4.

6.

accompanied by albuminuria and pyuria, but these are not necessary concomitants. The bacilli usually appear in the third or fourth week of the disease, and persist for a varying time-for weeks or months, and even 5. Bacilluria ocafter the patient is cured. curs more frequently in severe cases and in those with complications; but the severity of the case is not affected by the condition, which is of no progonstic significance. The presence of the bacilli in the urine does not aid in the diagnosis, except in some ty. phoid speticemia cases. 7. The presence of the specifio bacilli in the urine is more dangerous than their presence in the stools, because: (a) The disinfection of this fluid is apt to be neglected, and all attention paid to the feces, which, after the third week, may contain no typhoid bacilli. (b) Contamination by the urine is less apparent than that brought about by the feces, and thus cloths, etc., may be a source of great danger. Pollution of a water supply is more likely to occur through urination than defecation. All typhoid patients, at whatever stage of the disease, should micturate into special receptacles, where the urine should be disinfected. Urination during bathing and when outside should be strictly forbidden. 9. All patients from the third week should be given urotropine in ten grain doses, t.i.d., for ten days, and, after one week's interval, administration of the drug should again be carried out for another ten days. After this a bacteriological examination of the urine should be conducted, and if the bacillus be present, the drug should be continued for a week after the urine is sterile.

Enterospasm and Its Mimicry of Appendicitis. -Hawkins (British Med. Journal, Jan., 1906) makes the statement that the appendix is sometimes unnecessarily excised and that certain patients subjected to this operation suffer quite as much after it is performed as before. Careful study of a certain class of these patients lead to the conclusion that their troubles are functional rather than structural. That this is not recognized is due to a neglect to discuss the functional disturbances of the bowel, which is regarded as a hardy tube uninfluenced by defective states of other organs. The writer describes four cases, from which he concludes that it is not uncommon for men and women in early adult life to suffer from abdominal pain. which from its long duration and the absence of evidence of organic involvement is probably due to functional disturbance of the intestine. Such patients are often neurotic, and the abdominal troubles vary directly with the mental state. The pain in these cases

2. The

4.

bacilli invade the blood very early in the disease. 3. The bacilli usually disppear from the blood by the end of the third week. Relapse is associated with the reinvasion of 5. The bacterithe blood by the organism. ologic examination of the blood is a valuable adjunct in the diagnosis of obscure cases of typhoid fever.

Parallel Tests of Gastric Juice and of Blood in Chlorosis.-Arneth (Deutsche Med. Wochenschrift, No. 17, 1906) presents a table showing the results obtained in the examination of the blood and gastric juice in twentythree cases of chlorosis treated in Leube's clinic at Würtzburg. In fifteen of these patients he found hyperacidity. From these

figures he shows why it is that such discordant conclusions have been published in regard to the behavior of the gastric secretion in this disease. in this disease. In eight cases the improvement in the blood findings under treatment was paralleled by the restoration to normal of the gastric acidity. Arneth is of the opinion that in the milder and moderately severe cases of pure chlorosis there is usually a condition of hyperacidity, but that in general the acid values are in the neighborhood of the normal limit. In the severe cases the findings always indicate extreme hyperacidity. A subnormal or deficient acidity has never been encountered in a single case. The treatment employed did not essentially differ from that ordinarily resorted to. Rest in bed at first, sometimes for several weeks in the severer cases, with the subcutaneous administration of iron or arsenic proved successful. Iron in combination with arsenic was given internally in cases where the number of red blood corpuscles were very much diminished. The writer accepted an enlarged

spleen as an indication for quinine. A pill composed of 7.5 grams of reduced iron made into ninety soft pills with equal parts of glycerine and gelatine has proven effective and unirritating. He begins with one or two pills and then three after each meal.

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Therapeutic Pneumothorax. Brauer (Deutsche Med. Wochenschrift, No. 17,1906) recounts at length the application of Murphy's method of artificially induced pneumothorax and inflating the pleural cavity with nitrogen in a girl 18 of years with an extensive tuberculosis and cavity formation involving the entire left lung, the right being unaffected. A total of four nitrogen injections were made at intervals of several weeks. After each injection the temperature subsided abruptly for a long time. No undesirable manifestations attended the collapse of the lung, and according to the author no such good affect is attainable by any other method of treatment at our disposal. He describes the technic fully. The first injection is the most difficult. Judgment is necessary in selecting the site for the puncture in order to avoid pleural adhesions. An incision of the An incision of the skin is made under local anesthesia and the intercostal muscle separated by blunt dissection until the costal pleura is reached, which in turn is perforated with a blunt trocar, through which nitrogen is permitted to pass until the lung collapses. The nitrogen in time becomes absorbed, and it may be found advisable to substitute some other indifferent gas. The author's patient has improved considerably, and further experiments in this direction are now in progress. The object of the pulmonary collapse is to effect condensation of the lung tissue obliterating cavities and squeezing out the infectious material, thereby favoring progression of the process. The resulting passive congestion is also a factor contributing to the favorable result.

Cheyne-Stokes Phenomenon in Acute Cerebral Compression.-Trotter (Lancet, May 19, 1906) emphasizes the following on the periodic occurrence of Cheyne-Stokes breathing in cases of cerebral compression: 1. CheyneStokes phenomenon is in such cases no mere terminal symptom and, therefore, of necessarily slight interest, but one of the most characteristic forms of the vasomotor reaction and one which may be manifest nearly from the onset of compression. 2. Various modified forms of the phenomenon occur and may cause confusion, especially when the respiration periodicity is absent. 3. Periodic movements are no less frequent and characteristic than when the phenomenon occurs in disease, and that they may be of diagnostic

importance in rendering manifest a paralysis and in being movements which are to be distinguished from those due to focal irritation.

A small

Peculiar Form of Hemoptysis with Presence of Numerous Spirochete in the Expectoration.-Castellani (Lancet, May 19, 1906) report two very interesting, apparently idiopathic cases of hemorrhagic bronchitis occurring in male adults, one in a Cingalese, and the other in a native Indian. Tuberculosis could be excluded with reasonable certainty. Repeated and careful examination of the sputum for three weeks showed no tubercle bacilli. Several guinea-pigs were also inoculated, but the results were negative. Microscopical examination excluded the possibility of endemic hemoptysis from distomum, while the expectoration, especially when much blood was present, contained large number of spirochetes, sometimes practically without other germs. number of spirochetes were also present in the saliva and superficial scrapings from the gums. The spirochetes were always abundant and stained well by the Leishman method, generally taking on a bluish tint; they could be stained also with the ordinary aniline dyes, though not so well. They were generally mixed with some bacteria, but sometimes when the sputum was collected in sterile Petri dishes and preparations made at once, they were practically the only germs present. Vincent's fusiform bacilli were never observed. These spirochetes were not all alike. They might be divided morphologically into several groups: 1. Very thick individually, from 15 to 30 microns in length, with irregular waves which varied in number, but were never very numerous The parasites with the Leishman method stained deep blue; they were pointed at both ends. 2. Spirochetes resembling the spirochaeta refringens (Schaudinn) with a few graceful waves and pointed extremities. 3. Thin, delicate spirochetes with numerous small, rather uniform waves and tapering ends. Sometimes one of the extremities was blunt, while the other was pointed. 4. Very delicate parasite, though thicker than the spirochaeta pallida, with very few waves, generally irregular in shape.

Convulsions in Typhoid Fever.-Osler (Practitioner, Jan., 1906) groups convulsions occurring with typhoid according to the conditions under which the convulsive manifestations take place: First, at the onset of the disease. This symptom of invasion is more frequent in children, but has been observed in adults. Second, as a manifes tation of the toxemia. Such convulsion occur during the course of the infection

and, though alarming, leave no ill effects. Third, as a result of severe cerebral complications, thrombosis of the vessels, meningitis or acute encephalitis. Lastly, convulsions may be ncted, in rare instances, from unknown causes, in convalescence. The author details eight cases of these different groups. He does not regard the prognosis as very grave, although the nature of the complication is alarming.

X-Ray Diagnosis of Kidney Stones.Holland (Lancet, June 2, 1906) concludes his paper on the subject of renal calculi as follows: 1. When a stone or stones are present in such size as to produce symptoms suggesting the desirability of operation, if a careful and thorough examination is made such stone or stones can nearly always be shown by X-rays, and this would also apply to the presence of stone even if the symptoms alone were not sufficient to demand operation. 2. In most cases when shadows are shown the size, shape and position can be relied on in diagnosing them as from kidney or ureteral stones. In other cases when doubt may arise as to the cause of the shadows the experience of the examiner will often settle the matter and in some cases stereoscopic radiography, the use of ureteral bougies, etc., can be used as a help. 3. The negative diagnosis can be relied on only when the whole region on both sides is carefully examined, and when the plates are taken under the essential condition for successful examination and when they are of the necessary quality in showing sufficient differentiation of the soft structures in the kidney and ureteral regions. 4. There can be no justification for operation or prolonged medical treatment without an efficient X-ray examination being made.

Acetone-Fixation of Blood Specimens.Blood Specimens.Jagic (Wiener klinische Wochenschrift, No. 20, 1906) recommends acetone fixation as an efficient and time-saving method of preparing blood specimens. The specimens are placed in pure acetone and allowed to remain five minutes. This manner of preparation possesses all the advantages of Ehrlich's method of fixation by dry heat, the specimens staining well, especially the granules and nuclei.

An Obscure Febrile Disease with the Highest Known Recorded Temperature.-Heller (Muenchner Med. Wochenschrift, No. 25, 1906) publishes the case of a young woman with a fractured rib and an injured spine resulting from falling off a horse while on a hunting trip. Remarkable is the fact that the temperature registered between 45 deg.

C. to 47 deg. C. for seven days, the highest recorded axillary temperature measuring 49.9 deg. C. (122 deg. F.). For seven consecutive weeks the temperature did not fall below 42.2 deg. C. (108 deg. F.). During this entire period no alarming manifestations evidenced themselves, the pulse never registering more than 120 beats per minute and the patient herself felt comparatively good. She finally made a complete recovery.

A Method of Determining the Quantitative Amount of Albumin within an Hour.-Buckner (Muenchner Med. Wochenschrift, No. 24, 1906) devised a simple and accurate apparatus for the percentage estimation of albumin. The outfit, known as Geo. Buchner's albuminimeter, and manufactured by a firm in Berlin, consists of three graduated tubes, two small vials, one for nitric acid, and the other for a saturated salt solution, and a small magnifying glass. The estimation is made as follows: exactly eight cc. of filtered urine (mark 1) are placed in the reagent tube and gently heated to boiling; add two or three drops of nitric acid (mark 2) and 2 cc. of the salt solution (mark 3). In alkaline urine a sufficient quantity of nitric acid should be added to render the whole distinctly acid. After thoroughly agitating the above mixture it is poured into the graduated albuminimeter, corked and allowed to stand one hour when the amount of sediment is read with the aid of the magnifying glass. Each cubic centimeter corresponds to 1.0 prom., and each one-tenth cubic centimeter to 0.1 prom., of albumin. It sometimes happens that the albumin precipitate tends to separtate in the albuminimeter during the first five or ten minutes. This is overcome by a slight rotary motion of the albuminimeter between the fingers and thumb, or better still by carefully agitating with a glass rod.

GENITO-URINARY.

T. A. HOPKINS, M. D.

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Cystoscopy. Bromberg (So. Med. and Surg.) quotes Vander Poel on the advantages of cystoscopy over segregation as follows: "1. The cystoscope is more easy of introduction than are the separators or segregators, is less painful during the bladder manipulations, and much less so during the collection of the urines. 2. With urethral catheterism we can collect the urine during as long a time as may be thought necessary, the patient not requiring any supervision. 3. A cystoscopic examination of the bladder can be made at the same time, which in some

cases is useful, in others, indispensable. 4. We are much more certain of the exact results, especially when the two urines are of a similar character, whether clear, bloody or puruleni. 5. It is the only method by which we are fairly certain that there is no bladder contamination." Amongst those cases in which the cystoscope is contraindicated may be mentioned: First, acute cystitis. In fact it is practically impossible to use the instruments, unless the patient be anesthetised. Preliminary treatment will soon enable one to use the instrument if it is still indicated. Second, unskillful use in cases of tuberculous cystitis often aggravate the case, but used judiciously, it should not be regarded as contraindication. Third, large non-operable tumors are only made to bleed and no advantages are to be derived from its use. Fourth, it can be of no advantages in cancer of the prostate; though in Schauta's clinic in Vienna, it is the custom to use the cystoscope in all cases of operable cancer of the uterus. The uses of the cystoscope are by no means limited to the bladder, but give an insight into the condition of the kidneys which can not be had by any other means of diagnosis; and it is by no means necessary to enter the ureter to determine this fact; for in the best hands and with the best instruments failure to catheterize the ureter in a fair per cent of cases may be expected. In determining for example the existence of tuberculosis in the kidney the position of the tubercular nodules in the bladder, their peculiar grouping around an ureteral opening, or their downward radiation from it leave little doubt that the kidney on that side is involved. Even where no bladder involvement is present, the shape of the mouth of the ureter is often helpful in arriving at a decision. "If instead of being slit-like and rosy and projecting into the bladder, it be retracted, irregular or round a kidney lesion may be assumed."

The Diagnosis of Surgical Diseases of the Kidney. Albert A. Berg (Med. Rec.) states that the health or disease of the kidneys is determined from a study of the anamnesis from physical examination from urinary analysis, from the appearance of the ureteral mouths as seen with the cystoscope, and from X-ray examination. Examination of the urine drawn from each kidney will determine whether one or both organs are diseased. The functionating capacity of the two organs is ascertained from the total amount of urea eliminated in twenty-four hours, and from the cryoscopic index of the blood and urine. In order to determine this capacity in the case of the individual kidney, consideration must be given to the percent

age of urea in the separated urines, the cryoscopic index of the individual urines, and to a comparison of the rapidity and amount of chromogen and sugar eliminated by each kidney after a hypodermic injection of methylene blue and phloridzin respectively. When dealing with pyogenic affections of the kidney, the writer always looks for abrasions and suppurations of other parts of the body, which are so often associated with such conditions. The diagnosis of surgical renal diseases is especially difficult in their initial stages; but careful examination of the patient according to the plan outlined above will afford data that will greatly facilitate the solution of the problem.

The Contagiousness of Gumma.-C. M. Williams says (Med. Rec.) that if the spirochete is the specific organism of syphilis it must exist in gummata, though in such small numbers that up to the present it has escaped detection. The cases in which exposure to tertiary lesions have been followed by carefully reported to bring conviction to even contagion are not sufficiently numerous and a conservative mind. The experiments which have been conducted in relation to this problem are conclusive and prove that a gumma may be capable of transmitting the disease. This does not mean that a gumma is always contagious. The writer thinks that it is prob. able that the living growing border is always infectious. He explains the rarity of examples of infection by the fact that the organism is present in such scanty numbers and has so little chance to reach fertile soil. But his belief is not proven. Whatever may be the explanation of the various questions relating to the contagiousness of gumma, however, the practical lesson is the same. long as a man shows any sign of syphilis so long must he be considered a source of danger to the community.

As

Spirocheta Pallida.-W. C. Alvarez, San Francisco (Jour. A. M. A.) reviews the history of the discovery of this parasite in syphilis, describes its characters and the technic of examination for its presence. Brief reports of 10 cases of syphilis, in 7 of which it was found, also several control cases are reported. In two of the three negative cases the failure to find it may have been due to too superficial examination; the other was a tertiary case. In three of the control cases somewhat similar organisms were found, but differing in certain characters. The author considers the fact of the constant presence of this spirochete in the lesions of syphilis, its absence in non-syphilitic lesions, its presence in the organs of congenital syphilitics and the placenta, its presence in syphilis-infected mon

keys, its greatest abundance in the most infected lesions, the retention of syphilitic virus on the unglazed filter showing that the organism is not ultra-microscopic, the fact that it seems to be morphologically more distinct as a species than the other spiral organisms and that it seems to be more highly differentiated as a parasite and soon disappears when removed from living tissues, all significant as bearing on its causal relation to syphilis. When we are able to cultivate it successfully he thinks that we may obtain curative and immunizing sera for this disease.

The Anatomy of the Inguinal Region.The anatomy of the region of the inguinal canal is described by T. C. Witherspoon, St. Louis (Jour. A. M. A.) on the basis of some fifty dissections. He summarizes his conclusions substantially as follows: The internal abdominal opening is located in the extraperitoneal fatty tissue.

Hesselbach's ligament is formed of fibrous bundles from the outer end of Douglas's semi-lunar fold to the inner margin of the internal abdominal opening. The bundles are developed chiefly in the extraperitoneal fatty tissue and are closely connected along their course with the transversalis fascia. During intra-abdominal pressure this ligament, by its resistance, helps to enlarge the internal abdominal opening. The inguinal area of the internal abdominal wall is divided into two planes by Hesselbach's ligament, the more lateral one of which is normally advance of the other, but weakening of its muscles by disease or old age greatly exaggerates the difference. The internal abdominal opening being situated at the junction of the two planes, the greater the difference the more patulous the opening and the greater the liability of the escape of a viscus. The

transversalis fascia nowhere joins Poupart's ligament. The deep crural arch is formed by the junction of the transversalis and cremasteric fascias in the arch in front of the external iliac vessels as they pass into the thigh. The free (posterior) edge of Gimbernat's ligament is just external to and parallel with the deep crural arch. The fibrous bundles passing out of the pelvis into the so-called conjoined tendon give the abdominal wall its chief strength internal (posterior) to the inguinal canal. The aponeurosis of the transversalis muscle strengthens it just internal (posterior) to the external abdominal ring. The base of the conjoined tendon, the lateral edge of which is formed by the fibrous bundles from the pelvis, is the constricting agent in femoral hernia. In no case was the conjoined tendon formed by the union of fibers. from the internal oblique and transversalis

muscles, and this seems quite impossible with the usual anatomic arrangements. The external abdominal opening lies between the dividing fibers of the external oblique aponeurosis. The external abdominal ring is situated in the periaponeurosis which covers the external abdominal opening.

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FOR cracked nipples, brush them once a sults will surprise you and you will have one day with tincture chloride of iron. The reon the old moss-back doctor who carries nothing but a lump of gum opium and a few c.c. pills.

THE RELATION OF THE MEDICAL PROFESSION TO THE SOCIAL EVIL.-R. N. Willson, Philadelphia (Jour. A. M. A.), calls the medical profession to time for neglecting its duty as regards venereal infection. The social evil as conducive to disease comes particularly within the province of the physician as a guardian of the public welfare, but we neglect our duty and disguise its results under the names of apoplexy, brain softening and locomotor ataxia, "which injure by their silence in the neighborhood of curable misfortune and guilt. He shows how this evil breaks up homes, cuts off the legitimate birthright of innocent children and ruins the health and shortens the lives of innocent wives and mothers. He quotes letters of leading gynecologists, showing that some of them estimate that from 50 to 90 per cent of pelvic suppurations are due to this cause, and he shows how much is the public loss from the mortality, disablement, blindness, insanity, etc., from this evil. The remedy, as he sees it, lies largely in our imparting a sane knowledge of the normal sexual functions to our patients, in instructing parents as to the prevalence of abuse of these functions and its results, in making the criminal false modesty that has led and almost forced the medical profession to be silent on this matter, give way to measures calculated actively to protect the public. Societies should be formed for the prevention and study of this social disease, the work of which should be essentially educational, and in every phase of the consideration of the subject, public and private, strict emphasis should be laid on the dignity and nobility of a pure sexual life. We cannot cleanse the world of venereal disease in a day or in a lifetime, but effort will not be fruitless and the problem will eventually be worked out.