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ney. There is no patohlogical evidence of healed tuberculosis of the kidney except the organ has been completely destroyed.

The early subjective symptoms of renal tuberculosis are usually those of a cystitis. Suspicion should always be aroused when a cystitis begins. gradually without apparent cause, when it is very rebellious to treatment, or when it is very painful. Persistent polyuria or changes in the bladder reflexes may be early symptoms, as may be also hematuria either gross or microscopic. The most certain method of making a diagnosis is by the injection of the urinary sediment into a guinea-pig. Some differences of opinion were expressed as to the value of finding acid-fast bacilli in the urine, A. L. Chute holding that their presence in catherized urine was diagnostic of tuberculosis, while Hugh Cabot believed that more faulty than correct deductions were drawn from attempts to stain these bacilli, that the method was tedious and that the pig inoculation was far preferable. The cystoscopic findings were discussed in detail and the importance. of catherizing the ureter from the supposedly healthy kidney emphasized. The treatment generally favored was surgical, primary nephrectomy being usually preferable to nephrectomy after nephrotomy. The immediate mortality varied from about six to twelve per cent, though this could probably be reduced by a more careful examination of the urine from the supposedly healthy kidney and a more careful selection of cases along these lines. In Krönlein's experience the ultimate prognosis is relatively good if the patient survives the first year after operation. It has not been proved anatomically that hygienic and dietetic treatment will cure renal tuberculosis though symptomatic cures have been reported. Early operation is indicated if the disease is unilateral.

A. W. H.

THE EXCRETION IN THE URINE OF SUGARS OTHER

THAN GLUCOSE

GARROD (Quarterly Journal of Medicine, July 9, 1909, page 438) summarizes the knowledge to date concerning the methods of detecting the various sugars found in human urine and their significance. He adopts the term melleturia, which includes all sugars and should be applied to those cases excreting more than one variety of sugar, as for example, glucose and levulose.

Most sugars found in urine belong to the hexose group; these are either mono- or disaccharides, that is, they contain one or two hexose (Co H12 O6) molecules. The pentose and heptose sugars are on the five and seven carbon chain respectively. The nomenclature of the pentose sugars. is rather confusing. The prefix letters, and d, simply indicate their relationship to the hexose sugars and have nothing to do with their rotatory properties. As a matter of fact l-arabinose and 1-xylose are dextrorotatory whereas d-xylose rotates the polarized ray to the left.

LACTOSURIA.-Lactose, a disaccharide is not infrequently excreted in the urine or pregnant and nursing women. It reduces Fehling's solution

and other reagents. The reduction of copper solutions is slower than is the case with glucose. Lastose is dextrorotatory; under ordinary circumstances no fermentation takes place with fresh yeast until after twentyfour hours; it forms no crystalin osazone with phenylhydrazin. Taking into consideration the bodily conditions present the above facts will enable one to differentiate lactosuria. Lactosuria occurs at some time in almost every nursing woman; it is particularly apt to appear in the urine if for any cause lactation is suddenly arrested; it seldom registers more than one or two per cent; it is found during the latter months of pregnancy. Lactosuria is of no pathologic importance in adults but when present in infants' urine it is evidence of gastrointestinal derangement producing lowering of the assimilation limit which in sucklings is high, 3.3 grams per kilo of body weight (Grocz). Certain intestinal bacteria have the property of splitting lactose; the portion which skips inversion is absorbed and execreted in the urine.

MALTOSURIA.-Maltose, a disaccharide has been found in small amounts in diabetic urine and in urines associated with fatty stools as in pancreatic disease. It is slightly dextrorotatory; boiled with dilute acids it is hydralyzed to glucose. By such treatment the rotatory power is lessened and the reducing power enhanced. The reducing power of maltose is less than glucose. Fermentation with yeast removes rotatory and reducing power of maltose.

LEVULOSURIA.-Levulose in the urine is of much clinical interest. It not infrequently occurs in diabetes mellitus together with glucose. It is recognized by its levorotation of polarized light when excreted alone. When excreted together with glucose the dextrorotatory power of the lat ter may overcome or neutralize its rotation. The levorotatory power of levulose is, however, twice as great as is the dextrorotatory power of glucose. All known compound glycuronates are levorotatory; glycuronic acid on the other hand is dextrorotatory. These latter two substances are not fermented by yeast; accordingly if both the reducing power and the optically. active urine is abolished by fermentation it is certain that the levorotation is due to a sugar, presumably levulose. Betaoxybutyric acid, often present in large amount in diabetes, is strongly levorotatory.

Seliwanoff's Test for Levulosuria:-Heat the urine for a short time. with an equal amount of strong hydrochloric acid and a few particles of resorcin, The development of a red color indicates levulose. Rosin modifies this test by cooling the heated mixture in running water, pouring it into a beaker and rendering it alkalin with a bit of solid soda, then returning it to the test-tube and shaking with acetic ether. A yellow color indicates levulose. Boiling a solution of glucose with hydrochlorie acid may convert a portion of it into levulose, hence an objection to this test.

Phenylhydrazin yields with levulose solutions, glucosazone, and with methyl phenylhydrazin an osazone which melts after recrystalization at 153° centigrade.

Levulose seldom occurs in mild cases of diabetes. The author cites interesting cases of marked levulose rotation to which the reader is referred.

PENTOSURIA. In all about thirty cases of pentosuria have been reported. Arabinose is the variety usually encountered. An alimentary pentosuria may be provoked by so small a dose as one gram of arabinose, or the free ingestion of cherries, plums, and unfermented fruit juices. Pentose also appears as a product of animal metabolism. The pentoses are dextrorotatory, they reduce Fehling's solution slowly, also Nylander's solution and saffranin. They do not ferment with yeast. With phenylhydrazin an osazone insoluble in hot water results, which if recrystalized melts at 160° centigrade. If one-half cubic centimeter of urine is treated with five or six cubic centimeters of fuming hydrochloric acid and a small quantity of phloroglucin added and the mixture then heated in a water-bath, a deep red color develops if pentose is present.

Bial's Test for Pentose.-Bial's reagent is made as follows: One gram orcin, 500 cubic centimeters hydrochloric acid-specific gravity 1151, twenty-five drops of a 10% ferric chloride solution. Application-Heat five cubic centimeters of the reagent in a test-tube, add five drops urine. A green ring which quickly diffuses on agitation indicates pentose. No one test can be relied upon but it has been, asserted that a reducing substance which does not give Bial's test is not a pentose.

HEPTOSURIA.—One case of heptosuria has been reported. The urine was negative to Seliwanoff's test and Bial's test. There was no fermentation with yeast excepting in the presence of glucose. Acetone and diacetic acid were present. Fehling's solution was freely reduced. The urine was "optically inactive."

D. M. C.

THE EFFECT OF ATROPIN ON THE EXCRETION OF SUGAR IN DIABETES MELLITUS IN CHILDREN AND ADULTS.

Or the drugs which are safely and advisedly used in the treatment of diabetes for specific effects, sodium bicarbonate for the alkalies and codeia for the opiates have stood as prototypes. Rudisch (Jama, LIII, page 1336) reports some marked examples of the effect of atropin on excretion of sugar in three cases of diabetes in children nine, eleven, and fourteen years old respectively. The author states that "it is often possible to suppress sugar secretion solely by atropin without reducing the carbohydrates." The sulphate and the methylbromide of atropin are in greatest favor, The later is said to have the advantage of being less toxic and the disadvantage of being expensive. The sulphate is given to children in the dose of onehundred fiftieth grain ter in die. The author has given one-tenth grain daily to children and one-sixth grain to adults without harmful results. When atropin is withheld the percentage of sugar rapidly increases, to fall again when resumed.

Doctor Jacobi has probably had the largest experience with the use of belladonna. In pertussis the dose for the child is that number of drops which produces the physiologic effect. In this disease the remedy has been used for indefinite periods of time without any apparent harmful effects. This would seem to argue in favor of at least further trial of atropia in diabetes mellitus. Drugs should always be given guardedly in this disease. The iability of habit is not great with atropia.

D. M. C.

CLINICAL OBSERVATIONS ON THE EFFECTS OF CERTAN DRUGS IN DIABETES MELLITUS.

HALL (Quarterly Journal of Medicine, July, 1909, page 417) reports results of clinical experiments on the effects of codeia, opium, secretin, and aspirin in diabetes mellitus. The author's results seem to favor opium rather than codeia. The general results with the drug were more uniformly successful. He observed no tendency to craving after the withdrawal of the opiates. The dose must often be carried quite high, as much as twelve grains of codeia and of opium daily. Secretin was prepared from the upper three or four feet of fresh small intestine of the pig. The maximum dose of nine drams daily was given. Practically no noteworthy effects were produced. Aspirin produced no definite effect. The effect of these subtances was tested on the liquid intake, the urine output, the sugar output, and the body weight. The number of cases, eight, is small, yet they have a certain value in showing how unreliable some of these drugs may be in individual cases, and the importance of not relying upon general statements so frequently heralded of the effects of certain drugs in the cure of this malady.

D. M. C.

SURGERY.

FRANK BANGHART WALKER, PH. B., M. D.

PROFESSOR OF OPERATIVE SURGERY AND CLINICAL SURGERY IN THE DETROIT COLLEGE OF MEDICINE,

CYRENUS GARRITT DARLING, M. D.

CLINICAL PROFESSOR OF SURGERY IN THE UNIVERSITY OF MICHIGAN.

OSTEOMYELITIS OF THE LOWER JAW.

GERMAIN, of Boston (Jama, Volume LIII, Number XII), says that though the mandible is much exposed to infection it rarely becomes diseased. It is closely allied in structure to the long bones, but differs, however, in that it contains tooth germs in childhood, and alveoli for teeth in adult life. When the teeth are lost the body assumes the character of a flat bone which the rami have always maintained. Dependorf states that infection. readily travels along the canal in the body of the bone, making this portion particularly liable to hematogenous infection. A large number of these infections find entrance through the teeth, generally from gangrenous pulps or from abscessed teeth. Next in order is the impacted third molar, while

pyorrhea and gangrenous stomatitis are mentioned as causes in rare instances. Trauma without fracture may be a predisposing cause, furnishing a point for lodgement of infection. Fracture makes a direct opening for infection from the oral cavity. It may follow the acute infectious diseases, or septicemia. Long exposure to cold and dampness or the effect of metallic poisons are said to be predisposing causes.

There is the usual pain and swelling in the soft parts as the process advances. The periosteum may be stripped from the bone, and the teeth loosened. In time a sequestrum may form and may be removed. New bone forms from the periosteum with more or less deformity. An opening is formed usually on the facial side of the bone, which may appear inside of the mouth or through the cheek, always taking the direction of least resistance. Indications of chronic osteomyelitis may be due to a dead tooth or part of a tooth, and the opening may be some distance from the point of disease.

The diagnosis is usually easy. It may be mistaken for malignant disease, syphilis or actinomycosis. The x-ray is of great value in diagnosis, particularly in disease of the condyle or ramus.

The treatment consists in exposing the dental canal through an incision on the cheek. Remove dead tissues, open the large marrow spaces and drain. When operated early the disease may be cut short without the loss of the teeth. No definite rule can be laid down for the treatment of the subacute and chronic forms, as each case is a law unto itself. In general find the diseased teeth, the pockets of pus, and the sequestra. Watch for lymphadinitis, and angina ludovici. These must be operated promptly or the patient's life may be in danger. Very little can be done to overcome the deformity that results from destruction of the bone.

GYNECOLOGY.

REUBEN PETERSON, A. B., M. D.

C. G. D.

PROFESSOR OF OBSTETRICS AND GYNECOLOGY IN THE UNIVERSITY OF MICHIGAN.

GEORGE KAMPERMAN, M. D.

INSTRUCTOR IN GYNECOLOGY IN THE UNIVERSITY OF MICHIGAN.

POSTOPERATIVE SEPARATION OF LAPAROTOMY

WOUNDS.

RIES (American Journal of Obstetrics and Diseases of Women and Children, Volume LX, Number IV) gives his observations on postoperative separation of laparotomy wounds. He thinks the condition more common than the literature indicates. His discussion concerns only aseptic wounds, and also clean wounds which were left partly open for drainage.

Six cases are reported as having been observed. In these cases various stages and degrees of separation are reported. In his first case just as the abdominal wound after a laparotomy had been closed a distinct snapping noise was observed in the wound as the patient strained and vomited on

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