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REPORTS ON PROGRESS

Comprising the Regular Contributions of the Fortnightly Department Staff.

INTERNAL MEDICINE.

O. E. LADEMANN, M. D.

The Action of Quinin on the Different Malarial Plasmodia.-Craig's (American Medicine, April and May, 1906) study was undertaken to determine, if possible, the actual effect of quinin upon the various forms of the malarial plasmodia, and the best time for the administration of the drug, as shown by its action upon the parasites. The results obtained show that quinin acts upon every stage in the growth of all varieties of the plasmodia, but that its action is most marked upon the free spores and the young intracorpuscular forms, in the latter not preventing entirely the development, but producing very marked developmental changes. The first part of the author's manuscript is devoted to a resumé of literature and a personal consideration of the changes noted in the fresh blood containing the tertian quartan, and aestivo-autumnal plasmodia. The second part considers the appearance presented in the stained preparations and deductions in general. The most important practical deduction to be drawn from the study of the action of quinin upon the malarial plasmondia is that, in order to secure the best therapeutic results the drug should be present in the blood continually, and therefore should be administered in divided doses at regular intervals of time. This study demonstrates that quinin acts injuriously upon the plasmodia in all stages of their human life-cycle, with the possible exception of the large full-grown plasmodium just prior to segmentation, and thus to secure the best results, the drug should always be present in the blood. Given in divided doses at regular intervals the blood constantly contains a sufficient quantity practically to stop the development of the plasmodia which have succeeded in escaping it while free in the blood plasma, and recovery is thereby hastened. The practice of giving quinin in the manner mentioned is not only justified by the morphologic changes in the plasmodia, but its value is proved by practical experience. To illustrate the latter, the author presents the records of over four hundred cases of malarial fever, observed in soldiers returning from the Philippines and in the Philippines, including tertian, quartan and aestivo-autumnal infections, in which quinin was administered in doses of 0.5 gms. (7 grains) every three hours until from 1.5 to 2 grms

(22 to 30 grains) were taken, and in all these cases, recovery was prompt and occurred more quickly than in similar cases in which one large dose was administered prior to sporulation. In the tertian cases it was but very rarely that a second chill occurred, although in about 20 per cent of the cases a rise in temperature was noted upon the second day of the expected paroxysm. In the quartan cases a second paroxysm never occurred after the beginning of the administration of quinin in this way, while in the aestivoautumnal cases, which comprised nearly two-thirds of the total number, the temperature. except in two pernicious cases, reached normal in from two to three days and recovery occurred. It is in the latter type of malarial infection that the administration of quinin in divided doses is especially efficient, for in this type it is generally impossible to tell the exact time of the ensuing paroxysm, and thus it is impossible to attack the parasites while they are free in the blood plasma by administering one large dose of the drug. The following are the final conclusions which the author believes are justified: 1. Quinin exercises an injurious effect upon the plasmodia of malaria during all stages of their human life-cycle, whether intracorpuscular or extracorpuscular, except when it is administered just prior to sporulation, at which time the sporulating body is not injured and sporulation occurs, but most of the spores are destroyed by the drug while they are free in the blood plasma 2. The marked morphologic changes, degenerative in character, produced by quinin in all species of the malarial plasmodia, during all stages of their growth, prove that in order to secure the best therapeutic results the drug should be continually present in the blood, and this is only possible when it is administered in divided doses at regular intervals of time.

Remarks on Sahli's Desmoid Test of the Stomach. Einhorn (Jour. A. M. A., May 12, 1906; Deutsche Med. Wochenschrift, May 17, 1906) says that Sahli's desmoid reaction (see Medical Fortnightly, Vol. XXIX, No. 2) is unsuitable for the examination of the stomach function because catgut is digested in the bowel as well as in the stomach. The author applied the test in four cases in which there was a complete absence of gastric juice (achylia gastrica) with a positive desmoid reaction. In one case, where the desmoid test was administered four times, a varied condition was observed, the test being twice positive and twice negative. The days on which the desmoid test was applied the gastric secretion of these patients was usually

examined, by means of the stomach tube, in order to be certain that no gastric juice was present. As the reaction was usually positive it was to be inferred that the desmoid test did not indicate whether gastric juice was present or not. In order to controvert the idea of Sahli that after a test dinner there is sufficient gastric juice even when the test meal shows an absence of free hydrochloric acid, Einhorn made the following experiment: In case No. 2 he made a second desmoid test. Five hours after the patient had taken the methylene blue desmoid bag, and three hours after a larger meal the stomach contents were examined again with the result that the gastric juice was entirely absent and no blue discoloration of the stomach contents, although the urine voided shortly afterward was blue. In this case the reaction must have taken place in the intestines; otherwise the urine would not have been colored.

Determination of the Absence of Hydrochloric Acid by a Simple Stool Examination. -Hess (Med. Rec., April 28, 1906) bases the supposition that the stool may indicate the asbence of hydrochloric acid in the stomach by utilizing the fact that connective tissue. can be digested only by the gastric juice. For three consecutive days a test diet is given the patient, the chief requirement being that it shall contain one-fourth pound of chopped beef so cooked that it is still rare within. In the absence of hydrochloric acid, under these conditions, particles of undigested connective tissue will be recognizable on carefully examining the finely divided stool. Hess advocates the application of this method in those cases where the introduction of the stomach tube is inadvisable.

Vaccination with Attenuated Plague Culture.-Kolle (Deutsche Medizinioshe Wochenschrift, No. 11, 1906) reports forty-two

successful inoculations on men with atten

uated cultures of living plague bacilli by keeping the cultures at a temperature of from 42 to 43 deg. C. These experiments were done in collaboration with those of Strong

and demonstrate the harmlessness of such

protective inoculations in man, as no unpleasant symptoms exhibited themselves, although the inoculated were closely observed for a period extending over four months.

Myiasis and Its Treatment.-Rooda Smit (Deutsche Medizinische Wochenschrift, No. 19, 1906) discussing the subject of fly disease (Fliegenkrankheit) says the larva or maggots are developed from the eggs of either the lucilia hominivora or the aestres species. The flies usually select for the deposition of their

eggs excoriated surfaces of the skin, as eczema, acne, ulcerations, and suppurations of the auditory meatus and nose. Myiasis of the intestines occurs, but is an extreme rarity. The incubation period is of a short duration. The symptoms are variable and are dependent (1) on the part. invaded and the organs which they may penetrate, and (2) on the sensitiveness of the individual. In one of the author's cases the patient complained of severe headache and intense itching with a temperature of 39 deg. C. Maggots inhabiting the nose or nasal sinuses, the external auditory canal or middle ear, or beneath the eyelids may produce symptoms of a malignant or dangerous type. The prognosis, therefore, is often dubious and sometimes may be fatal. The diagnosis is simple. The maggots are seen from time to time emerging from the deeper structures (skin and mucous membranes) to the surface. Insufflations and tampons of calomel in the nose and external ear are highly lauded by the writer, and far more efficient than any of the other remedial agents which have been recommended.

GENITO-URINARY.

T. A. HOPKINS, M. D.

Gastric Syphilis.-J. A. Armstrong reports (Montreal Med. Jour., June, 1906) his surgical findings in this rare condition as follows: The stomach wall thick, about 1 c. m., in places 1 c. m.; very little bleeding, muscular tissue showed complete denudation of the mucosa over an area extending completely around the stomach at the pyloric end of the incision. The same condition extended along the interior and anterior aspect of the stomach toward the cardiac end of the organ fully four inches. Here and there, especially toward the margin of the bared surface, there

were small islets of mucous membrane hav

ing a rough cockscomb appearance and a purplish tint.

The edges of the ulcerated area are well defined, serpigenous in out line and abrupt. The edge was slightly heaped up and undermined and just in the undermining angle was a whitish line. The surface of the

ulcerated and denuded area was rather smooth (neither caseous nor necrosing) of a pinkish red color and almost bloodless. In the thickened area some cicatrization and contracture had occurred, producing a certain degree of hour-glass contracture, two or three inches from the pylorus. A slice of mucous membrane, a section through the muscular wall and mucosa and a snipping from the edge of the ulcer were taken for microscopical examination. After extending the wound to give

sufficient space the exuberant edges of the ulcer were pared, the base was curetted, and the thermo-cautery lightly applied to as much of the ulcerated surface as could be reached, the very slight bleeding following curettage being easily checked by the same means. The gastric and abdominal wounds were then closed by suture. The tissues removed were examined by Dr. P. G. Wooley, who reported as follows: "The tissue from the base suggested malignancy, for there were small masses of epithelial cells surrounded by a fibrous stroma; but the edges of the ulcer were simply fibrous tissue and muscle, the former in excess and there was no marked infiltration. The base was markedly inflammatory and not malignant." That the condition was not one of ulcus simplex of unusual dimensions such as have been reported in medical literature, from time to time may be difficult to prove. Dr. Lafleur, however, reports that the man was not a chronic dyspeptic and that an acidity and not hyperacidity existed from the onset of the illness. The chief argument is drawn from the anatomic character of the lesion. Histologically the tissue removed bore a close resemblance to those in the case reported by Dr. Flaxner as gastric syphilis, in Vol. XIII of the Transactions of the Association of American Physicians. It is over three years since the operation was performed. During this period he has been in prefect health, weight up to his standard and no indigestion.

Bacteriuria. Bacteriuria, understanding by the term the presence of bacteria in the urinary tract above the compressor urethrae muscle, is, according to G. P. La Roque (Jour. A. M. A., June 16), a much more common condition than is generally supposed. Unless associated with suppuration it produces none of the symptoms of true inflammation in a healthy person, but such may follow in conditions of lessened vital resistance. Local symptoms, when present, are: Slight increased frequency of micturition, mild ardor urinae, occasionally incontinence, and in children there may be nervous disturbances. If no abrasions exist, toxins are not absorbed In many cases there are no subjective symptoms. The most common infecting organism is the bacillus coli and it is present in nearly all cases, often in pure culture. In some cases of typhoid bacteriuria it is absent. Alkalinity of the urine means the presence of the staphylococcus or bacillus proteus vulgaris; all other organisms, these being absent, produce an acid urine. When When the bacteria come by way of the kidneys, as in typhoid septicemia or scarlatina, there is always a positive albuminuria. When they

enter from the genitalia or the lower intestinal tract, the presence of albuminuria is dependent on the previous condition of the kidneys. The history will probably suggest the causative germ. In treating the condition, urinary and intestinal antiseptics, urotropin (hexamethylenamin), salol, boric acid and large draughts of water are advised. Vesical instrumentation and irrigations are to be avoided so far as possible. In spinal disease with paralysis of the compressor muscle, bacteriuria is a constant attendant affection, and when the urine becomes ammoniacal, cystitis is inevitable. The danger of life in these cases from ascending urinary affection makes bacteriuria a serious matter, and every one recognizes the value of thorough, gentle, aseptic bladder drainage in their treatment. In cases, as in the aged, dependent on colitis and constipation, free purgation, regulated diet and intestinal antiseptics are essential. Colonic lavage for two or three months is practiced by Janet. A case of very marked bacteriuria following dysentery is reported.

THE reduction in the amount of typhoid fever is the most remarkable fact in the sanitary history of Chicago during the last decade. The weekly bulletin of the health department reports that the mortality there from typhoid fever during the ten years from 1885 to 1894 inclusive was 7.9 per 10,000. In 1891 it was 17.31, being greater that year than in any other city in the civilized world. After the drainage canal and intercepting sewers were built the typhoid mortality was reduced in the decade from 1895 to 1904 inclusive to 3.2, and in 1905 it was 90 per cent less than it was in 1891.

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FORMIC ACID IS THE LATEST REJUVENATOR. It is better than the once celebrated Brown-Sequard elixir, or the much praised glycero phosphates. It is claimed that sodium formate in fifteen-grain doses three or four times a day is the proper administration for a healthy individual who is anxious to work without fatigue. The Critic and Guide quotes physicians who profess faith in this 'wonderful" remedy. The British Columbia Pharmaceutical Record states that a customer far advanced in years regularly buys formic acid which he believes has prolonged his life. Sometimes he eats red ants, we suppose with a view of getting the formic acid at nature's fountain. It is worth while to mention that formic acid has for many ages been an article of materia medica. -Meyer Bros. Druggist.

THE MEDICAL FORTNIGHTLY

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M. Sig. To be used as an irrigation to the lids.

Three or four hours later the following should be applied locally:

B Argenti nitratis (crys.)...... gr. iij
Aq. dest..

3 v

M. Sig. To be applied locally by means of an application. This should be neutralized by a solution of sodium chloride.

If a one to two per cent solution of silver nitrate gives no relief in two or three days, it should be increased to four or five per cent. In case of corneal infiltration or ulceration, the silver nitrate should not be allowed to come in contact with the cornea. In such cases the following ointment should be applied:

B Iodoformi (dissolved in ether). gr. iv
Vaselini (neutral)...

M. Sig. Apply locally.

3 iiss

If perforation seems probable, instill a few drops of a four per cent solution of atropine into the eye.-American Medicine.

INHALATION IN CHRONIC BRONCHITIS.The Bulletin Generale de Therapie recommends the inhalation, from a bottle provided with two tubes, of air saturated with the vapor of the following mixture: B Oil of eucalyptus.. 30 parts

Menthol....

Thymol... Guaiacol, crystal Water....

5 parts

2 parts

5 parts

..200 parts

During the performance of a hernia operation it is often helpful for the anesthetist to allow the patient to react sufficiently to strain. into view a sac that has slipped back into the abdomen.

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Papers for the original department must be contributed exclusively to this magazine, and should be in hand at least one month in advance. French and German articles will be translated free of charge, if accepted.

A liberal number of extra copies will be furnished authors, and reprints may be obtained at cost, if request accompanies the proof.

Engravings from photographs or pen drawings will be furrushed when necessary to elucidate the text. Rejected manuscript will be returned if stamps are enclosed for this purpose.

COLLABORATORS.

ALBERT ABRAMS, M. D., San Francisco.
M. V. BALL, M. D., Warren, Pa.
FRANK BILLINGS, M. D., Chicago, Ill.
CHARLES W. BURR, M. D., Philadelphia.
C. G. CHADDOCK, M. D., St. Louis, Mo.
S. SOLIS COHEN, M. D., Philadelphia, Pa.
ARCHIBALD CHURCH, M. D., Chicago.
N. S. DAVIS, M. D., Chicago.

ARTHUR R EDWARDS, M. D., Chicago, Ill.
FRANK R. FRY, M. D., St. Louis.

Mr. REGINALD HARRISON, London, England.
RICHARD T. HEWLETT, M. D., London, England.
J. N. HALL, M. D., Denver.

HOBART A. HARE, M. D., Philadelphia.
CHARLES JEWETT, M. D., Brooklyn.

THOMAS LINN, M. D., Nice, France.
FRANKLIN H. MARTIN, M. D., Chicago.
E. E. MONTGOMERY, M. D., Philadelphia.
NICHOLAS SENN, M. D., Chicago.
FERD C. VALENTINE, M. D., New York.
EDWIN WALKER, M. D., Evansville, Ind.
REYNOLD W. WILCOX, M. D., New York.
H. M. WHELPLEY, M. D., St. Louis.
WM. H. WILDER, M. D., Chicago, Ill.

LEADING ARTICLES

SUDDEN ABDOMINAL PAIN-ITS SIGNIF

ICANCE.

BYRON ROBINSON, B. S., M. D.

CHICAGO.

(Continued from page 358.)

APPENDICITIS.

Appendicitis is the most dangerous and treacherous of abdominal diseases-dangerous because it kills, and treacherous because its capricious course cannot be prognosed. The peritonitis it produces is either enteronic (dangerous-absorptive) or colonic (mild

-exudative).

A concise clinical history should be obtained when sudden pain arises in the right side of the abdomen for it might be due to perforated appendix, gall-bladder or gestating oviduct. The right-sided pain may arise from biliary, pancreatic or ureteral calculus or ureteral flexion.

Pleurisy or intercostal neuralgia (right) may confuse. In the right side, so closely adjacent are eight important viscera, momentous in surgery, that a silver dollar will touch the pylorus, gall-bladder, head of the pancreas, kidney, adrenal, duodenum, ureter and possibly the appendix. Hence differential diagnosis of sudden abdominal pain in

No. 1

the closely adjacent multiple organs of the right side is difficult-frequently impossible.

The conditions that cause the excruciating, agonizing, shocking pain in appendicitis is perforation and extravasation into the peritoneal cavity. Right-sided muscular rigidity means that the motor (intercostal) nerves supplying the abdominal muscles are irritated. It may be any kind of peritoneal infection (extravasation from any viscus, hepatic, intestinal, ureteral or genital). Rightsided cutaneous hyperesthesia means that the sensory (intercostal) nerves supplying the abdominal skin are affected. It may depend on any kind of peritoneal infection. Sudden cessation of severe symptoms, as rapid dim. inishing of high temperature and pulse and abdominal rigidity is an evil omen-gangrene of the appendix has probably occurred. Immediate operation should occur.

For years I have made it a rule to recommend appendectomy to patients having experienced two attacks. Fifty per cent of subjoets who have had one attack experience no

recurrence.

In perforation it is very difficult to interpret the sudden abdominal pain. Associated circumstances would aid. In typhoid fever one would naturally suspect perforation if sudden acute abdominal pain arose, and my colleague, Dr. Weller Van Hook, successfully operated on a typhoid perforation diagnosed by his medical friend. One might think if he was called to a young woman with sudden acute abdominal pain that it was a round, perforating ulcer of the stomach, after excluding pelvic and appendicular disease, but the sudden acute abdominal pain of perforation is so vague and indefinite that only an ploratory incision would interpret it.

ex

The sudden acute abdominal pain from appendicitis (perforation) is more apt to be diagnosed from probability. Now probability is the rule of life, and when one is called to a boy or man with sudden acute abdominal pain, it is likely appendicitis. The pain of appendicitis is at first sudden and generally diffuse, and in appendicitis this is, in my experience, a characteristic and conspicuous feature. The sudden acute pain in appendicitis is doubtless due to violent appendicular peristalsis (colic) of an inflamed appendix, or to the rupture allowing the bowel contents to come in contact with the peritoneum, and also inducing violent irregular peristalsis of the adjacent bowel loops. It is the agonizing, excruciating, pain of peritoneal extrava

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