REPORTS ON PROGRESS

Comprising the Regular Contributions of the Fortnightly Department Staff.

DERMATOLOGY.

ROBERT H. DAVIS, M. D.

Notes on the Treatment of Epithelioma by Means of Caustic Potash.-Van Harlingen (Jour. Cut. Dis. August, 1906) reports a series of fifty-five cases treated by this method. In the main, his results have been excellent. Milder caustics, such as nitrate of silver, or the weaker acids, have, for the most part, failed in effecting cures of morbid growths without relapses, and but litte more can be said of the selective caustics, such

as pyrogallol. The most satisfactory of the destructive caustics, and the one, in his experience, giving the best results, is caustic potash. It dissolves the horny layers of the skin, lays bare the diseased tissues, and while destroying everything indiscriminately can be accurately limited in its effects by one accustomed to its use." The pain is not too great for most people to endure. It need not be prolonged, and can be arrested at any moment by a neutralizing agent such as acetic acid. The only caustic which can be compared with it, is arsenic, and arsenical pastes are liable to give rise to severe and prolonged pain. The length of time for the wound resulting from the cauterization to cicatrize, he finds to vary between ten days and eight weeks. Four weeks was about the average. His conclusions are as follows: 1. In a certain number of cases, epitheliomata of the skin are best treated by means of caustic potash. 2. These cases comprise such as display small, well defined, pearly lesions, from one-half to one, or even two, centimeters in diameter, chiefly found upon the face and adjacent parts. 3. Larger lesions are best treated by the X-ray, but here caustic potash may be used to soften and dissolve the horny epithelium, and perhaps, in some cases, as an adjuvant. 4. In cases treated by caustic potash, the use of the X-ray does not appear to hasten the process of reparation, or to modify, in any marked degree, the cicatrix resulting from cauterization. (Many rayists have obtained sufficiently satisfactory results with X-ray, in the cases included under the second heading, to make them feel justified in, at least, using this agent first.-Ed.) In the discussion of this paper, Dr. Hartzell praises highly the combined use of caustic potash and pyrogallol. The method he fol. lowed was to first apply the caustic potash very superficially, remove it as soon as it began to cause pain, and then apply a 40 to 50

per cent plaster of pyrogallol. The action of the latter was very much accelerated by the use of the caustic potash first, and a slough resulted that looked like it had been cut out with a sharp punch. Stelwagon cautioned against its use on the side of the nose, as perforation was liable to result.

Dis., July, 1906) cautions against the misPemphigus Vegetans.-Ravogli (Jour. Cut. take of diagnosing this rare malady for syphilis, especially as both diseases are liable to attack the mouth or the genitals. In his case the disease began on the navel, thus confirming the opinion that pemphigus vegetans has its origin on or near the mucous membranes. The mucous membranes of the mouth were badly affected, but the appearances were complicated when first seen, by a severe stomatitis due to salivation from heroic treatment under a false diagnosis of syphilis. The eruption on the navel was followed very shortly by a similar outbreak on the genitals, then, on the fossa cruro-genitalis, the axillae, and between the toes. On account of the peripheral spreading of the cutaneous lesions, Köbner expressed the opinion of a possibility of an infection spreading from one bulla to another. The author, however, considers the infection to be of systemic origin The condition of the urine showed alterations in

quantity and quality. The quantity of urine was constantly below normal, but increased during remissions. The reaction was constantly alkaline except towards the end. The specific gravity varied between 1010 and 1012, and a large amount of albumen and casts were present. The vegetations occurred, as usual, at an advanced stage of the disease, and on the folds of the skin subject to maceration. He does not agree with the opinion of some that pemphigus vegetans is a disease distinct from ordinary pemiphgus, but considers it only a variety of the latter affection. As to the claim that the lesions and blood findings in dermatitis herpetiformis and pemphigus vegetans are identical, he finds an eosin ophilia in the blood of patients suffering with dermatitis herpetiformis, but none in pemphigus vegetans. Clinically, the marked differences between the two diseases have been well pointed out by Brocq.

On Leprosy and Fish Eating.-Hansen (Scot. Med. and Surg. Jour., July, 1906) replies to Jonathan Hutchinson's recent publication on this subject. Hutchinson's argument falls under two heads: He maintains, (1) that fish is eaten every where where leprosy prevails; (2) that fish, per se, does not produce leprosy, but only badly cured fish which is more or less decomposed. With regard to the first contention, Hansen points

out that in certain parts of Eastern Norway, where there is no leprosy, the people prepare trout in a special way, allowing it to decom. pose somewhat before being salted, and thus to attain the very condition which according to Hutchinson, should cause leprosy. Hutchinson holds that the dried cod which is exported from Norway to Spain and Portugal is responsible for the leprosy in those countries. Hansen points out that the dried cod, so exported, is not decayed, and, also, that leprosy diminished in Norway while the population was still, to a large degree, using decayed fish as food. He refers also to certain statements, which he believes to be incorrect, for example, that the leprosy bacillus can be transformed into the tubercle bacillus, and that the lepra bacillus has not been demonstrated in the maculo-anesthetic lesions. "The weak point in the whole fish hypothesis, however, is that the bacillus has not been found in fish, so that the theory is without basis and altogether destitute of proof." He believes that contagion is the means of transmission, cites a series of cases which were explicable on this supposition, and draws attention to the great diminution of lepers in Norway since segregation was adopted (Per review in British Jour. Derm., Sept., 1906).

An Experimental Study of Some Cases of Urticaria.-Paramore (Brit. Jour. of Derm., July and August, 1906) gives the results of a series of cases treated with calcium chloride internally, the treatment being based on the earlier (1896) suggestion of A. E. Wright that the disease was of the nature of a serous hemorrhage associated with defective blood coagulability, and due to a diminution of the content of the blood in calcium salts. Though, in the cases examined, no large diminution in the lime content of the blood was observed, as compared with the presumed normal, yet, in three of the cases, an exaltation of blood coagulability brought about by the administration of calcium chloride 3i by the mouth, resulted in almost immediate recovery. one case, a papular urticaria was converted into one consisting essentially of wheals, by the administration of a decalcifying agent, citric acid. In the same case, an urticaria of a wheal type was reconverted into one of a papular variety by the administration of calcium chloride. "Milk is known to be one of the chief sources of calcium in the food supply, large milk drinkers being possessed of a blood characterized by an abnormally large lime content associated with a proportionately accelerated coagulability. Parallel with this observation, it is found clinically that, in children, a papular urticaria is of frequent Occurrence. The value of a milk diet in

In

chronic urticaria has chronic urticaria has been mentioned by Stelwagon. The author considers its usefulness dependent "not only on the diminished strain that is imposed on the excretory functions of the kidney by the diminished ingestion of nitrogenous materials, hence enabling the organ to deal more completely with toxic and other waste products already present in the circulating blood, but also on the calcium element as a resultant of which an increased viscidity of the blood associated with an acceleration of the coagulability should obtain." The explanation of the value of antacid magnesia in all forms of urticaria lies in the fact that magnesium has a similar effect to calcium on the lime content of the blood. Moreover, in the event of calcium being poorly absorbed, or retained, by the individual, magnesium is found to have, for that individual, a correspondingly increased effect. In many people, the eating of sour fruit, unripe apples, etc., is followed by an urticarial outbreak, the acid in these substances acting as a decalcifying agent for the blood. Such a condition of the blood does not, however, in the majority of cases, mean urticaria. He considers that in the event of overloading the kidneys, if the particles thrown on the skin to be excreted be comparatively unirritating, such as a crystal of calcium oxalate, the serous exudation would be relatively small, and therefore no visible lesion or a papule at most would result. If the material to be excreted, on the other hand, is of a highly irritative (toxic) nature a wheal would result; also he finds that a large salt content of the blood predisposes to hemorrhage and "in a blood possessed of a large lime and salt content, if the lime content be reduced, the salt content will now be too large for efficient clot formation, and in consequence hemorrhage may be expected." urticaria, the result of insect bites, stinging nettles, etc., is of course due to a local alteration in the tissues in the immediate neighborhood of the lesion, the outpouring of serum being due to the dose of irritative (toxic) substance that is introduced into the minute lymph spaces. The outpouring of serum dilutes the toxic substance, resolution can take place, and recovery occurs. Accordingly, he divides urticarias into three main groups: 1. Decalcification urticaria. 2. Urticarias due to an alteration of the salt content of the blood. 3. Inflammatory or toxic urticarias which may be either (a) general e. g., papular, or (b) local, e. g., due to nettles, insects, etc. As secondary factors, adjuvants, or perhaps, determining causes, acquired or inherited degeneration, or alteration in the skin, cutaneous vessels, or nervous mechanism, may, play a certain part.

An

OTOLOGY.

ALBERT F. KOETTER, M. D.

Toxic Action of Aspirin. (J. D. Dockray, British Med. Jour).-A woman of fifty taking ten grains of aspirin every three hours for an attack of lumbago, noticed ringing in the ears, and later after she had taken about one hundred grains in all, had severe pain in right ear. After discontinuing the remedy and putting warm applications to the ear the pain disappeared, but the ear became totally deaf and showed serous discharge. After a few days the pain and discharge ceased; in fourteen days the hearing returned to normal. Author recommends in the beginning a dose of not exceeding seven and one-half grains.

Three Cases of Objective Ear Noises.-(G. S. Ryerson, Canadian Practitioner and Review, Toronto.)-Case I.-A child of two years, the examiner when placing, his head against the left ear of the child heard a pronounced tone. The parents claimed that the noise is sometimes so loud as to be heard all over the room. Very likely we have to deal with a vascular murmur. Case II-Young woman in placing stethescope against the ear and intermittent ticking sound is heard. Treatment of the existing mild middle ear catarrh caused the noise to disappear. Case II.-Man of fifty with hissing noises and ticking, the latter heard by the author when he placed his ear to the left ear of the patient. Intratympanic injection and massage brought relief. In cases two and three we have to deal very likely with movements in the tubes.

Disturbance of Circulation in the Labyrinth. -(Shambaugh, Archives of Otology.)-The disturbance of circulation may be limited to one or more terminal arteries without involving other parts of the labyrinth, so that such an isolated disturbance of circulation is not able to cause Meniere's symptom complex. So that for instance an embolus of the anterior vestibular artery may cause disturbances limited to the utricle and the horizontal and superior vertical semi-circular canal, rupture or embolus of posterior vestibular artery would cause disturbance limited to the posterior vertical semi-circular canal. In both cases there would be disturbance of equilib rium without involvement of the function of hearing. Embolus of the terminal arteries which supply the tip of the cochlea would cause deafness for the low tones exclusively; embolus or hemorrhage of one or the other of the arteries which run longitudinal to the lamina spiralis to the organ

In both

of Corti, there would be loss of hearing for certain parts of the scale.

sue.

Thiosinamin in Tinnitus Aurium.-(S. McCullagh, Medical News.)-This remedy was used with success in all ear affections accompanied by new formation of connective tisThe action rests in a softening of the tissues causing a better influence of the usual method of treatment. Consqueently the usual mechanical measures must at the same time be adopted. The same results are reached, whether by internal or subcutaneous treatment. The more recent the case the more prompt the result. It also has a good affect on the vertigo. Attention must be paid to the counter-indication. On subjective noises the affect is better than any other remedy.

Operative Treatment of Tormenting Subjective Noises.-(W. Sohier Bryant, Jour. A.M. A.)-As with the trigeminus so also with the auditory nerve, the best results are obtained when the nerve is searched for in its intracranial course. The intralabyrinthian destruction of the nerve offers enormous technical difficulties, and is even then very often incomplete. Considering the dangers which the intracranial dividing bring with it, the operation should only then he proposed to the patient when all others means and remedies have failed. An existing suppuration must first be gotten rid of. The cases favorable for a division are those in which the air conduction is reduced but the bone conduction is still good. Noises of a deep tone and such with a changing tone height are favorable, whereas the noises of a high tone, musical noises, complete absence of bone conduction are counterindications. For in a case of total deafness and absence of bone conduction it is to be assumed that the noise. is in a part of the auditory nerve more central than the cochlea, whereas we can assume in a case with good bone conduction that the cause of the noise lies peripherally from the cochlea. Author has performed sixtyfive neurectomies of the acoustic nerve on the cadaver after the Carleton Flynt method. By using instruments constructed for this operation he had no difficulty in resecting the intra-arachnoidal part of the auditory nerve without injuring the facial nerve. Oftentimes he was successful in avoiding severe hemorrhage caused by injury to the cerebral veins.

Technique. The best way leads through the middle cranial fossa. An inverted Ushaped skin periost flap is formed behind the posterior margin of the mastoid process and reaches about one and one-half inches upwards from the knee of the sinus, the pos

terior margin of the flap lies about a one and one-half inches behind the anterior flap. To form an osteo-plastic flap is injudicious on account of the thickness of the bone, and because it is impossible to locate with certainty the sinus from without. The bone is removed to the front to the upper angle of the pyramid and below to the lateral sinus. The dura mater is incised by a U-shaped cut open anteriorly, the cerebrum lifted off carefully with a spatula and on the anterior surface of pyramid the emineutio arcuata is looked for, this serves as a good point of information. Then the tentorium longitudinal is incised for one and one-half inches parallel to margin of pyramid, but behind the latter. to avoid the superior petros. sinus. Veins that usually run parallel to margin of pyramid are if possible to be avoided. Then the posterior incised margin is pushed back with a spatula, and the cerebellum with a spatula introduced is drawn back until the white nerve is shown in the back of the wound. It lies four to five cm. from the anterior angle of the wound, outward and posterior from the facial, it is picked up with a hook forceps, then pulled outward and forward. Then the facial is inspected to see if any remnants of the acoustics may be found on it, and removed in the same way. The main difficulty in the operation exists in avoiding the veins. while dividing the tentorium. The dis. charge of liquor may be. considerable even from a cadaver. A small drain from the stump of the acoustic leads through the outer angle of the incision in the tentorium, the anterior inferior angle of the dura incision and the anterior inferior angle of the skin flap. The tentorium need not be sewed, but dura, periosteum and skin are sewed with the exception of a small place for the drainage tube The reports of the cases published to date justify the following conclusions: 1. Carefully chosen cases in which the nerve irritation is localized in the peripheral part of the acoustic indicate a gcod prognosis. 2. A technique which avoids a severe hemorrhage, bony splinters, the cerebrum and cerebellum compromised only in a minimum degree, lowers the danger of operation. 3. We are justified after conservative treatment of tormenting noises has failed, to propose the operation, providing the origin of the noise is in the peripheral portion of the nerve. 4. The dividing of the acoustic is then proper for the removal of noises, and also for the vertigo.

PROFESSOR PERKIN'S DISCOVERY OF COALTAR. When certain varieties of bituminous coal are heated in a closed retort, three classes of substances are obtained: gas, for

which purpose a coal was, for a time, so treated; coke, which has subsequently become important in the smelting of iron ores and tar, a complicated mixture, which for many years was a waste product. Studies of this tar showed the presence of many valuable substances, among them a limpid, water-like liquid, with a characteristic odor, which burns with a sooty flame, called "benzene," or benzol. This liquid, which contains carbon and hydrogen in equal atomic numbers, must not be confused with our ordinary "benziue" used for cleaning, which also contains these same chemical elements, but in different proportions, and is obtained primarily from American petroleum. When benzene is treated with concentrated nitric acid, a liquid named nitro-benzene is obtained, In turn, when hydrogen is generated in the nitro-benzene, it is changed into aniline, also a liquid. In fact, aniline is the benzene in which one hydrogen atom has been replaced by what is called a compound radical, namely, one nitrogen atom combined with two atoms of by. drogen. The reader is spared further technical discussion, but to illustrate to the uninitiated, a diagram is given to show the steps: Nitro-benzene. Aniline.

Benzene.

CN.H CH: NO2 CHs:NH, Perkins oxidized this aniline by heating it with the proper chemical and obtained his "mauve, which gave a beautiful fast color to silk and wool. By elaboration of the method of application, cotton was also dyed, and thus in England was founded the coal-tar industry. This was followed quickly by the discovery of fuchsin in France and magenta in Germany. From "The Coal-Tar Industry and Its Jubilee," by Charles Baskerville, in the American Monthly Review of Reviews for October.

THE tenderness in appendicitis may not be (probably usually is not) just at McBurney's point. The base of the appendix is, however, usually at, or near, that point. The site of greatest tenderness is often over the tip of the appendix. A line drawn between that site and McBurney's point will many times represent the general direction in which the appendix is lying.

CALCIUM SULPHID FOR COUGH.- French recommends (International Clinics) calcium sulphid one grain three or four times a day in the coughing of bronchiectasis, fetid bronchitis and the mixed infection of late tuberculosis. When the remedy is given an hour or so after meals, unpleasant eructations are avoided. The sputum is reduced in quantity as the pus-forming cocci diminish under this treatment.

MEDICAL MISCELLANY

THE WESTERN SURGICAL AND GYNECOLOGICAL ASSOCIATION.-At the annual meeting of this association, held at Salt Lake on September 1st and 2d, the election of officers resulted as follows: President, Dr. C. W. Oviatt, of Oshkosh, Wis.; vice-presidents, Dr. S. C. Baldwin, of Salt Lake, and Dr. Jabez N. Jackson, of Kansas City; secretary and treasurer, Dr. A. T. Mann, of Minneapolis. St. Louis was named for the next place of meeting.

THE DELAWARE ANTITUBERCULOSIS So. CIETY, which was incorporated recently, will build a sanatorium and dispensary for the tuberculous near Newcastle, on a plot of ground of several acres, given by a member of the Du Pont family. Patients will be cared for in tents until the buildings are completed. The establishment will be constructed along the same lines as those followed at White Haven, and recommended by Dr. Lawrence F. Flick, of Philadelphia. Dr. John J. Black is at the head of the movement, in which many prominent citizens of the State are interested.

A MUNIFICENT BEQUEST TO THE LLOYD LIBRARY OF CINCINNATI-- It is announced that by the will of the late Surgeon General James P. Walker, of England, the Lloyd Library receives the sum of $30,000 and the entire library owned by the distinguished surgeon. The collection of books and manuscripts is known to scientists as one of the most valuable private collections. The Lloyd Library, which is free to the public, and is devoted to botany, pharmacy, materia medica, and allied sciences, was founded by Mr. John Uri Lloyd and Mr. Curtis Gates Lloyd.

SUBINVOLUTION OF THE UTERUS: HOW IS IT BEST PREVENTED?-Dr. Joseph B. De Lee advises the following to prevent subinvolution of the uterus: 1. Avoid sepsis; conduct the labor with the same aseptic and antiseptic precautions that one uses in laparotomies. 2. Leave the cases to nature as much as possible. Avoid practices to shorten the life of normal labors. 3. Avoid lacerations of the cervix. Repair them if deep or if they bleed. Repair the torn perineum accurately. 4. Leave the uterus empty of clots, membrane, and placenta; therefore conduct the third stage of labor properly. 5. If the uterus does not decrease in size rapidly in the early puerperium, give ergot. 6. Don't allow the patient to lie on her back too long. 7. Build up an atonic general system. These are my means of prevention, and I have had only two cases of subinvolution in twelve years' practice. Southern Medicine and Surgery.

FRENCH SCALE FOR AMERICAN CATHETERS. --At a meeting of the American Surgical Trade Association, held in Philadelphia, June, 1906, it was resolved after January 1, 1907, the trade adopt the French scale for all catheters, bougies and sounds. A committee was appointed for the purpose of getting up a proper and accurate French scale card, and the same will be mailed to physicians. Every physician will see the importance of this step, as they are all acquainted with the annoyance of having catheters, bougies and sounds, and other instruments marked in American, English or French numbers. They are requested from above date to use only the French scale in ordering such goods, and when no scale is specified orders will be filled by the French scale.

THE FLOATING HOSPITAL OF ST. JOHN'S GUILD. According to the Brooklyn Daily Eagle for September 2d, St. John's Guild has had one of the heaviest seasons in its history, not only on account of the large number of mothers with babies and children who have come to its floating and seaside hospital for treatment, but because of the unusual number of critically sick cases. To meet the need for this service, which still exists, it has been decided to keep both hospitals in operfloating hospital will continue its daily trips ation for a longer period than usual. until September 8, the Saturday before the public schools open. The seaside hospital at New Dorp, Staten Island, will keep open indefinitely, or as long as there are funds to continue its work. Thus far the floating hospital has carried over 36,000 women and children and the seaside hospital has admitted over 2,500 patients, for an average stay of ten days.

The

A NEW METHOD OF LIBELING.-The PostGraduate comments on a new form of libeling recently reported from London, as follows: "A woman named her illegitimate offspring for the doctor who took care of her, and it was two years or more before he was able to get the matter straightened out with a written statement from the woman herself and her mother. We speak of this because it was not uncommon in years gone by in the maternity hospitals here for mothers of fatherless children to name their offspring (according to the sex) for either the nurse or the doctor who happened to take care of them, and we suspect that some of the physicians, after they have gotten along in life and have entirely forgotten the compliment paid them in their hospital service, will wonder where their namesakes came from. We have never heard of any misuse having been made of what was thought to be a compliment to the skill, care and tenderness of the attendants."