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neurosis. In the third test alone it was excessive in seven cases, including two of subacidity and one each of anacidity, hyperacidity, ulcer, neurosis and cicatricial pyloric stenosis. In healthy persons, the author's observations substantiate those of Schmidt and Tellering, who assert that the presence of mucus in the stomach is insignificant. After reviewing carefully these various affections he believes his work in this direction will establish the conception of catarrh of the stomach on a more solid basis, although he does not attempt to draw any general conclusions.

Rhythmic Lateral Displacement of the Heart as a Sign of Unilateral Pleuritic Exudate.Greene's (Am. Jour. of the Medical Sciences, March, 1906) more extended observations have convinced him of the accuracy of a statement he made in 1902 regarding the value of rhythmic lateral heart displacements as a sign indicative of unilateral pleuritic exudate. This dispalcement is most marked in exudates of medium size. During inspiration the heart approaches the side containing the effusion, while during expiration it moves outward. The extent of the displacement is quite variable sometimes as much as two inches. The movements are easily controlled by the fluoroscope, auscultatory percussion, or in case of right sided exudate by deep percussion of the free cardiac border, or in some cases even by mere inspection of the apex beat. Forced inspiration and expiration, especially the latter are prerequsite to success of the phenomena, and to accomplish this the administration of morphin must sometimes be resorted to. These rhythmic lateral movements have not been encountered in pneumonia, pulmonary tuberculous infiltrations; malignant disease of the pleura or lung, or in subphrenic abscess.

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ulum it is so arranged that a rubber tube can be attached, and to this in turn can be attached a syringe or air pump. The speculum is placed on the portio and then suction is established at first only very slight, later gradually stronger. After a sufficient amount of suction is established the suction is stopped, this operation is done every other day for a period lasting thirty minutes each time. This form of treatment in cases of endometritis seems to draw from the uterus the secretion and the increased blood circulation evoked aids in restoring the endometrium to its normal condition. Under this form of treatment the author has seen tense painful bands in Douglas' cul-de-sac soften, and finally entirely disappear.

The Hemorrhage of Placenta Previa.-(A. M. Dermid (American Jour. Obst., Dec., 1905).—If in the early months of pregnancy placenta previa can be diagnosed an abortion should be produced. Later on, when hemorrhage has occurred, the vaginal tampon is recommended to control the bleeding, and for delivery Braxton Hick's method of version is advised. If a piece of placenta becomes detached severe hemorrhage may follow, and in this case the head should be brought down with forceps as soon as possible, in order to get the advantage of its pressure, the fur. ther delivery will depend on the urgency of the conditions. It may at times be necessary to do a Cesarean section.

My Experience in the Treatment of Retrodisplacements of the Uterus by Operations on the Round, Uterosacral and Uterovesical Ligaments. (A report of 129 cases by J. Wesley Bovee, Surgery, Gynecology and Obstetrics, Dec., 1905). Retrodisplacements of the uterus has become the bugbear of women, but no woman ever applied for treatement for uncomplicated retrodisplacement. Certain classes of cases are successfully treated without directly treating the displacement; yet there are a large number of cases which must be treated surgically. The etiological features. and the existing pathology must determine. the nature of the procedure. After a fair experience with various surgical operations for the cure of retrodisplacements the author says that he is convinced that the Alexander operation has a very limited field, which could be extended largely by Goldspohn's modification; that vaginal fixation is hazardous; that ventro-suspension is unsurgical and dangerous; and that the mechanical features of the forces that maintain the position of the uterus is too much ignored by all procedures. He believes that the vaginal roof, including the uterosacral and uterosvesical ligaments, is the structure largely concerned in holding

the uterus in normal position. Of the 129 cases 61 were operated by the vaginal route and 68 by the abdominal route, with no mortality. By the vaginal route the round ligaments alone were shortened twenty-one times, the uterosacral alone sixteen times, and both in 24 cases. In the 68 cases done by the abdominal route, curettage was done 62 times, trachelorrhaphy 12; perineorrhaphy 16; colporrhaphy 10; removal of both appendages 51; herniotomy 6; appendicectomy 49. The round ligaments were shortened by the Baldy method in 60 cases, and the uterosacral in 52 cases. He thinks his results as nearly perfect as could be expected from any surgical procedure. The following deductions are drawn: 1. That the complications rather than the displacement furnish the cause for surgical relief. 2. All operations done, having in view the correction of uterine displacements, should be based upon the pathologic and anatomic abnormalities of the uterus and adjacent structures. 3. That any operation that changes one dislocation of the uterus into another is illogical, and hence unsurgical. 4. As a rule, the largest proportion of cases of retroversion of the uterus that require special operations are best treated by proper procedures upon the round and uterosacral ligaments.

The Technique of Shortening the Round Lig

ament.-(C. H. Mayo, Surgery, Gynecology and Obstetrics, Feb., 1906). The following description is given by the author who has employed this method in many cases during the last two years: With the patient in the Trendelenburg position, the hand is inserted through a three or four inch median or slightly lateral incision in the lower abdomen and passed into the upper abdomen, to explore by touch the region of the gall bladder. As the hand is withdrawn the cecum is brought into the wound and the appendix examined. After dealing with such pathological conditions as are found, the pelvis is isolated from the general cavity by gauze and examined. The uterus is now placed in normal position. At the lower angle of the incision, a pair of curved forceps, Cleveland ligature carrier, or other similar instrument, is passed laterally beneath the aponeurosis, just over the muscle, to the point where the round ligament leaves the abdomen. This is facilitated by lifting the wall of the abdomen out and up with a tractor, also drawing the ligament tight with forceps from within. The handle of the instrument is now elevated, and its point seen from within is made to pass over the pulley of the round ligament, not under it, and only beneath the peritoneum, but is made to traverse the true course

of the ligament, passing with it beneath the peritoneum, and when one-third or one-half way to the uterus it is pushed through the peritoneum and the ligament grasped at a point from 1 to 2 inches from the uterus. This loop is withdrawn with the forceps. A similar procedure is followed on the other side. The loops are ligated together at the lower part of the wound.

Placenta Previa; A Series of 94 Cases.(R. Warren, Lancet, Feb. 3, 1906). In this able paper the following conclusions regarding the treatment of placenta previa are arrived at: The only certain means of arresting the hemorrhage is by pressure on the bleeding points. The progress and completion of the labor is secondary. In case of antepartum hemorrhages where the os will not admit a finger, bimanual and abdominal examination should be made, to reveal whether the placenta be implanted on the lower segment. These cases can almost certainly be saved if treatment be begun early. Labor should be induced early, since its completion is the ultimate cure. Should the os not admit a bag, or the performance of bipolar version, it must be dilated until one of the modes of treatment can be adopted. Having checked the hemorrhage the next step is to keep up the patient's strength. In severe cases this is best done by autotransfusion; i.e., raising the foot of the bed with chairs; next, in rapidity of action, comes intravenous infusion. Rectal injections cannot be given until labor is complete. As regards the third stage of labor, it is often necessary to remove the placenta manually.

The Gonococcus in the Puerperium, with Report of Seventeen Cases.-(W. S. Stone and Ellice McDonald, Surgery, Gynecology and Obstetrics, Feb., 1906.)-A review of the literature is given with a detailed report of 17 cases in which the gonococcus was found either alone, or in conjunction with the streptococcus or colon bacillus. All cases were in primiparae. In nine cases pain was located in one or both sides of the pelvic region and rigidity was marked in seven cases. The lochia were distinctly purulent after the fifth day and smears taken from the cervix after the discharge had become altered were much more apt to show gonococci than during the first few days. Premature labor occurred in three patients at periods varying from six and one-half to seven months. In one case there was streptococcus and gonococcus infection, suppurative salpingitis and general peritonitis. Another had a vulva-vaginal abscess. The third was uneventful and made a good recovery. These three abortions were the only late abortions occurring in 172 lying-in

patients. In view of this fact, it seems that the gonococcus may be a cause of late abortions, and in all cases of unexplained late abortions this infection should be considered. Gonoccccus conjunctivitis occurred in three infants. No infant at birth showed any signs of inflamed eyes, and all had Crede's treatment from the prevention of the infection. The conclusions are the following: Gonococcus infection was present in a much larger proportion of cases of the obstetrical clinic than was previously supposed by the writers. The failure to discover the gonococcus by means of smears is explained by the fact that such smears are usually taken early in the puerperium, and are obscured by blocd. The positive diagnosis of the gonococcus is difficult in the absence of pus cells, and these do not, as a rule, appear until later in the puerperium. The temperature cure of the patients having fever were so varied and differed so much from one another, that no reliance could be placed upon this as an aid to diagnosis. The most common type, however, seemed to be that of a sudden rise followed by return to the normal in three or four days, simulating sapremia. The puerperal state has a direct influence upon the course of the disease. Gonorrhea, which has been latent before labor, commonly spreads upward with rapidity during the puerperium. Gonorrheal infection is a frequent cause of abortions, and in all cases of late abortions this should be considered. Thus if adnexal disease follows an abortion, it should not be ascribed to the abortion, as gonorrheal infection may have been the cause of both. No positive conclusions are drawn as to the relation of this infection to nutritional, or other disturbances in the children, except from the well known frequency of ophthalmia. The morbidity and the mortality, however, are relatively so marked in this series of cases that a relation between the disease in the mother and nutritional disturbances in the child is probable.

GENITO-URINARY.

T. A. HOPKINS, M. D.

The Diagnosis of Renal Calculus.-G. L. Hunner, Baltimore (Jour. A. M. A., March 24), remarks that few diseases present more protean symptoms and simulate so varied an array of other maladies as stone in the kindey. Large calculi may exist in and cause destruction of both kidneys without marked symptoms, while minute caculi may give rise to agonizing pains. The more common kid. ney diseases to be considered in the diagnosis

of calculus are tuberculosis, pyelitis, pyelonephritis and pyonephrosis from the ordinary pus-producing infections, tumor and intermittent hydronephrosis. Each of these is noticed separately. The only positive evi. dence of renal tubercuosis is the finding of the tubercle bacillus in the urine or during the disease in animals by inoculation with the diseased urine or tissues. Other symptoms are a more or less unreliable. The differential stain must always be employed in diagnosing tuberculous from the finding of acid-fast bacilli in the urine, as is shown by a case here reported. It may be impossible to diagnose pyelitis, pyelonephritis or pyonephrosis from an infected nephrolithiasis except by operation, nor is it easy to differentiate between calculus and tumor, and here also the chief dependence is on the urinary examination. A movable kidney and kinking of the ureter may cause attacks closely simulating those of calculus, but the enlarged and movable kidney during the attack and the relief of pain and increased flow of urine on its return to normal size will aid the diagnosis. this connection, Hunner mentions the unaccountable renal hemorrhages known as idiopathic hematuria or renal epistaxis, and says there is, he believes, a tendency nowadays to connect these with the chronic interstitial form of Bright's disease. The diseases of neighboring organs noticed as having to be differentiated from calculus of the kidney are gallstones, appendicitis, intestinal obstruction, pancreatic calculus and Henoch's purpura and angioneurotic edema; cases are reported illustrating the difficulties sometimes encountered. The history of the case, examination of the urine, etc., are generally the main dependence in the differentiation. Kelley's method, injecting the kidney pelvis with a bland solution, is mentioned as one of the best diagnostic aids in case of suspected gallstones. In conclusion he refers to Israel's saying that in diagnosing other than typical cases, one must, first of all, divest himself of the schematic picture so often presented in the text-books.

In

The Choice of Method in Operating upon the Hypertrophied Prostate.-Willy Meyer (Med. Record) advocates the use of the three methods in general use in operating on the enlarged prostate, according as each method fits the case be treated. It is not wise to practise one to the exclusion of the others. Each of the methods, perineal, and suprapubic prostatectomy, and galvano-caustic prostatotomy has its own decided merits, and holds a distinct place in surgery. Operation for enlarged prostate must be urgently recommended to most patients with enlarged pros

tate as soon as it becomes necessary for them to use the catheter habitually. The death rate following operations is 5 per cent or less; the mortality due to pyelonephritis resulting from self-catheterization is much greater. The author has performed Bottini's operation in fifty-nine cases, perineal prostatectomy nine times, the sprapubic operation twenty-two times. The only deaths by the perineal method were from the anesthetic in one case, and in a case almost moribund at the time of operation. Of the twenty-two suprapubic operations, seventeen cases of benign hypertrophy are living, two died of causes not due to the operation; three of cancerous hypertrophy died of causes due to the operation; three of cancerous hypertrophy died of causes due to the nature of the disease. The author believes that it is possible to cut the grooves with the galvanocautery both deep and wide; that a median lobe is a contraindication to the Bottini operation, if is possible to do an enucleation; the cystoscope is of value in explaining the conditions at the neck; Bottini's operation, even when done twice, does not prevent a prostatectomy, should that become necessary. But, being a purely intravesical operation, it has many failures, and sometimes entails tedious after-treatment. If radical operation is refused it should be done. When prostatectomy is done full power over the urine is obtained. A small portion of the urethral mucous membrane may have to be removed with the gland, but it is no disadvantage. There is little choice between the perineal and suprapubic routes. In the perineal operation there is a rapid return to normal control of the urine, and leakage over the abdomen is not present. The suprapubic operation can be done in less time. Cystoscopy should always be performed before Bottini's operation, as the hypertrophy may be entirely intravesical. In advanced carcinoma Bottini's operation is to be preferred, since all the cancerous tastases cannot be removed. A gland palpable by rectum and rising not far from the sphincter muscle can best be attacked from below; when higher up and projecting into the bladder it should be operated on from above. When soft and composed of small lobes, operated from below. When complicated by a large calculus work from above. The preservation of sexual power is important, and the suprapubic method retains it in the largest number of

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fever in tertiary syphilis. He illustrates his
point by giving the history of two cases re-
cently observed. The first patient was a man
twenty-four years old, who was admitted to
the hospital with remittent fever said to have
been contracted at Panama. He was treated
with quinine and arsenic. He denied syph-
ilis. The plasmodium of malaria was not
found and quinine was stopped. Fowler's
solution, with an iron tonic pill, was given.
Night sweats with occasional chills developed.
The tubercle bacillus was searched for with
negative results. Still later a slight swelling
over the sternal notch was noticed and the
patient reluctantly admitted having had an
attack of syphilis four years before. Specific
treatment was instituted and exploratory in-
cision was made, revealing a pocket of thin
brown pus at the sternal attachment of the
sternocleido mastoid muscle. The necrotic
parts were removed. In a few weeks a small
ulcer of the velum palati appeared. With a
mixed treatment containing mercury, it was
noted that whenever the dose was moderately
increased the lesions seemed to become ag-
gravated. Observation of these cases shows
the necessity of administering mercury with
caution. Both of the patients whose histor-
ies are here reported improved more rapidly
when potassium iodide was used alone.
the danger of large doses of mercury in syph-
ilitic cachexia was realized, and since its use
was regarded as a necessity in the cure of the
disease, it was only after repeated trials in
both of these cases that the true value of the
iodide was appreciated.

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Transperitoneal Ligation of Renal Vessels. George Walker, Baltimore (Jour. A.M. A., Nov., 25), concludes from a study of the subject that with the ordinary methods of performing lumber nephrectomy there is danger that the operator may squeeze out tuberculous or malignant material, and thus cause a general infection. general infection. He gives his reasons for this belief in detail, and in order to prevent such a possibility proposes the following operation: "Do a laparotomy, push to the intestines to one side, incise the posterior peritoneum, expose the renal vessels, put a double ligature around each of them, cut between and free the distal end for a short distance. In passing the ligatures it is well to include a certain amount of the immediately surronding tissue, so as to pass around and ligate the lymph tract, which is not visible, but which runs alongside of and very near to either the artery or vein. The peritoneum is then closed posteriorly, and the anterior abdominal wound sutured in the usual manner. The patient is then turned on his attention to the difficulty in the diagnosis of side, and the usual lumbar nephrectomy is

cases.

Fever in Tertiary Syphilis.-Dudley N. Carpenter (Med. Rec., March 17, 1096) calls

done." He notes the objection that the procedure produces two separate wounds, but thinks that the opening of the peritoneum under proper precautions does not add to the mortality of the operation. On the other hand, he believes that removal of the kid. ney, through the laparotomy wound or performing a simple transperitoneal nephrectomy would probably be more dangerous than by removing it by the lumber route.

Scarlatinal Nephritis.-This most important complication of scarlet fever, its etiology and prophylaxis, is discussed by H. Lowenburg, Philadelphia (Jour. A. M. A., February 17). In scarlet fever, he states, the function of the skin is almost completely suppressed, thus overtaxing the kidneys, which are also called on to carry of the toxic agent of the disease. There seems to be evidence that this last alone may be sufficient to produce the kidney disorder without the usual clinical manifestations of scarlatina. Constipation, diet and exposure to cold are allimportant contributory factors, the last mostly in susceptible and anemic patients. For prevention, Lowenburg would insist on good ventilation and constant, carefully regulated temperature (68 to 70 F.), a milk diet varied toward the close of the disease, with tender vegetables, fruits and farinaceous substances cautiously added. Fruit juices are refreshing and help to lessen urinary acidity. Daily urinary examination should be made, especially after each change of diet, and on any appearance of albumin a return to an absolute milk diet should be made at once. Hydrotheraphy is mentioned as the one chief remedy. The free use of water aids in elimination of toxins and it should be

or

given as regularly as food. If plain water can not readily be taken, some of the mineral waters may be used, or better, lemonade or orangeade, to each pint of which a teaspoonful of cream of tartar may be added. A daily bath with friction is a valuable adjunct in promoting the skin functions, and its temperature should never be lower than 8 or 10 degrees below that of the patient. Enteroclysis is also of use; from 1 to 8 ounces of saline solution may be given once twice a day. The only drugs of any value in preventing renal complications are alkalies and laxatives. Lowenburg would give 5 or 10-grain doses of acetate or citrate of potassium. Minute doses of calomel should be given at intervals of three or four days during the disease, followed by broken doses of magnesium sulphate. The use of antistreptococcus serum is mentioned and authorities favoring it are quoted, but without special recommendations.

MEDICAL MISCELLANY

REMOVES TAX.-The unjust tax to which Virginia physicians have been annually sub. jected was recently removed by a bill framed by Dr. Powell and passed by the House.

OFFERS REWARD.-The New Orleans Board of Health offers a reward of $5 for the first live female specimen of the stegomyia fasciata brought to them, providing it is found in that city.

HOSPITAL FOR ACUTE ALCOHOLISM. — A Chicago alderman has introduced an ordinance providing for the construction and maintenance of a hospital for the treatment of acute alcoholism.

HOTEL BELLECLAIRE.-Physicians in attendance at the Boston meeting of the American Medical Association next June, who visit New York City, en route, will find Hotel Belleclaire a pleasant place to stop. Conveniently located, and complete in all its appointments. Make arrangements now to meet your friends there.

A TRIP TO CHINA AND JAPAN -Dr. Alexander J. Stone is oragnizing a party of physicians, their families and friends, for a trip to Japan and China, and can offer transportation, including sleepers and dining car service to Seattle and return-hotel accommodations in Seattle-transportation on the 28,000 ton Steamship Minnesota to Japan and China and return; railway transportation and first-class hotel accommodations in Japan, with jinrickishas every day if desiredhotel accommodations and transportation in China, all included for $700. The party will leave St. Paul about July 21st; sail from Seattle July 25th, and reach St. Paul on its return about October 9th, making an expense of less than $10 per day. The cheapest trip of its kind ever offered. Those wishing to join the party should communicate with Dr. Alexander J. Stone, St. Paul, Minn.

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