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In other cases the incised duct is sutured with catgut and the gall bladder drained. Drainage is life-saving and very imperative in cases accompanied by much inflammation. The author further adds that when streptococci are found in the bile either in the gall bladder or ducts an unfavorable prognosis should be made. The author reports 76 chol. edochotomies with three deaths. The first from pyemia, the second from septicemia and the third from cholemia. The latter case as well as the second the author states if drainage was rigidly established the results might have been better.
New Technic for Breast Amputation.In Jour. A. M.A. Jabez Jackson describes the quadrilateral flap operation originated by himself in amputation of the breast. The skin incision is begun at a point about one and one-half inches below the middle of the clavicle, in the sulcus between the deltoid and pectoralis major. The incision is carried down along the outer border of the pectoralis major, and then follows the lower fold of the mamma. It then forms an ellipse encircling the nipple with a radius of about two inches. The long diameter of the ellipse is parallel with the first incision. The whole figure is likened to a dipper the first incision forming the handle and the ellipse the cup portion. C. H. Mayo modifies this operation, making the ellipse more obliquely. The advantages of this operation are manifestly evident. The flap covers without tension the chest defect and skin grafting is not needed. The drawing of the skin up the arm does away with axillary fossa and with the space necessary for nature to fill in with granulations and scar tissue. The operation after the skin flap is made does not differ materially with the radical Halsted. All vessels are ligated close to their origin, and both pectorals are removed. Mayo preserves the clavicular portion of the pectoral muscle. The scar formed by this operation is small, and healing is rapid. The author aptly illustrates by photographic pictures of cases operated on thereby, showing the marked cosmetic advantage of this operation over previous technics.
Acute Postoperative Dilatation of the Stomach, with Report of Case Following Nephropexy.--Halsted in Jour. of Surgery, Gynecology and Obstetrics, reports case of postoperative dilatation of the stomach. The patient, age 18, complained of right-sided abdominal pain. On examination movable kidney was found. Nephropexy under morphine-ether anesthesia was performed. Patient vomited, complained of great abdominal pain after the operation. Temperature and pulse rose and vomiting green fluid
continued up to the sixth day with abdominal distension. Patient died on sixth day after operation. Post-mortem showed enormously dilated stomach and duodenum. The dilatation terminated sharply at a point where the descending limb of the duodenum dipped underneath the peritoneum. The stomach contained about three pints of greenish fluid. The above diagnosis might have been confused with acute obstruction due to volvulus or intestinal paresis.
OBSTETRICS AND GYNECOLOGY
W. H. VOGT, M. D.
(Abstracts contributed by Dr. E. S. McKee, Cincinnati.)
Obstetrics in the Philippines.-Bell (Med. Record) says that the idea that semi-civilized women escape many of the pangs of childbirth is entirely erroneous in regard to the Philippinos. The Filipino woman lives a short life, owing to her many pregnancies and hard manual labor, insufficient food and most of all the crude, brutal and ignorant practices employed as obstetrical aids. The two chief aids used to assist expulsion of the child are: first, a stout band of cloth passed round the woman's abdomen and pulled tight by four persons, who are seated two on each side of the patient, with their feet against the body. Second, a plank six or eight feet long bý a foot wide, which is placed across the woman's abdomen while another person mounted on the plank raises on his toes and descends on his heels forcibly. The birth of the child is followed by the expulsion of the placenta after the above means, and should the process be delayed, forcible traction upon the umbilical cord is made with such energy as to tear away portions of the placenta, and often large sections of this body are left to find their way from the uterine cavity of their own accord. Weeks and even months later the results of such practices are noticed in the septic conditions which should naturally follow retention of the membranes.
Pregnancy Plus Appendicitis.-Fueth (Archiv. fuer Gynecologie) finds appendicitis a serious complication of pregnancy, especially from its tendency to recurrence. Recurrence was noted in 21 per cent of his cases. Monod and others advise the removal of the appendix, as a rule, even when there are no symptoms, at the third or fourth month of pregnancy, if the patient has ever had appendicitis. In a case of incipient appendicitis in a pregnant woman he thinks operation offers the only chance for cure. He found the difference in the temperature in the rectum and axilla, higher in rectum, to be an
important aid in the diagnois. The anatomic condition of pregnancy favor the opening of the abscess in Douglas' pouch. The abscess can be opened through the rectum if there is too much danger of interrupting pregnancy.
Unusual Complication of Labor.-Clark (Cleveland Medical Journal) reports a patient in whom the lower part of the vagina was entirley separated from the upper with a transverse membrane. The anterior attachment of the membrane was one and a half and the posterior two and a half inches from the vulva. Pressure against the membrane showed it to be firm except at one side, the left, which yielded slightly. The color of the membrane was the same as that of the va
ginal mucosa. Its thickness was about that of ordinary blotting paper. The second case was one of congenital displacement of the urinary bladder. The cavity of the pelvis was well filled with what appeared to be a cystic tumor attached to the pelvic wall. The tumor disappeared on catheterizing. The catheter had to be passed upward, inward and to the left and then downward before the urine could escape.
Value of Ergot in Obstetrics.-Davis (Therapeutic Gazette) says that he is accustomed to use ergot in some form in the great majority of cases of obstetrics. The only contraindications to its use are excessive hemorrhage with depleted condition of the vessels and a feeble heart. Strychnia is given with the ergot because it rouses the ganglia of the uterus and stimulates the patient's nervous system. He never gives more than two drachms of ergot at one time. He has never witnessed any untoward results from the use of ergot. Hirst has used ergot as a routine course of practice in all cases of labor as soon as the child is born. A very irritable stomach and persistent vomiting are contraindications to its use, but even in these cases after the labor is over, Hirst has succeeded in having the ergot retained. If it has been necessary to anesthetize the patient he gives a deep hypodermic injection in the thigh as soon as the uterus is evacuated. In case of twins he gives a dose of ergot as soon as the first child is born if there is no obstruction to the birth of the second. Cameron uses ergot in all cases of labor after the uterus is emptied, unless contraindicated. He has not seen any untoward effects or accidents from it.
Uterine Colic is shown by Theilhaber (Zentralblatt fuer Gynekologie) not to be the result of the passage of blood clots, for it is most severe from twelve to twenty-four hours after the flow appears. Fritsch has suggested that premenstrual engorgement of the
endometrium and the blood acting as a foreign body in the uterus may act as causative factors.
Intermenstrual Pain, Rosner (La Gynecologie) concludes is really a pelvio neuralgia, without apparent lesions, occurring usually in arthritic subjects and resulting from some abnormal action of the ovaries. Ovarian or pelvic neuralgia, at one time held in derision, has now gained recognition.
Periodical Variation in the Menstrual Blood Pressure according to the observations of Van de Velde (Zentralblatt fuer Gynekologie) are due to some chemical irritation proceeding from the ovaries. He shows the uterus, is distinctly enlarged at the time when intermenstrual pain is marked. It was formerly held, and some still claim, that this latter symptom is always associated with a cystic ovary, operation being consequently indicated.
Female Sterility.-Is the treatment of sterility in the female justifiable without examining the sperm of the husband? Pincus (Monatsschrift fuer Geb. u. Gyn.) cautions against the tendency among gynecologists to ascribe the fault too readily to the woman. In every case he believes the husband should be questioned as to his power to have intercourse and a careful examination of his sperm made. Pincus reports 58 cases of absence of spermatozoa in 483 cases of sterility. Further he found 37 instances of persistent oligospermia and 13 of necrospermia. Examinations should be made several times, and at rather long intervals. Temporary azoospermia occurs after repeated intercourse hence examinations should be made.
Placenta Previa.-Warren (Lancet) reports a series of 94 cases in which six mothers died or 6.3%, while of 93 infants 49 died or 52%. As regards parity in the 76 cases in which this was mentioned 12 were primipara, while 36 had had five or more labors previously. None of the primipara died, which is a matter of interest since King in his series found the mortality of primipara to be 30%, the general mortality of his series being 22%. Twin labors occurred twice in the series, of which three infants and one mother died. Recurrences in one case is noted in the three preceding labors. Hyrdramnios was reported in four cases, two of these being of the ten cases seen personally. Prolapse of the cord occurred in three cases out of the 54 in which the de Ribes bag was not used, and in 4 cases out of the 40 in which it was used. Post partum flooding was noted in 14 cases, in four of which the placenta was adherent. Adherence of the placenta was found in two other
cases without post partum hemorrhage. There seems to be a peculiar tendency for placenta with a low attachment to become adherent. In two cases of adherent placenta there was atony of the uterus; both died. One case of puerperal melancholia was recorded. In one group of 27 cases only such minor steps as rupturing the membranes or giving ergot was taken. There was no case of complete placenta previa in the group. In six other cases bipolar version was the treatment adopted. Twenty-one cases were treated by internal version or manual delivery in the case of pelvic presentations. Of the 21 mothers 5 died; of the 22 children 14 died. Forty patients were treated by the insertion of the de Ribes bag. None of the mothers died; 25 of the infants succumbed.
Medical Treatment of the Uterine Fibroids is the title of a paper by Thomas Wilson; of Birmingham, Eng., in the Lancet. He shows that these tumors have not wholly been given over to the knife. "Uterine fibroids are extremely common, but only in small proportion give rise to symptoms, in 30 per cent of those that do the consequences are so serious as to demand operative treatment. Of the 70 per cent some with no active symptoms merely require watching, while others call in addition for medical treatment, under which heading may be included minor surgical and other local means. Medical treatment may be direct or symptomatic. The direct or absorptive treatment does not promise much advantage, especially if we bear in mind the many sources of fallacy that interfere with the correct appreciation of the results of treatment. Symptomatic treatment is successful in many cases in tiding the patient over a crisis and obviating the necessity for operation. Bleeding is most often successfully treated by rest, ergot and the intrauterine application of iodine. Pain requires treatment adapted to its cause; alcohol and morphine should be only administered in temporary and exceptional circumstances. The general condition of the patient, and especially the state of general nutrition and the cardiac and renal functions should be carefully watched. And, finally, operation should be recommended when bleeding gives rise to anemia and does not yield to ordinary treatment; when pain is severe and obstinate; when pressure symptoms, especially retention of the urine occur; when the tumor is rapidly increasing in size; and generally when there is evidence that the health of the patient is becoming impaired, and such impairment appears to be referable to the uterine fibroid.' Surely a very conservative consideration of the subject.
PATHOLOGY AND BACTERIOLOGY.
R. B. H. GRADWOHL, M. D.
Pathologic Histology of Hereditary Syphilis, With Especial Reference to the Spirochaeta Pallida.-(C. Levadati, Annales de l'Institut Pasteur, Tome XX, No. 1, January, 1906.)-The presence of the spirochaeta pallida in the organs of newly-born children afflicted with hereditary syphilis was determined shortly after the first publication by Schaudinn and Hoffman by several observers, Buscke and Fischer, and Levadati; this was subsequently confirmed by Hoffman, Babes and Panea, Bodin, Nigris, Bronnum, etc. Staining according to Giemsa's method showed constantly the existence of spirochaetae pallida in cutaneous and visceral lesions of hereditary syphilis. Herxheimer and Huebner were the first to stain with Nile blue the sections of syphilitic chancre showing the spirochaeta. The small number of parasites demonstrable by this method in relation to the severity of the lesion indicated a flaw in the technical worth of this procedure. Later, Bertarelli, Volpino and Bovero (Rivista d'igiene, 1905, No. 16, p. 564) proposed a method of staining based upon the impregnation of spirochaeta in silver nitrate, with the use of Van Ermengen's fluid as a reducing agent. They claimed that this enabled one to stain the organism in tissue satisfactorily. The writer tried this method and found that it was not uniformly successful; thus prolonged immersion of sections in a solution of silver nitrate, from 0.05 to 38% in strength left the organisms very pale. There was also a precipitation of the silver in the sections which made it quite objectionable. The writer changed the method somewhat by fixation in formol and impregnation of the whole piece of tissue in silver, much after the method of Ramon y Cajal in staining nerve fibrillae. With this method a study of lesions of man and monkeys afflicted with syphilis was made and published in C. R. de la Societe de Biologie, vol. LIX, No. 34, p. 527. The present work is a study of the lesions of four cases of hereditary syphilis. Method: I. Pieces of tissue, Imm thick, were fixed in formol, 10%, for 24 hours. 2. Washing and hardening in alcohol, 96%, 24 hours. 3. Washing in distilled water several minutes until pieces fall to bottom of glass. 4. Impregnation in silver nitrate solution, concentration varying from 1.5 to 3%; 3% solution is preferable for pieces of tissue obtained from living cases. The impregnation should take place at a temperature' of 38 C., for 3 to 5 days. 5. Short washing in distilled water and immersion at room temperature for 24-48 hours in following solution:
100 C C.
Distilled water..... 6. Washing distilled water, dehydrate in alcohol; xylol, paraffin, section (5 microns maximum). 7. Stain as follows: Geimsa's solution for several minutes, wash in water, differentiation in alcohol with few drops of essence of girofle, clear in oil of bergamot and xylol, mount in Canada balsam. Staining as follows can also be accomplished: concentrated solution of toluoidin blue, differentiation in alcohol with few drops of ether-glycerin mixture (Unna), clearing with oil of bergamot and xylol.mounting in Canada balsam (method of Manouelian). With this method, the spirochaeta appears dark, with the nuclei of the epithelial cells and leucocytes blue, while the connective tissue is yellow, Four cases of infants dying shortly after birth and showing visible signs of hereditary syphilis were studied, skin, viscera, etc., examined. A number of definite conclusions were forthcoming as a result of this investigation: I. The spirochaeta pallida is found in those parts of the body in cases of hereditary syphilis in which the lesions themselves predominate, viz., the liver, lung, supra-renal capsule and skin. They are most abundantly found in the liver where there are lesions of diffuse interstitial hepatitis (hepar silex) and in lungs afflicted with pneumonia, in hypertrophic supra-renal capsules, and in the cutaneous lesions of syphilitic pemphigus. The absence of the organism from organs not commonly affected by hereditary syphilis, viz., the brain and kidney for example, together with the presence of these self-same organisms in still-born infants as well as those dying after the first few inspirations exclude the possibility of the interpretation of the bodies as agents of secondary infection. 2. The finding of the parasites in the internal viscera of cases of tardy hereditary syphilis entitles the writer to speak of the possibility of a heredo-syphilis which is exclusively splanchnic. This is a form quite different from that showing external cutaneous lesions. 3. The predominance in these findings of the parasites in the liver indicates in some measure the route by which the parasite enters the fetal body from the maternal placenta, i. e., the liver is the first organ to receive blood from the mother, by way of the placental villosities. The hepatic organ being thus the first to receive the incoming blood laden with parasites, it is but natural that it should show the heaviest signs of attack by invading parasites. This is shown by the numerous parasites in the liver sections and by the presence of parasites in the hepatic blood vessels themselves. 4. The marked
absence of the parasites from the blood vessels themselves in most situations would seem to indicate that the circulating blood is not a favored site for the development of these spirochaeta. They seem to rapidly leave the blood vessels and fix themselves in the adjacent tissues. This differs from most spirilloses of man and other animals, e. g., recurrent fever, spiriliosis of chickens of Marchoux and Salimbeni. The spirochaeta seems to have the faculty of penetrating certain histological parts by preference, notably the hepatic and renal cells, the cells of the supra-renal capsule and even the cells of the sudorific glands. 5. As to the pathogenesis of the lesions of syphilis in connection with the mere presence of the parasites, it can be said that these lesions are caused by the spirochaeta pallida. 6. As to the explanation of the macerated state of a hereditary syphilitic-afflicted fetus, we can say that this state of maceration is an autolytic act, due to fermentation in tissues killed by an intense intra uterine spirillary disease. 7. A last point to be considered is the manner in which the fetal organism defends itself against the morbigenic action of the spirochaeta pallida. We have only the observation of an intense phagocytosis in the liver adjacent to the spirillary onslaught, also the rarity of the finding of the parasite in the spleen as contrasted with its relatively frequent appearance in an adjacent organ (the liver). It has already been established that there is an intense phagocytosis accompanying the disappearance of the parasites of recurrent fever and of spirillosis of hens respectively (Metchnikoff, Cantacuzene, Levaditi). 8. Regarding the infectivity of the various excretions and secretions from syphilitic disease, we have but little to offer that is new. The presence of the spirochaeta pallida in the protoplasm of the renal epithelial cells in the bronchial tree suggests the danger of syphilitic contagion from products of expectoration and perhaps the urine (Lavadati and Salmon). On the other hand the conservation of the tinctorial and morphological characteristics of the spirochaeta not only in the dermic papilla, but also in the contents of the vesicles of syphilitic pemphigus proves the possibility of contagion from that source.
W. T. HIRSCHI, M.D.
The Internal Treatment of Appendicitis.Mooslrugger (Muench. Med. Wochen., No.37, 1905) has used argentum colloidale Credé internally and inunctions of ung. Credé exter
nally in cases of appendicitis with good results. In mild cases of several days duration with slight pain, slightly irregular stools and absence of tympanites bed rest, warm applications or poultices and internal administration of argentum colloidale 0.5 per cent, aqueous solutions of which one-half to one tablespoonful are taken every hour. More serious cases with symptoms of nausea, vomiting, chills and high fever, and severe constitutional disturbances receive 10 grams of a I per cent solution argentum colloidale every hour, and in addition ung. colloidale is used. Remedies to relieve the meteorismus, or to make the bowels move often dogreat harm, and if indicated must be used guardedly. The same is true of the used of opiates. Improve ment with this method is usually observed on the second day. The writer has used his method in 75 cases of appendicitis with but two fatal results, and believes that an early diagnosis and a systematic use of collargol will often save the patient from surgical treat
The Effect of Various Substances on Artificial Gastric Digestion.-(J. Tijitain, Arch. internat. de pharm. et de therapie.)-The salts of inorganic bases, excepting the acetates, retard gastric digestion. This is due to the nature of the acids and not of the bases. Weak solutions of boracic acid have little effect, but a 2 to 4 per cent solution retard digestion entirely. The sulphates have the most depressing effect, the chlorides have the least. The salts of organic acids act like the borates. The salicylates are decidedly depressing. The effect of alkaloidal salts depends on the alkaloid and the acid. Quinine and cocaine retard and morphine increases digestion. Among acids, sulphuric acid retards digestion decidedly. Alcohols retards digestion if used in excess of 10 per cent strength, and therefore the depressing effect of alcoholic beverages is usually due to some other factor. Coffee, tea and sugar, if used in small amount are beneficial, but depressing
if used to excess.
First Aid and Artificial Respiration. —(Dr. Kuhn, Ther. Monatshefte, No. 2, 1906.)—The cause of asphyxia almost always is not due to the absence or small volume of oxygen in the inspired air, but to the large amount of carbonic acid in the air, or the difficulty with which it is given off. This has led to confusion in the method of treating asphyxia. The following factors have been overestimated in the treatment of asphyxia: 1. Increased pressure of inspired air or oxygen, and aspiration of exhaled air, since atmospheric pressure is sufficient in all cases. Increased pressure will injure the parenchyma of lungs and interfere
with pulmonic circulation. The inflation and collapse of the lungs should only follow the variations of the thoracic movements. 2. Importance of oxygen in extra amount (excepting in CO poisoning) since normal air contains 20.8 volume of oxygen, and we can easily get along with less oxygen. Expired air contains about 4 per cent carbonic acid, and if air contains a larger amount, this gas is given off with difficulty by the lungs. With air containing 12 per cent oxygen some difficulty in respiration is experienced; with 6 per cent the condition becomes serious. The following factors have been underestimated in the physiology of respiration. The free elimination of carbonic acid in respired air, and for this purpose the respiratory passages must remain open, i. e., elevation of jaw, pulling forward of the tongue, etc. The systemic rhythmic ventilation of the lungs best accomplished by the Sylvester method.
Floating Kidney in Women.-Heidenheim (Ther. Monatshefte, No. 2, 1906) does not believe that the shrinking of adipose tissue. about the kidneys plays a role in the etiology of movable kidneys. Trauma, empyema of the lungs, chronic coughs, chronic constipation, heavy labor and pregnancy are etiologic factors. Wolkow and Delitzin have found paravertebral depressions in which the kidneys rest normally. In men these are funnel shaped with the apex downwards, in women they are cylindrical. The intra-abdominal pressure normally retains the kidneys in these depressions. It is still undecided whether a movable kidney precedes gastroenteroptosis, or whether it follows the latter. Probably it is not always the same. The ideal treatment for movable kidney is surgical, but it only becomes necessary in the more severe cases. The wearing of abdominal supports which hold the abdominal organs in place do much good. These must compress the lower abdomen to force the bowels upwards. Special pads to hold the kidney in place do more harm than good. The writer prefer Glenard's hypogastric girdle in most cases of movable kidney, especially if it is associated with gastroenteroptosis.
LARYNGOLOGY AND RHINOLOGY.
HERMAN STOLTE, M. D.
Syphilitic Empyema of the Accessory Sinuses of the Nose, with a Report of Four Cases. -Joseph H. Abraham (Med. Rec., March 3, 1906) declares that although luetic lesions. may invade any part of the upper respiratory tract, and although tertiary lesions seem to