fection, as in many cases of loose kidney, there may be little or no tenderness at McBurney's point, but there is persistent tenderness at the point here described. There is no tenderness at the point of the left lumbar ganglia." Under these conditions (a, b, c) the point here described is of primary importance, while McBurney's point is of secondary or no significance. It will be found useful in differentiating between appendiceal and pelvic irritations. If it is alone tender, it means appendix trouble. If both right and left lumbar ganglia points are tender, it signifies pelvic disorder. If neither of these points are tender, the abdominal irritation must be looked for somewhere higher up than the pelvis or the appendix.

The General Surgical Klemm (Volkmann's Infections Following Sammlg.klin. Vortr., Acute Ostemyelitis. N. F., 456-457, 1907). Upon the basis of his investigations the author arrives at the following

conclusions:

I. There is no difference between septicæmia and pyæmia.

2. Both these terms should be abandoned, as liable to lead to misunderstandings and misconceptions.

3. The blood mycosis is best designated ætiologically as a staphylo-mycosis, streptomycosis, etc. The clinical character of the infection may be specified by the term metastatic or non-metastatic.

4. In those cases where the special bacteriological diagnosis cannot be rendered the terms metastatic or non-metastatic blood infection are applicable.

5. The most common cause of blood infection, especially in youthful individals, is furnished by the suppurations of the lymphatic tissue.

6. The great groups of blood infection may be differentiated: (a) the naso

oro-pharyngeal type; (b) the intestinal type; (c) the medullary (bony) type.

7. Osteo-myelitic infection of the blood takes, as a rule, a metastatic course. 8. The presence of metastases can sometimes not be clinically demonstrated, although these exist anatomically.

9. The outcome of the infection is dependent upon its degree and upon the localization of the metastases.

10. The leukocyte curve, in combination with the temperature and pulse curves, may be utilized for the rendering of the prognosis.

II. Parallel curves are of favorable significance, whereas a divergence in such a way that a low leukocytosis corresponds to a high temperature must be regarded as a very gloomy sign.

12. An extremely favorable influence upon the course of the infection is exercised by sweating, in transpiration beds and by the subcutaneous infusion of physiological salt solution. F. R.

drainage, the peculiar shape of these abscesses preventing the escape of the pus. F. R.

The Asepsis of Spinal Grosse (Münch. Anæsthesia.

med. Wochenschrift,

No. 40, 1907). The present method of sterilization of the instruments serving for spinal anesthesia only very imperfectly meets the double requirements of a rigorous asepsis and the exclusion of all other substances. The entrance of the latter into the lumbar canal is responsible for a part of the undesirable by-effects of spinal anesthesia, such as rise of temperature, headache, nausea and vomiting,

etc. The author therefore suggests the employment of steam as a sterilizing agent, and gives the description of a useful apparatus for the purpose. The instruments are placed in a closed glass tube, in which they are exposed for 10 minutes to the action of steam. After cooling and drying they are ready for use. Since the adoption of this procedure the author observed no particular by-manifestations or after-effects of spinal anæsthesia. Steam sterilization of instruments is recommended by him also for all other operations, in order to guard against the entrance of foreign substances into the wound. F. R.

case of pleurisy should be settled as far as possible, as it is a most important point both for treatment and prognosis. James Barr (Bradshaw Lecture, Brit. Med. Jour.), in a discussion of the cause and treatment, says that every case is due to some micro-organism or their toxins. Even those cases following injury or cold have only thus been rendered vulnerable. This also applies to those cases associated with some chronic illness, such as granular kidney, or those due to extension from the pericardium or peritonæum. The vast majority of cases are tuberculous, but a considerable number are rheumatic or due to pneumococci, streptococci, staphylococci, the bacillus coli, typhoid bacilli and the influenza bacilli, etc. Many of these organisms are readily found in the serous effusion, but not the tubercle bacillus. It is often difficult in any given case to decide whether it be tuberculous or not. If any evidence of tuberculous

disease is found in the lungs or tubercle bacilli in the sputum, the question may be considered settled. Failing this direct evidence, add a little citrate of sodium to the fluid withdrawn to prevent coagulation, then centrifuge, and examine the sediment for leucocytes, tubercle bacilli and other micro-organisms. If the case be tuberculous, the cells will be mostly lymphocytes, whereas if the pleuritis be due to other micro-organisms the polymorphonuclear cells will predominate. Even in undoubted tuberculous cases generally tubercle bacilli are not found, and the injection of the fluid into the guineapig is a very slow and often impracticable test. A blood count often assists, as in tuberculous pleurisy there is no leucocytosis, whereas in that associated with other processes there usually is. A hæmorrhagic effusion is usually associated with tuberculous or malignant disease. A specific gravity of 1018 is generally put down as the dividing line between a transudate and an exudate, but it does not al

ways hold good, as in some undoubtedly inflammatory cases the specific gravity of the fluid is as low as 1006.

Cases of dry pleurisy are frequently tuberculous, though not necessarily so. In such cases there is a small effusion of plastic lymph, which is gelatinous in appearance and consistence and contains a large number of cells with a relatively small amount of fibrin. This effusion quickly organizes and joins the two pleural surfaces together. In tuberculous cases accompanied by effusion there is not much fibrin, and even the cellular elements may be small in amount. In pneumococcal pleurisy there is usually a large amount of fibrin whether there be much fluid or not. Those cases associated with streptococci, staphylococci and bacillus coli are frequently purulent or sero-purulent and contain a large number of cells, and in the case of the bacillus coli the fluid is very offensive. In cases of transudation the liquid contains a few endothelial cells and much fibrin, and the specific gravity is below 1018. There are many cases, such as those arising in chronic Bright's disease, when the effused fluid is a mixture of a transudate and an exudate.

Pernicious Anæmia and Ceconi (Rif. Med., Cancer of the Stomach. July 6, 1907) points out the extreme difficulty in certain cases in differentiating between latent cancer

of the stomach and pernicious anæmia. By latent cancer of the stomach he means cases where there are many signs and symptoms suggesting cancer (for example, pain, sickness, vomiting, hæmorrhage, loss of weight, etc.) and yet nothing can be felt to suggest the existence of a new growth. Again, some cases of pernicious. anæmia may show absence of HCl after a test meal. The only real test is an examination of the blood, which shows the characteristic changes of pernicious anæmia (megaloblasts, poikilocytosis, megalocytes, etc.). But there are some cases of true pernicious anæmia where for some not easily explained reason megaloblasts are not present in the blood. These are known under the name of "anæmia aplastica." The case recorded by the author never showed any megaloblasts in the blood. The diagnosis of pernicious anæmia as against gastric carcinoma was found chiefly on (1) the leucopenia present (leucocytosis being more often seen in carcinoma); (2) the hæmorrhagic diathesis; (3) the contrast between the general nutrition and the degree of anæmia; (4) the functional state of the stomach and intestine (achylia diarrhoea), and (5) the presence of indicanuria. Laparotomy was performed and a few days later an autopsy, and no new growth was found, but abundant evidence of profound anæmia.

the

Maternal Mortality in Dr. F. G. Goldsborthe First 5000 Obstet- ough reviews rical Cases at Johns record of Johns HopHopkins Hospital. kins Hospital (Bulletin, January, 1908) for the purpose of determining the maternal mortality as

well as the relative seriousness of the various complications.

He says that their obstetrical department embraces two services, one an outdoor service, the other the house service. The first is somewhat larger, including

2750 cases, the second 2250 cases. Whenever possible abnormal cases are brought into the hospital. This explains the preponderance of fatalities among the hospital cases, among whom 48 out of the 55 deaths occurred.

Of the 5000 cases 4631 (92 per cent.) were delivered at term, while 369 (7 per cent.) failed to progress, a proportion of twelve to one. The causes of death were divided into groups: (1) Infections, (2) toxæmia, (3) hæmorrhages, (4) all other causes. In group one the relation of operative procedures to obstetrical infection is instructive. Thirteen per cent. were operative, with a mortality from infection of 1.37 per cent. Craniotomy, Cæsarean section were included.

Group 2. There were 16 deaths. Eclampsia was the most frequent form. of toxæmia met with in this series. Onehalf of the fatalities from this cause occurred within 12 hours after admission to the hospital.

It is generally conceded that nephritis may give rise to intoxication during pregnancy independent of its association with eclampsia. Two such cases terminated fatally. Two fatal cases of vomiting of pregnancy also occurred.

Group 3. There were eight deaths in the 5000 cases attributable to excessive loss of blood-a mortality of o.16 per cent. Viewed from the total number of deaths, of which they constituted 14.5 per cent., these fatalities demonstrate the importance of hæmorrhage as a cause of death in obstetrical practice, ranking third, being preceded by infection and toxæmia. The anatomical basis for the excessive loss of blood was most frequently placenta prævia, which was present in onehalf of these cases.

Group 4 includes death from intestinal obstruction, typhoid fever, pneumonia, thrombosis, embolism and exophthalmic goitre.

Anæsthesia would seem to be accountable for but a single death in the 5000 cases, and in this instance æther was employed. It is indeed notable that no fatality from chloroform occurred, although it was given as a matter of routine to every patient at the end of the second stage of labor and to the point of complete anesthesia when the vulva was fully distended. Abstracts of histories of selected cases are also given.

The Sensitive Short Dr. Edward J. Ill of Uterosacral Ligament; Newark, N. J., in a Its Clinical Signifipaper read before cance and Treatment. the Southern Surgi

cal and Gynecological Association, drew attention to the sensitive short uterosacral ligament as a pathological entity. Schultz and Burrage had written of the condition long before this. Schultz gave no special advice as to treatment, while Burrage recommended incision of the ligament through an abdominal section. Ovaries had been sacrificed under a false apprehension. The condition should not be confounded with intraperitoneal adhesions or with shortening of the base of the broad ligament due to scars resulting from puerperal injuries. Outside of the acute pelvic exudate, the writer knew of no condition so painful on pressure as the short and sensitive uterosacral ligament. During the last 12 years 5 per cent. of all his operative gynæcological patients had suffered with a short and sensitive uterosacral ligament. When but one ligament was diseased, it occurred in 73 per cent. on the left side. The disease might be congenital or acquired either in childhood or during active sexual life. Because of the short ligament fixation of the uterus resulted. The circulation of the organ became impaired. Catarrhal and metritic changes resulted in menstrual disturbances. In the acquired case, when but one ligament was short and sensitive, the

The

pain was commonly referred to the sacroiliac synchondrosis or the iliac region of that side. Menstrual pain seemed to be common to all, and was produced by metritic and endometritic changes. neurasthenic cases offered a bad prognosis. Sterility was a frequent symptom, and abortion sometimes resulted from a very short ligament. The objective effects, when both ligaments were shortened, were to elevate the uterus and drag it into the hollow of the sacrum. Its mobility was much impaired. When one ligament was short the uterus was elevated and displaced to the side of the short ligament and retroposed. The short ligament stood out sharply when the cervix was drawn forward and downward. Great pain resulted from such a procedure. The prognosis was bad for those who came from a neurotic family or where from long-standing conditions the resulting pathological changes had become incurable. The operation suggested by the writer consisted of a most thorough stretching of the tense and sensitive uterosacral ligaments, while the patient was under profound anæsthesia, until the uterus became freely movable. A free A free dilatation of the uterus with graduated steel sounds, curettage, etc., should be added. New York Medical Journal, January 25, 1908.

nearly or entirely dilated. The waiting was dangerous to the child. When the placenta is central, two fingers introduced for combined version should be passed around the front lobe, if possible, as this is less injurious to the child than boring through the placenta. Rarely any child survives when this is done, and consequently there is no need for haste in delivery. None of his patients have been benefited by Cæsarean operation. The total mortality was 8 per cent. He suggested the prompt removal to a maternity hospital in suspicious cases of placenta prævia.

Two Cases of Puerperal Sepsis Treated by Vaccines.

The Edinburgh Medical Journal for January, 1908, has the following abstract, which is of particular interest to the readers of the MEDICAL REVIEW OF REVIEWS:

Lloyd (Intercolon. Med. Journ. Austral.) reports the following cases: Case I-Patient, I-para, æt. 18, was admitted to hospital with a temperature of 101° F., and pulse 110, membranes ruptured, os the size of a florin. The patient was delivered with forceps next day, and the placenta was removed manually, sterilized rubber gloves being used. Four hours. later patient had a rigor; temperature 103°, pulse 168. On the third day cultures of uterine discharge showed streptococcus and staphylococcus. The uterus was plugged with iodoform gauze, and strychnine, iron and alcohol given internally. Later the uterus was swabbed with 2 per cent, solution of formalin and replugged. As the patient's condition did not improve, a vaccine was made, and an injection containing 100,000,000 cocci given on the sixth day, the blood examination at the same time showing a pure culture of Staphylococcus albus. Next day there was a leucocytosis of 21,800.