and gall stones could with certainty be excluded. The course of the case differed in many respects both from Laennec's atrophic and Hanot's hypertrophic cirrhosis. Perhaps it is a special form of cirrhosis associated with diabetes; the liver and spleen are enlarged, there is periodical jaundice and considerable ascites, the course is prolonged with a tendency to recover, and there are no gastro-intestinal symptoms. The author, among other conclusions, points out that attention should be given to the liver in diabetes and to the presence of glycosuria in cirrhosis. After two years and a half of fairly good health the patient died. There was an evenly distributed cirrhosis of the liver with some shrinking. The pancreas was atrophied to half its Our Daily Bread.-Many points of interest to the sanitarian are to be noted in connection with this topic. In the first place, flour may be quite unfit for use through the presence of fungus growths affecting the seed. Ergot, the well-known disease of rye, is capa. ble of producing a peculiar chronic gangrene, and epidemics of such a disease have been produced by the use of flour made from rye affected by this fungus. Other cereals are liable to similar diseases. Minute amounts of copper are not unfrequently found in wheat flour, but there is little cause for alarm on this point, since it seems that copper is not distinctly a cumulative poison. K. B. Lehman, of Wurzburg, has recently published elaborate observations on the sanitary relations of cop. per, the details of which we will discuss further in a later issue. He has, among other points, made analysis of the tissues of wild plants growing in soil known to contain copper compounds. He found small amounts of copper in many plants. He also found the metal in minute amount in the viscera of some animals that had been raised in the district. We hear, also, from time to time of the use of alum in flour and of its possible harmfulness, but the danger from this source has doubtless been overrated. The question will be further discussed in connection with use of alum baking powders. yeast. The general manner of action of yeast is pretty well understood, it acts by fermenting the starchy matters so that alcohol and carbon dioxid (commonly but erroneously called carbonic acid) is produced. The alcohol is formed in but small amount, yet a proposi tion was once made to recover it from the bread, since it is nearly all expelled in the baking. The enterprise was not a commercial success, and it is said that a certain baker sought to secure attention to his own products in competition with the company's bread by advertising "bread with gin it." The baking of the bread expands the gas during the fermentation and thus the necessary lightness or porosity is obtained. Ordinary yeast is a miscellaneous mixture of fungi. There are many species of yeast-fungi proper, and with them are usually associated many species of bacteria. Each species has its own fermentations; hence the total result varies with the composition of the yeast. In brewing it is of so much importance to control the fermentation exactly that pure cultures of yeast, prepared with considerable care, are now used, but in bread. making no such exactness has been developed. It is found, therefore, that there is some variation in the flavor and quality of bread, and this depends in part on the nature of the yeast. It is obvious that an article of so mixed a nature as yeast must introduce a variety of microbes into the bread. It is generally supposed that all danger from this is avoided by the baking, which is assumed to sterilize the bread. Experiment shows, however, this is not always the case. Some investigations made in England not long ago proved that the interior portions of well baked loaves contained living microbes. It is, indeed, now well-known that several species of bacteria have high resisting power to heat, withstanding even the action of water boiling at ordinary pressure for several minutes. Spores, especially have high resistance. Fortunately most of these obstinate bacteria are not distinctly disease-producing. It follows, therefore, that the process of baking bread can not be implicity relied upon to render bread sterile. We may dismiss the question of adventitious fungi in the yeast as being rather technical in interest, the danger of introducing disease-producing microbes being slight, but we can not dismiss the consideration of the danger from infection by the unsanitary conditions and surroundings of bake-shops. Attention has already been called to this topic in several cities. It is a matter of common observation that the sights in the interior of bake shops are not always appetizing, particularly during busy hours. The "sweat of the brow" is not infrequently directly incorporated into the bread. Basement bake-shops are very common and vermin must be abundant in them. It has been shown in certain trade agitations that journeymen bakers have hard work and not good pay and such conditions tend to degrade the sanitary character of workmen. Unwholesomeness in bread seems to be more likely to arise in connection with the methods of making it than with the accidental or intentional adulteration of the raw materials. Articles of this class are required to be "light" in order to be palatable, this lightness be Bread making should be carried on by machinery in ing simply an inflation of the dough by gas. From a large establishmenis. By this means all contact with remote period, mankind has obtained this by the use of human hands may be avoided. Light and ventilation mum. can be secured, and vermin may be reduced to a mini- branch of the fifth nerve is affected; if the painful area The rising of the dough can be brought about receives filaments from the branches near their exit by the introduction of a pure carbon dioxid, or if this from the head; if the pain is not the expression of a be deemed unsatisfactory, pure yeast culture may be constitutional disorder; if a cause central to the gan. employed. Such establishments are largely subject to glion does not exist; if other measures have failed to sanitary control without involving the inquisitorial fea give relief. The intracranial operation which should be ture that attaches to visits to private shops. done is removal of the lower two thirds of the Gasserian ganglion, together with the second and third branches as far as their foramina of exit from the skull, all in one piece, so as to be certain of the amount of tissue taken away. It will not be inopportune to discuss briefly the mat ter of baking powder. Much has been said on this topic, but very little is scientific. It is generally known that three classes of substances may be employed for the "acid" portion of baking powder, viz., cream of tartar, alum and phosphates. Alum has been an object Operation for Movable Kidney, Followed of criticism for years, but it does not seem that any. by Gangrene of the Stomach.-J. W. Irwin, thing definite has been deduced from the experiments. M.D. (Medicine.) A young lady 26 years of age, from As used in baking powder it is completely decomposed an interior town, consulted me two years ago. I in the act of mixing it with the moist dough so that no found upon examination that she had a movable kidney. inference drawn from its physiologic effects as alum can Her general health was much impaired, and she suffered be applied to its use in baking powder. To our mind a great deal of pain, mostly in paroxysms. She desired there is little choice between the three forms of baking to know if the trouble could be cured, or whether a surpowder. All are inferior to the direct inflation of the gical operation would restore her to to health. Her con dough by pure carbon dioxid, and it will be a great addition at the time was such that I was very much invance in bread and cake-baking when such a method clined to believe an operation would prove disastrous, becomes universally employed.-Diet. and Hygienic and advised against such a procedure. Gazette. SURGERY. The case was placed under medical treatment, consisting of a regulation of diet, rest, etc., and for two years her health improved, though the kidney at times troubled her; it seemed to be pushed forward under the margin of the liver. She had had several attacks of gastritis, possibly acute; I had not seen her in any of these, but the history pointed in that direction. I did, however, see her in one or two mild attacks during the two years she was under treatment. Operative Treatment of Facial Neuralgia.-Tiffany (Annals of Surgery; Brit. Med. Jour.) publishes an analysis of 108 cases of facial neuralgia treated by intracranial operation. Of these nearly two A few months ago she called at my office to inform thirds were subjected to the Hartley-Krause method, me that she had made up her mind to have an operaand nearly one-fourth to that of Rose. Of these cases tion; that she was not well and was tired of the pain in 24 were fatal, including one in which the patient died her side. As she contemplated marriage in case of ultithree months after the operation from cerebral abscess mate recovery, she had consulted several physicians in Shock and sepsis, it is shown, are the chief causes of regard to her condition-one in Cincinnati who was not death. The author, in discussing the result of surgical able to make a diagnosis, but suggested that the facts treatment in the cases of recovery, asserts that intra- could be ascertained by means of an exploratory inciscranial excision of branches of the fifth nerve relieves ion. The surgeons told her that if the condition hap pain, certainly for a time, and perhaps permanently; but pened to be a movable kidney it might be stitched in pain may recur, possibly in the territory subject to the position and ultimate cure effected. Her mind was so excised branch, possibly in other branches. Recurrence impressed with the importance of having an operation of pain after known removal of the ganglion of Gasser to restore health and relieve pain, that she would listen is not recorded. The expediency of removing the to no argument or suggestion which did not point in whole of the ganglion is questioned. The first branch, it is stated, is never affected alone, and trouble of one kind or another in the eyeball has been often met with after removal of the first division of the fifth nerve. It is well, in the author's opinion, not to take away the to make an exploratory incision and if need be to fix the upper portion of the ganglion and the first branch, but rather to remove the second and third branches with the corresponding portion of the ganglion. The fol lowing suggestions are made with the object of assisting the surgeon in his decision with regard to the necessity previous two years. of a central operation in a case of facial neuralgia. An The operation was done by Dr. Wathen, assisted by intracranial operation is indicated if more than one Dr. W. C. Dugan, and at the patient's request I was that direction. I called Dr. W. H. Wathen to see the case in consul. tation, and he agreed with me that the lady had a movable kidney, and in defere ace to her wishes he consented kidney in place. A few days subsequently she entered the infirmary and was prepared for the operation. Her health was fairly good; the condition of her system appeared to be much better than at any time during the present. For two or three weeks after operation the ted omentum was resected where necessary, and sutured wound progressed favorably, and was about healed with silk sutures, as these when left in the peritoneal when one morning I was called and found her vomiting cavity do not give rise to the remote ill effects of a green flaky mucus and suffering great pain in the sutures buried in the abdominal walls. Ligature of vesregion of the stomach. The vomited matter was ejected sels was never necessary. The pillars were approximawith a great deal of force. Her sufferings were int nse, ted by means of silver wire sutures comprising as large and she was much prostrated and nervous. Upon ex- a quantity of the soft parts as possible. The cicatrix amination I gave it as my opinion that she had gastritis, was in every case firm. No post-operative complications this time possibly due to sympathetic disturbance be- had resulted in the majority of the cases which were tween the kidney and stomach. I called the attention seen at varying intervals from six weeks to six months of the friends and physician to the fact that the case afterward. was a serious one, and that subsequently gangrenous patches would result in the stomach and that she would Influence of Ligatures, etc. upon Sublivomit blood and portions of the membrane of the stom-mate Solutions.-Von Zeignek (Wien. klin. Woch.; ach; all of which were verified by an expert examination Brit Med. Jour) reports that a solution of corrosive of the contents of the stomach. This showed that the prognosis in the case was correct, and the trouble pro gressed from bad to worse, for upwards of two weeks, when she died. sublimate containing a reserve stock of rubber drainage tubes was sent to him for investigation, and that he could not detect a trace of mercury in the fluid. This led him to experiment upon the changes induced by I report the case mainly because upon five previous india-rubber and silk when immersed in solutions of the Occasions I had seen similar inflammatory conditions of perchloride. Two solutions were made-A and B A the stomach result in death, and upon two occasions an contained 0.227 per cent, B 0.284 per cent Hg. Cl,. autopsy revealed sarcoma of the kidney. What connection existed between the condition of the kindey and the stomach appeared to be mostly of a sympathetic nature, and the gravity of the disease seemed to be out of all proportion to what we usually see occurring with out local irritant such as mineral poison. This, in my opinion, then, was a case of gastritis induced by the dis turbed condition of the nervous system, caused or aggravated in the fixation of the kidney, and resulting in gangrenous patches and death. Radical Cure of Hernia.-Duplay and Cazin (Sem. Med.; Brit. Med. Jour.) describe an operation for the radical cure of hernia, in which buried sutures in the parietal tissues are done away with. Twenty pa tients were operated on, and all recovered without complications of any kind. Ligature of the hernial sac was abandoned, and the following method was pursued: The sac was completely dissected out, the peritoneal layer alone being taken. This was pulled out until parts normally 2 or 3 cm. above the inguinal canal were exposed. The sac was then tied in a knot as near its base as possible. Several knots were tied where length permitted, and the remainder of the sac split in two, and the strips tied together. Lastly, to ensure absolute firmness a hole was made in one strip, and the other strip passed through it, and this was repeated as often as possible in both strips. When the sac was short one knot was tied, and the ends split and tied together once or twice. The tying was easily done by means of forceps. When the sac was released it disappeared into the abdominal cavity, and, in all the cases operated on, could be felt 3 or 4 cm. above the internal ring. In two cases of old standing hernia with thickened sac the entire sac was split at once, and the ends tied together; in one case the sac was split into four, and the ends tied two and two. The results were equally good. Hernia They were placed in similar bottles side by side, and Laparotomy for Intestinal Perforation in Typhoid Fever. - The Gazette hebdomadaire de medecine et de chirurgie for November 26 publishes an account of a recent meeting of the Societe de chirurgie at which M. Monod stated that he had been called to see a man who showed very grave symptoms during the course of typhoid fever which pointed to intestinal perforation. As the general condition of the patient was satisfactory, M. Monod performed laparotomy. The abdomen was filled with serosity, pus, and fecal matter. There was a perforation of the small intestine near the cecum, which was sutured. On the following day there was very little improvement and the patient died in a few hours. At the autopsy it was seen that the sutures of the intestine had remained in place, but that there had been a generalized adhesive peritonitis. In the researches undertaken by M. Monod in regard |