tis, if not too severe, possibly aids in the rapidity of the encapsulation of the drain. A drain in the presence of infection is deleterious to peritoneal resistance, and should only be introduced to exclude more malign influences. Postural methods, unless destined to facilitate encapsulation, are both futile and harmful, as far as drainage is concerned. Peritoneal drainage must be local, and unless there is something to be gained by rendering an area extraperitoneal, or by making from such an area a safe path of least resistance leading outside the body, there is, aside from hemostasis, no justification for its use."

The Injection of Air into the Circulatory System of Animals. In the Journal of Surgery, Gynecology and Obstetrics, Ezra Read Larned gives the results of seven experiments on dogs by injection of air in the crculation. It has been the general impression that if air should enter a vein when given a salt solution intravenous injection, the danger of death by air emboli was a thing to be anticipated. The injection of air in hypodermic medication is a very frequent daily occurrence, and yet no case of death is shown to have ever resulted. Pirogoff, Laborde and Muron found that when 200 grains of air was injected in jugular vein of a horse death resulted. Hare claims that the small air emboli are more to be dreaded than the large. The author found after injecting air into the circulation of animals merely a transitory dyspnea resulted, due to pulmonary emboli. Senn's conclusions from similar experiments are as follows: 1. A small amount of air in the right side of the heart in a healthy animal gives rise only to temporary symptoms, referable to the heart's action and the pulmonary circulation. 2. When air has been injected into the right side in such quantities as not to arrest the contractions of the heart itself, it is forced through the pulmonary capillaries into the left side of the heart by the contractions of the right ventricle. 3. The danger attending the insufflation of air into veins is proportionate to the amount of air introduced, as well as to the capacity of the right ventricle to resist intracardiac pressure. 4. When a fatal dose of air has been introduced into the circulation, death takes place almost instantaneously from arrest of the heart's action, or later from suffocation. 5. Spontaneous ingress of air into a wounded healthy jugular vein never occurred in these experiments, and must be considered almost a physical impossibility, as the resilent walls of the wounded. vein collapse readily when exposed to atmospheric pressure.

When we consider some abdominal and cervical operations and realize the amount o

air that must necessarily enter the circulation at the time we can not conclude otherwise that death from air emboli is uncommon. In the mere sewing up of wounds we always enclose a certain amount of air and never with ill effects. Still that death may ensue from air emboli we can not doubt, but the experiments indicate it must enter rapidly and in very large quantities. How it disappears after entering the circulation is a point not well explained. The air molecule is absorbed after disintegrating into its component parts of oxygen and nitrogen.

Cartilage Plates from the Scapula of the Calf for Liver and Spleen Suture.-Stamm, in Surgery, Gynecology and Obstetric Journal, comments on the article of Payr and Martin in Archiv fuer klin. Chruirurgie, in which the use of cartilage plates from the scapula of a calf are used for suture material in liver and splenic injuries. Anyone who has had to deal with these injuries can appreciate this suggestion. In experiments on dogs the cartilage plates were fully absorbed and no depression found at the site of suture. The cartilage plate is easily sterilized and its application does not entail much difficulty. The plates are fastened with mattress No. 2 dry catgut suture. A straight or curved needle is used.

Antiseptic Action of Bromine.-A solution of bromine two drachms, bromide of potash two drachms, and one pint of water, mixed and kept in glass stoppered bottle, has been used by Stroud in the treatment of infected wounds as an antispetic. The results obtained by Stroud justify the imitation by other surgeons.

Action of Roentgen Rays on the Blood.A very instructive article in the American Medicine, Morris explains after much clinical work the effects of the rays on the blood as follows: 1. The Roentgen rays cause a marked diminution in the absolute number of leucocytes in the peripheral circulation. 2. Preceding the leukopenia, there may be a moderate rise in the number of leucocytes from eight to twelve hours after the exposure, the increase being due largely to the greater number of polynuclear cells in the circulation (observed only in the rabbit); the same condition may be found just at the end of the exposure, subsiding rapidly. 3. The lymphocytes are especially susceptible to the action of the rays; they are affected first and most intensely. 4. Alterations in the histologic characters of the lymphoctyes and polynu. clear amphophiles may be found in the rabbit, similar to those described in the lymphoid tissue and bone marrow. 5. Hard tubes

produce the most marked changes in the leucocytes. 6. No noteworthy numeric or histologic alteration takes place in the red blood cells within the first few hours following exposure; the percentage of hemoglobin is not essentially within the same time.

PATHOLOGY AND BACTERIOLOGY.

R. B. H. GRADWOHL, M. D. Aneurism of the Right Sinus Valsalvae of the Aorta and its Relationship to the Upper Ventricular Septum.-Karl Hart (Virchow's Archiv, Bd. 182, Heft. 2, 1905) states that aneurism of the sinus valsalvae is not commonly spoken of in the standard works on pathologic anatomy. Orth speaks of its rarity. Heyman in his Dissertation of 1874 collected cases. English writers, Redi, Sibson, Peacock, have made most of the observations on the subject. They call aneurism of the sinus valsalvae "those cases which while not located directly in the sinus are seen at point behind the aortic valves, just on the edge of the sinus valsalvae, aneurisma which grow in such a manner as to obliterate the form of both sinuses. In this connection, a finding made by Rokitansky (Wiener med. Jahrbuecher, 1867, Heft III) is interesting, i.e., he reports an aneurism at the common insertion of the two aortic valves, that the sinus was separated from the valve attachment. Sibson and Peacock made similar observations. On account of the rarity of this lesion, it has been impossible to determine the exact relationship an aneurism of the sinus would bear to the right and left ventricular cavities, to the pulmonary artery, and to what extent a lesion of this kind would contribute to aortic insufficiency, and finally to rupture into the pulmonary blood vessels, into the pericardial sac or right heart. The right sinus valsalvae is most frequently affected of the three. Sibson accounts for this on the basis that the arterial wall is thinnest at this point (Med. Anatomy, London, Fasc. V). This can be explained from an embryological standpoint by the observations of His on the anatomic structure and the observations of Krzywicki on the pathologic changes induced at this point, to wit, the right sinus valsalvae lies over and anterior to the pars membranacea of the ventricular septum. Its wall is developed according to His, from the septum inferius aortae growing out from the right ventricle, which accounts for the fact that the right sinus contains the elements of the muscle of the right ventricular wall on the one side and on the other side, it is traceable directly to the maus

cular tissues of the ventricular septum. The walls of the sinus valsalvae (right) consists of the elastic tissue of the aorta, the intermediary connective tissue, and partly the muscular tissue of the right ventricle. Naturally, the wall is thinner than the walls of the other two sinuses, and, according to Krzywicki and Kraus, constitute a locus minoris resistentiae. Several reports of cases at autopsy are given in this paper. One of these cases showed an aneurism of the right sinus valsalvae perforating into the left ventricle of the heart. There was an insuffi. ciency of the aortic valves. The aneurism in this case was directed backwards, which accounted for its perforating into the left ventricle of the heart. A communication had been established between the aorta and the ventricular cavity, just as if it were an aneurisma dissecans. As causes of aneurism of the right sinus valsalvae, Krzywicki gives the following: (1) atheromatous (aneurisma spurium); (2) pressure on a locus minoris resistentiae (aneurisma verum); (3) lues.

Phlebitis Migrans (Non-syphilitica).-Gottfried Schwartz (Virchow's Archiv, Bd. 182, Heft 2, 1905) repcrts two interesting cases of phlebitis migrans which presented clinical symptoms of this disease, which were verified at the obduction in each case. The first case was a woman of forty years with well marked pulmonary tuberculosis. She had no specific history. She entered the hospital (Vienna) in March, 1903, and in May presented a painful swelling in the left sulcus cubitalis ulnaris. A few days later a palpable and visible strand-like swelling was seen extending from the sulcus bicipitalis med. to the axilla. The skin over it was slightly reddened. The arm seemed warmer than the right. In June the right arm became similarly affected. The sensory symptoms finally disappeared. The patient died of cachexia on July 6, and obduction showed chronic tuberculosis of the lungs. The superficial and brachial veins of both arms were excised. The second case, a man of 33 years, presented himself on April 24, 1903, showing lung tuberculosis with tubercle bacilli in sputum. No history of any venereal disease was elicited. On June 23 he complained of pain in the sulcus cubitalis ulnaris and in the sulcus bicipitalis medialis up to the middle of the left arm. At these places could be seen an edema and diffuse reddening of the skin; pressure showed tender cords along these sites. Immediately over the vena basilica mediana down on to the forearm, for a space of 7 mm. diameter could be seen a distinct, painful swelling. The pain disappeared in these places after a day or two, leaving the tender cord-like swellings behind.

It

But the painful areas extended distal-wards to the vena cephalia, and by the 2d of July had reached the middle of the forearm. could be definitely determined that the vessels affected were not obliterated. Blood continued to pass through them. On the 4th of July, an area 1 cm. by 3 mm. was seen over the left vena mediana antibrachialis. An

Vena ce

other node was seen on the right arm in the sulcus cubitalis ulnaris. The forearm was similarly affected afterwards, the first nodes. losing their painfulness. On the 27th of July, nothing remained but the thickened vessels. Death occurred on the 31st of July. Autopsy showed chronic tuberculosis of both lungs, atrophy of the muscles of the right upper extremity, acute hemorrhagic nephritis, skin covering this part pale. phalica thickened. The intima showed no visible changes. The veins of the right arm were excised, as in case 1, laid open and hardened in 95% alcohol, imbedded in celloidin and cut into sections. These sections showed that the intima was not affected and that the process was an inflammatory one, affecting the media and the adventitia. There were numerous round cells and lymph cells in these two parts of the blood vessel wall. The cases were apparently free from syphilis. The writer explained the phlebitis on the ground that he had to deal with a chronic disease (tuberculosis of the lungs), that the patients were bed-ridden for some time, that they lay in bed with their arms under their head, thus making an undue pressure upon these arm veins; that there was a mixed infection, pus and tubercle organisms; that toxins of these two sources were floating in the blood stream and that with the pressure above described marking in the veins a locus minoris resistentiae, phlebitis began and ran from one vein to the other. In short he calls attention to the difference between this kind of phlebitis and the syphilitic form which was described by Neisser; in the syphilitic patient, phlebitis occurs in strong, healthy appearing persons, while in the non-luetic kind the patient was weak and bed-ridden. The syphilitic phlebitis yields readily to anti-syphilitic treatment only, while the cases just described seemed to do well under simple local treatment of compresses of aluminum acetate. In the syphilitic phlebitis, the veins histologically showed "islands of infiltration," while in the non-syphilitic variety there is a uniform infiltration. In the syphilitic phlebitis, the intima showed hemorrhagic areas, which was not true of these cases. In conclusion, the writer believes that there should be a distinction made clinically and histologically between the specific and the non-specific phlebitis migrans.

OBSTETRICS AND GYNECOLOGY

W. H. VOGT, M. D.

Origin of Oblique and Transverse Positions. -(Fritz Kermauner, Centralblatt fuer Gynaekologie, No. 34.)-An oblique position was observed by the author in a 19-year-old primipara. The pelvis was somewhat generally contracted, and the head lay on the left ileum. The patient was placed on her left side during labor in the hopes of correcting the position, but without any effect. An internal examination was then made, and it was found that the entire pelvis was filled with a fairly tense cystic tumor about the size of a child's head. The membranes were unruptured and the os was dilated to a degree sufficient to allow two fingers to pass. This tumor was immediately suspected as being the filled bladder. Upon catheterization 900 cc. of urine was drawn, whereupon the tumor immediately disappeared and the head entered the pelvic inlet. He mentions the fact that transverse positions in primipara with a full term child are rare and usually the causes of the same are obstructions preventing the presenting part from entering the pelvis as tumors, contracted pelves and that the bladder remained in the pelvis after in very rare cases placenta praevia. The fact being so tensely filled with urine makes this case interesting, for we know, although the bladder is a pelvic organ it rises out of the pelvis when greatly filled. Strange, too, is the fact that on the second day of the puerperium the bladder at one time contained 500 cc.of urine, and still it was not to be felt above the pelvic inlet.

Operative Treatment of Retrodisplacements. (Channing Barret, Surgery, Gynecology and Obstetrics, Nov., 1905).-The following propositions are made: (1) That retrodeviations of the uterus are frequent; (2) that they are pathological per se; (3) that they tend to create further pathology; (4) that because of the symptoms which they produce, and the further pathology which they create, they are with few exceptions, deserving of treatment. This treatment should be either operative or non-operative. Cases without intra-abdominal complications, with a fair pelvic floor and with only moderate pathology in the uterus, may be given the non-operative treatment if the conditions are such that the patient can remain under observation and treatment for some months. The best results are obtained in this class of cases shortly after delivery. All of the rest of the cases come under the head of operative cases. The requirements of any operation should be: (1) The operation must have the slightest mor

tality; (2) the incision must allow the correction of complications; (3) the operation must create the least possible pathology; (4) in a child-bearing woman it must allow of no interference with future pregnancy; (5) it must assure us of a permanency of results, with or without future pregnancy must stand Goldspohn's "double test of pregnancy;" (6) it must have the least possible morbidity. The author thinks well of the AlexanderAdams operation where no complications exist. But in order to find an operation that will meet with all the above requirements the author has devised the one described by him, and finds it extremely satisfactory. His operation consists in opening the abdomen by a median incision of 1 to 2 inches in length; intra-abdominal complications are then dealt with and the round ligaments are then picked up and a control ligature is thrown around each about 2 inches from the angle of the uterus. The edge of the aponeurosis over the rectus muscle is caught near the lower angle of the wound, and the author's curved ligature forceps are carried between the aponeurosis and the rectus muscle outward to the internal ring, where the forceps is guided into the abdomen, the control ligature is now grasped by the forceps, and along with it is a loop of round ligament, and the same is withdrawn. Each loop of round ligament while being held by the control ligature, is sewed to the under side of the aponeurosis with catgut, about one inch from the median line, and if the loops should be long enough they are sutured together over the recti muscles. He terms the operation intramural transplantation of the round ligaments. He believes that anything that can be said in favor of the Alexander-Adams operation as regards pregnancy can also be said of this operation.

OTOLOGY.

ALBERT F. KOETTER, M. D.

The Movement of the Ossicles and the Part They Play in Hearing.-L. Bard (Journal of Physiology and General Pathology) reports his observations in the study of physiology of the middle ear. First of all he differentiates distinctly between active and passive motion of the chain of ossicles, the former are caused by muscle contraction, the latter by movement of the tympanic membrane. The passive movement may be traced to three causes: 1. Driving back the membrane dependent on a considerable change of air movements. 2. Acoustic vibration of the membrane corresponding to the rhythmic periodicity of the sound waves. 3. Morpho3. Morphological deformation of membrane formed by

the wave motions of the air, these again dependent on the form of the tone waves, they are much slower than the others and differ with them particularly, in their variability, lack of periodicity, and the absence of oscillatory character. The first group of movements Bard ascribes to a function for the protection of the inner ear; the second group transmitting to the labyrinth the intensity, tone, pitch and location of noise; the third group is the acoustic form of the sounding body. The active movements of the chain of ossicles serve for the accommodation for tones. The first group of passive movements (refoulement tympaniques) plays no roll in the hearing, the second group of movements the true, acoustic vibrations take place without any participation of the articulations of the chain of ossicles. The third group was first described by the author, and he ascribes to it an important roll in the perception of acoustic forms. Regarding the accommodation the author remarks that the movements of the tensor tympani do not swing the malleus around its neck, but draws the handle toward the inside. These changes of the tension of the membrane called forth are the expression of the adaptation of the membrane to noise, respiration quiet. The contraction of the stapedius draws the neck of the stapes and with it the entire chain of ossicles, including the handle of the malleus, backward. Therefrom result differences of tension between the vertical halves of the membrane, making it possible for the membrane to adapt itself to the distance of the origin of the sound. Whilst he compares the internal muscles of the ear with the muscles of accommodation of the eye, he places the tensor with the iridis muscle (adaptation for the intensity) the stapedius with ciliary muscle (accommodation for distance).

Pathological Anatomy of the Inner Ear and the Question of Primary Brain Abscess. -(Schwabach).-Girl of fifteen received in hospital with headache, vertigo and nausea, which have been present for five weeks following a suppurative otitis media sinestra, which appeared seven weeks before. Left membrane slightly congested. Lumbar puncture reveals 40 ccm. of clear sterile fluid. Pulse continually sluggish. When author saw patient she was in a stupor, pupils irregular, deviation conjugée to the right, contraction of left elbow joint. Death occurred with the appearance of paralysis of respiration. Postmortem.-On right under medullary substance of the frontal lobe an abscess the size of a hen's egg filled with sterile pus, capsule several millimeters in thickness. Brain sinus free. Right petrous portion of temporal

bone clear; on left tough yellowish mucus in the tympanum. Histological examination besides slight inflammatory changes on the non-perforated membrane, small quantity of free pus, considerable tumefaction of the mucous membrane of the tympanic cavity. Eruption of pus, with partial destruction of the annular ligament of the stapes into the vestibule, furthermore, on different parts of the labyrinth capsule in the cavity of the cochlea, with simultaneous appearance of connective tissue and new bone formation in the spongiosa of the temporal bone. Slight changes in the mucous membrane of the mastoid cells. Extensive suppuration and connective tissue formation in the labyrinth, small cell infiltration of the vestibule, suppurative hemorrhagic exudate in the semi-circular canal both in the endo- and peri-lymphatic spaces. Inflammatory infiltration of the cochlear nerve, also traces in the vestibuler nerve. Facial nerve intact. Of importance is the incongruity between the comparatively slight changes in the middle ear and the extensive destruction in the temporal bone as well as in the cochlea. The brain abscess although it existed, in an otitis media suppurative sinestra, on the right side can be traced back to this suppuration, an abscess membrane can occur in abscesses whose existence can be dated back only a few months.

The Exudative and Plastic Processes in the Middle Ear.-(Goerke, Archiv fuer Ohrenheilkunde.)—The interesting and painstaking examinations of the author, embracing the post-mortem sections of hundreds of cases and the histological description of eighty temporal bones refer to the pathological anatomy of acute otitis media without perforation of the membrane. They prove first of all that

the exudates found so often in the middle ear cavity in post mortems are not transudates, but in fact inflammatory exudates. Whereas, the exudate was found in the tubes in small quantities, the tympanic cavity was usually entirely filled. Parts most often involved are the windows, the posterior pouch of the membrane, the floor of the tympanic cavity, the smaller and smallest spaces between the ossicles and their ligaments and Shrapnell's membrane. In the antrum and mastoid cells the exudate enters the dependent parts if it does not entirely fill them. The exudate undergoes remarkable changes until it becomes connective tissue. While now the epithelium grows down to the vessel carrying bridges which spread out between the mucous membrane and the exposed exudate there arise the so-called cavity proliferations of Preysing, a condition which was perhaps erroneously connected with the involution

of myxomatous tissue. In the bone there were observed in one case extensive softening, and in four other cases in a slighter degree. When the resorption foci are nearly all found in the mastoid process, Goerke thinks the tympanic cavity which is rich in connective tissue submucosa offers great resistance to the extension of the inflammatory process. Author has found the middle ear exudate almost exclusively in weak individuals, those suffering from long continued disease, which eventually causes death; he therefore thinks that the origin of the otitis (otitis of the cachectic) is favored by the lowered vitality and diminished resistance of the tissues with also the insufficiency of the normal protection. With this he divests, as compared to Preysing and others, the otitis media of the infant and many other middle ear inflammations considered specific, in so far as they belong to the above mentioned group, completely of their specific character.

The Relation of Diseases of the Circulatory System to Diseases of the Ear.-(C. Stein, Zeitschrift fuer Ohrenhilkunde).-Of the diseases of the circulatory system, arteriosclerosis, mitral stenosis and myodegenerative cordis are most frequently associated with disease of the ear, and in the majority of the cases, arteriosclerosis. The symptoms on the part of the ear were tinnitis, deafness and other subjective symptoms of a non-inflammatory nature, most often as a result of disease of the sound perceiving apparatus. Author thinks there is a direct connection between arteriosclerosis and diseases of the sound perceiving mechanism, which is of especial value to the clinician, in that the ear symptoms in conjunction with increased blood pressure, can be utilized as early symptoms of arteriosclerosis. The above mentioned affections of the circulatory apparatus influence the middle ear processes in that they favor the spread of the process to the labyrinth. The cause for the detrimental in

volvement of the ear is due to the anemia

brought about by disease of the blood vessels. Therefore all local therapy should be discarded, and in its place, the treatment of the heart, respectively the blood vessel affec

tion is advised.

PEDIATRICS.

A. LEVY, M. D.

"Gone Off His Legs."-(G. A. Sutherland, Brit. Jour. of Children's Diseases, March, 1905).-The occurrence of weakness of the lower extremities in a child previously able to stand, walk and run normally is a