The Medical Fortnightly

a late tertiary manifestation. In the first variety, other symptoms of the constitutional disease make the diagnosis clear. It is in the second variety that diagnostic errors are so frequently made. It occurs in two forms: 1. As a true interstitial orchitis. 2. The gummatous variety. The first variety occurs late in the course of the disease, and may appear long after other symptoms have disappeared. The enlargement is usually gradual, and for some time may not attract the patient's attention. While there may be slight pain at first it soon disappears, and when the condition is well developed, in most cases, the testicle is insensitive to pressure. The enlargement is smooth, hard and board-like, and the gland is about twice its normal size, or even larger. The epididymis is usually not involved. Both testicles may be affected, though usually but one is. The gummatous variety is characterized by the formation of multiple nodules and by the greater size of the testicle. When a patient presents himself with a large smooth testicle, hard, and almost entirely insensitive to pressure, it is next to impossible to make a differential diagnosis between syphilis of the interstitial variety and some form of malignant disease. The additional question of a possible tuberculous origin may further obscure the diagnosis. The "clam shell"'enlargement of the epididymis which Keyes considers pathognomonic of the gummatous variety would help to clear the diagnosis in that form of the disease. To quote from his book: "The globus major is commonly involved, globus minor less often. The inflamed portion of the epididymis forms a solid mass with a sharp edge which I have seen half as large as the palm of the hand. It caps the end of the testicle, separated from it by a distinct sulcus, so that the organ seems to be resting in a clam shell. There are no nodules, as in tuberculosis, and the cord is uninflamed. The pathognomonic clam shell is usually seen above the testicle, sometimes below it; at the same time the body of the testicle is usually implicated."

The Diet and Albuminuria.-H. Stern, New York (Jour. A. M. A., Nov. 17), recapitulates the results of a series of experimental studies of 82 patients who had the one common symptom of excretion of serum albumin in the urine. The object was to determine the influence of certain types of nutritives and ingests not on the underlying disease, but on the accompanying symptoms of albuminuria. The substances tested were proteids in the form of milk, eggs and meats. The commonly employed carbohydrates and water. Before adding the other proteid-containing in

gesta the patients were kept on an exclusive milk diet for two weeks; other proteid materials were then substituted for the milk. The changes observed during the milk diet were diminution of the albumin, in the larger number of cases in which any changes at all ocourred, and in a smaller proportion, an increase. The influence of rest in diminishing the albuminuria seems marked in these experiments. The change to other proteid diet was more frequently accompanied by a transitory increase than by a decrease though_in the majority, no effect was observed. His conclusions as regards carbohydrates and fats are that they have practically little effect on the production of albumin and rise and fall of the albuminuric excretion. The ingestion of large amounts of water, while it enhances diuresis and intestinal peristalsis, and favors gastro-intestinal disorders, has little or no effect on the albuminuria in the vast majority of cases. With smaller amounts (up to 35 c.c. per kilogram of body weight daily) there may be slight temporary but not permanent augmentation of the albuminuria. treatment of albuminuria per se the maximum amount of water taken is of little practical importance unless some advanced heart or kidney trouble, or some gastrointestinal disorder exists; and the minimum amount of water should not for any length of time be less than is required for the introsystemic osmotic processes.

In the

The Treatment of Tuberculosis of the Urinary Tract of Women.-E. Garceau, Boston (Jour. A.M.A. Nov. 3), reviews the subject of tuberculosis of the bladder, kidneys and ureters in women, reporting eighteen cases. The prognosis of these conditions is today vastly better than it was, thanks to better means of diagnosis and better methods of treatment. The treatment of vesical tuberculosis is considered under the three heads of hygiene and climate, local treatment and surgery. In very early cases in the well-to-do and in those not suffering severely a change of climate, with close observance of hygienic requirements, exercise and rest, abundant nourishment and constant medical supervision, will be best to begin with and has affected cures. Patients suffering severely demand immediate relief. A general hygienic treatment is also recommended in very advanced cases in which the whole urinary tract has been invaded; in these, outdoor life in a well-regulated sanitarium will make conditions more endurable while life lasts and may even arrest the disease. Vesical tuberculosis has two stages; the one before tubercle formation, and the other after. In the first, local treatment does no good and is ex

cessively painful and it is best to enjoin rest and to administer general sedatives. The urine should be kept as bland as possible and hygienic measures, rest and a regulated diet should be insured. In the second stage when the tubercle has broken down and ulcers are appearing, local treatment with corrosive sublimate and nitrate of silver can do a vast amount of good and sometimes effect a cure, and a great advantage is that the method can be carried out in hospital practice and is available for the poor. Garceau gives details of the methods of using both these remedies, the former in solution according to the Guyon method and the nitrate by direct application to the ulcers under local or general anesthesia. If this treatment should fail or it can not be borne by the patient, recourse should be had to a vaginal cystotomy which gives immediate relief and makes subsequent local measures more endurable. He believes that it should be resorted to early in a larger number of cases, provided the patient is willing to submit to subsequent careful supervision. Tuberculous ulcers only rarely are deep enough to require excision, and this measure should be resorted to only after failure of the persistent use of nitrate of silver. Granulations may call for curetting, but this should never be done in an early case while the tubercles are just appearing as it çan then do nc good and only opens up new areas for infection. Incipient kidney tuberculosis is best treated by a change of climate, but this is sometimes disappointing, and it is, moreover, seldom diagnosed in the incipient stage. Its frequent association. with tuberculous disease in other parts of the body is also noted by Garceau, and the additional peril it involves in operation. Nevertheless a moderate focus elsewhere does not absolutely prohibit operation and the question must be decided according to the surgeon's judgment. A diseased kidney left in the body can only do harm and in time. must be fatal, so a certain risk is justifiable. The mortality of nephrectomy, though still high, has been reduced and improvements in technic and better selection of cases will probably reduce it still more. Nephrotomy is only palliative and unless followed by nephrectomy leaves usually an intractable fistula. When the two operations are done successively the results have been brilliant and in bad purulent cases this should be the course adopted. Resection is unjustifiable as one can not be sure of leaving no diseased tissue. A tuberculous ureter should always be removed and an ulcer of the bladder at its lower end can well be removed with it. the ureter is diseased only in its lower portion it may be worth while to try the climate

cure before operating. Eighteen cases of bladder and kidney tuberculosis are reported and discussed, including three absolute cures. In two of the bladder cases the disease was primary, but the series does not throw much light on the question of primary involvement of the kidney. Garceau thinks that a more careful routine practice by physicians of watching for symptoms and of urine examination ought to aid us in this matter.

CORRESPONDENCE

PHILADELPHIA, December 5th, 1906.

MY DEAR DR. HOPKINS:

I have just received a copy of the MEDICAL FORTNIGHTLY for November 26th with a note on some "Errors in Medical English" to which I called attention. I am very much obliged to you for copying this, because it is only in this way that we can diffuse the knowledge of these errors. Curiously enough, my criticism of the use of such a phrase, "Three Further Cases have been Observed and Operated Here," seems to have been interpreted as a criticism of the use of the word "case" instead of "patient" or some equivalent, missing entirely the point of the criticism on the verb "operated" instead of "operated on Yours very truly,

or upon.

W. W. KEEN.

After tracheotomy the air of the phtient's room should be kept reasonably warm and moist. Draughts of cold air provoke much irritation.

Aneurism of the Posterior Wall of the Left Ventricle.-Riehl's (Münchner Med. Wochenschrift, Oct. 30, 1906) case is all the more noteworthy on account of the unusual location of the aneurism. The patient, a woman eighty years old, presented the following subject symptoms: attacks of dyspnea with a sense of oppression in the precordial region. Pain in the region of the heart radiating in the arms (angina pectoris), quite a constant symptom of aneurism of the heart, was absent. The objective symptoms were those common to sclerotic changes; dyspnea and cyanosis, cardiac murmurs-a small pulse, but no enlargement on percussion, either to the right or left, was discernable. The lungs were emphysematous. At the autopsy there was found, among other things, a thrombosis and complete obliteration of the posterior branch of the right coronary artery with an unruptured aneurism of the musculature about the size of a hen's egg.

MEDICAL MISCELLANY

ALCOHOL in diabetes is advocated by American Medicine on the ground that there is reason to believe that the first step in sugar metabolism by the cells is to convert it into alcohol. During the period then that sugar and starches are withheld it is believed to be well to deliver alcohol to the cells in minute doses and frequently, in order that the body may, by being built up, secure control of sugar metabolism. Small doses frequently repeated and well diluted appear to give excellent results.

THE HOT SAND BAG.-Many people appreciate the value of a hot water bag to relieve pain or improve the circulation. It is said that a hot sand bag is still better for this purpose. A physician gives the following directions: "Get some olean, fine sand, and dry it thoroughly in a kettle on the stove; make a bag about eight inches square, of flannel, fill it with the dry sand, sew the opening carefully together, and cover the bag with cotton or linen cloth. This will prevent the sand from sifting out, and also enable you to heat the bag quickly by placing it in the oven or on the top of the stove. After once using this you will never again attempt to warm the feet or hands of a sick person with a bottle or a brick. The sand holds the heat for a long time, and the bag can be tucked up to the back without hurting the invalid."

A DYING PROFESSION.-The Medical Age for October 25th says that an interesting commentary on recent progress is shown in a statement recently made by the president of the London Royal College of Veterinary Surgeons, who asserts that in so short a period as three years from the present time there will be employment for only 300 veterinary surgeons in London. Before automobiles were introduced into the English capital 6000 veterinary surgeons were practising their profession in that city. This is prob ably the first instance in the world's history where machinery has affected those following a profession; heretofore only the trades have been in any way affected by the introduction of some labor-saving device.

THE PUBLIC HEALTH DEFENSE LEAGUE. -A national society for the protection of health and morals, to be known by the above title, was formed November 15 in New York City, under the auspices of the New York County Medical Society. Resolutions adopted define the objects of the society as follows: To disseminate accurate information concerning practices dangerous to public health; to work for the enactment of laws in prevention of quackery and criminal practhe interest of public health; to work for the tices; to prevent adulteration and substitution of drugs and foods, and to prevent the sending through the mails of matter advocating quack medicines. A large number of laymen were present and practically directed the meeting.

MASSACHUSETTS ADMITS THE HOMEOPATHS. -At the one hundred and twenty-fifth annual meeting of the Massachusetts Medical Sociey, held at Boston, June 12 and 13, the question of amending the by-laws relating to membership in the society provoked an animated discussion. For thirty years or more the society had forbidden its members to practice "spiritualism, homeopathy, allopathy, Thomsonianism, eclecticism or any other irregular or exclusive system, generally recognized as such by the profession, or de

TABLET IN HONOR OF DR. WALTER REED. -At its annual dinner, November 21, the Society of Ex-Internes of Kings County Hospital, Brooklyn, presented to the hospital association a bronze memorial tablet in memory of the late Walter Reed, who was an interne there in 1871, prior to his entrance into the medical department of the United States Army. The presentation address was made by Dr. A. T. Bristow, and that of acceptance by R. W. Hibberd, commissioner of public charities of New York City. Short addresses commendatory of Dr. Reed and his work were made by Dr. Howard Kelly of Johns Hop-clared so by the councilors of the society." kins University, Dr. Joseph Bryant of New York City, the Rev. Lindsay Parker, and Colonel Phiilp F. Harvey, assistant surgeon general, United States Army. The tablet bears the following inscription:

"Erected by the Association of Ex-Internes of Kings County Hospital to the memory of Walter Reed, M.D., interne in this hospital, 1871. Major and Surgeon, U. S. A.; chairman, U. S. Yellow Fever Commission, 1900-1901. He robbed the pestilence of its terrors and caused the cities of the southland to sit in peace within their gates."

Practically homeopaths formed a class chiefly under discussion, and a committee, of which Dr. F. C. Shattuck of Boston, was chairman, after calling attention to the demise of some of the other sects, presented an amendment allowing, under strict educational qualifications, one to become a member, provided he does not profess to treat diseases by, or does not intend to practice any exclusive system, generally recognized as such by the profession, or declared so by the councilors of the society." After considerable discussion, the amendment was adopted.

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