Medical Review

ample, the presence of blood discharging from the vagina may be the sign of an abortion, placenta previa, or a diseased condition of the uterus, and should be re ported at once. If she suffers with frontal headache, she should report it, as it is a symptom of the obstet rical kidney and if left alone might result in puerperal eclapsia. They should report any swelling of the hands or feet, or any epigastric pain which latter is a pathog nomonic sign of eclampsia, according to Olshausen.

The remarks just made may give Dr. Soper an an swer to his question as to the prevention of eclampsia. It is recognized in 90 per cent of the cases as con nected with insufficiency of the renal function. The urine should be examined; and, with albumin in the urine, or a lessening in the quantity of urine passed and a deficiency in the normal amount of uric acid, with casts present such as hyaline, granular or epithelial, then he will know that he has a renal trouble to deal with. She should be put upon a strictly milk diet until the albuminuria disappears. Pinard, of the Baudelocque Hospital, of Paris, reported in 5,000 cases of pregnancy not a single case of eclampsia, as the cases were all treated by diet, etc. But the diet is only one thing. The simple matter of proper clothing will prevent the eclampsia in some cases. A woman suffers with albuminuria; she goes out, has the function of the skin suppressed by being exposed to cold, there is a result ant condition of congestion of the kidneys and then she is thrown into an eclamptic fit. Every pregnant woman should have flannel clothing.

Should the kidneys continue to functionate badly, medicinal measures are necessary. Thorough catharsis, thorough diuresis and thorough diaphoresis should be the rule. These measures failing, and her symptoms growing alarming, then it is proper and justifiable to perform abortion, of course, with consultation. That called to his mind a case which he had last summer, where all the danger signals existed and where all the ordinary remedies failed. A friend was called in consultation, in the morning. He was told by the speaker that abortion ought to be performed, but the consultant hesitated because he did not know the woman. suggested a line of treatment. She was put upon it but grew worse and the Doctor was called at the beginning of eclampsia; she had twitching of the face, dyspnea and suppression of urine. At 11 o'clock P.M. of same day consultation was made and the consultant acquiesced at once that abortion should be induced.

was deemed best to produce an abortion, but the woman died while they were attempting to deliver her. This was a case where he believed hesitancy caused the woman's death. These cases of eclampsia often may be prevented by the proper dietary and by giving the proper treatment.

In regard to Dr. Gorin's case, where the woman died in the hospital, all efforts on the part of the physician would probably have been in vain as she had a contracted kidney, which was not an acute condition. The condition of pregnancy made her condition worse, but with proper treatment and management, abortion might have prevented death for the time being only, as the condition of contracted kidney is generally fatal, sooner or later.

THE PRESIDENT asked Dr. Hypes to explain a little more fully what was meant by the condition termed obstetrical kidney.

DR. HYPES replied that it was a condition of over. work; that there was no other organ of the body charged with excreting so much of the remains of metabolic change as the kidney; and especially was the kidney over worked in the pregnant woman on account of having to excrete the effete material from both the mother and child. So marked is this increased work in excreting effete material from both the mother and child, that an attack of eclampsia may be checked by the death of the child. In other words, kidneys charged with the excretion of the effete material from both mother and child, will often fail to do their work and will precipitate an attack of eclampsia. This condition disappears after pregnancy. It is a condition which resembles the kidney in diphtheria, or in scarlet fever, where it is due to a poisonous condition of the blood which renders this organ inefficient to eliminate all the poisons.

DR. JOHN GREEN, JR. wanted to know whether urinalysis could serve to differentiate a condition of contracted kidney from one of obstetrical kidney, and whether that would not have some bearing on the treatment.

DR. HYPES replied that, of course, the differentiation could be made by the microscopic findings. In the obstetrical kidney there are not found the more serious forms of casts that are present in contracted kidney.

* *

STATED MEETING THURSDAY EVENING, DECEMBER 15. THE PRESIDENT, DR. GEO HOMAN. IN THE CHAIR.

DR. M. GEORGE GORIN presented (see page 3, this issue) a

Prior to the time he arrived, twenty minims of the fluid extract of veratrum viride was administered by podermically, and she improved. On the next day, when it was contended that operative interference should be instituted, the family objected and both physicians left the case. Another physician, of high standing, was called in, who was told what had been done and what had been advised but he thought that he could get along without producing abortion. He treated her for two weeks, during which time he had several other physicians in consultation with him. Finally it issue)

Report of a Case of Irritable Urinary Bladder Relieved by Rapid Dilatation of Urethra.

DR. H. WHEELER BOND reported (see page 4, this

Two Cases of Urinary Calculi.

DISCUSSION OF BOTH PAPERS.

peritoneum may be incised to the required extent, and subsequently united without deleterious effect. Neces sarily the operative scope has been enlarged by this

DR. H. JACOBSON asked Dr. Bond if the stone was procedure. There are surgeons, chiefly of the English encysted.

DR. BOND replied that it was not.

DR. JACOBSON said he was sorry he did not hear the entire paper. An encysted stone does not cause trouble because the stone does not come in contact with the delicate mucous membrane during contraction of the bladder walls. He asked which operation was performed.

DR. BOND said the suprapubic.

DR. JACOBSON said there were several ways of removing stones from the bladder and among them was the crushing method. This answers except in cases of young children where the stone is small or when there is an enlarged prostate present. In that case two operations would probably have to be done at one time. The suprapubic would then be the best because the op erator can see what is being done and can also ascertain what portion of the prostate it might be necessary to

remove.

DR. CHARLES SHATTINGER asked Dr. Bond why he did not suture the bladder in this case. He did not understand that there was any cystitis present.

and India schools, who almost always took the perineal route. (In searching literature he said he had never found any satisfactory reason why this should be done). Among the inhabitants of Arabia and the desert Bedouin tribes there is a strong lithemic tendency. In children enormous stones are sometimes found, and these men almost invariably choose the perineal route for extraction, for no special reason, as far as may be observed, nor with results not more brilliant than by the suprapubic method; but often with great laceration and inconvenience.

Comparatively recently the suprapubic method has been coming to the front and its advocates certainly secure desirable results.

THE PRESIDENT inquired as to the bacteriology of these bladder conditions.

DR. GIVEN CAMPBELL did not think that any bacteri ological cause for such conditions could be given. The case of Dr. Gorin's he thought rather a nervous one. He considered it analagous to vaginismus. Dilatation he thought a rational treatment and believed good results should be obtained from it.

DR. H. JACOBSON said the cystoscope was a very important instrument in the diagnosis of irritability of the bladder, especially in tuberculous conditions. Tuberculosis of the kidney will cause irritability of the bladder, and, in the male, if this is associated with tu berculosis of the prostate and testicle, we can often de. termine the cause of the irritability. Other important symptoms, of course, are the finding of tubercle bacilli in the urine and elevation of the temperature and also, of course, the history of the patient's family.

Calculus in the kidney or ureters, new growths and other diseases of the genito-urinary tract cause irritability of the bladder. Besides reflex causes in the neighborhood of the bladder, like hemorrhoids, worms and other diseases of the gastro-intestinal tract, a remote reflex cause is adenoid of the naso pharyngeal region.

DR. NORVELLE W. SHARPE said he thought Dr. Bond was quite justified in the suprapubic incision. He con sidered it preferable. He could see no advantage in going through the rigid perineum when the suprapubic operation was manifestly the more convenient mode of ingress. The point made by Dr. Shattinger was worthy of consideration, and in an operation where the details were so perfected, he thought it was not mal apropos to discuss the finer points of technique. In cases where there was no cystitis, and the bladder had be come tolerant of the existence of the stone, there was no special value in leaving the wound open nor in unit ing the bladder to the abdominal wall; nor was there any special advantage to be obtained in vesical irriga tion in cases of this class. There was rather a disad vantage in that the bladder being sutured to the parietes and forming a part of the subsequent cicatrix, would be held to the abdominal wall in a malposition, and a Dr. Carl A. W. ZIMMERMANN said there was a case complete detrusor action would be impossible. Now, at the Female Hospital which was very interesting. It this condition in a normal individual would probably was that of a woman delivered of a child eight years have no deterrent influence nor result; but in cases ago by forceps, and before the birth of the child the where there is a lithuric tendency, the residual urine precaution of emptying the bladder had been neglected. resulting from incomplete contraction of the bladder The bladder was ruptured in two places and the woman would, without doubt, favor subsequent stone formation has now a double vesico vaginal fistula and no operaHe said he believed in cases where there was no cys tion to close them has been attempted. A year ago titis it was better to suture the bladder independently, she began to notice tenesmus, bleeding from the bladand then unite the abdominal wall. There had been der and pain, and on making an examination herself, in the past a very considerable dread of suturing the she felt two rough surfaces on the roof of the vagina. peritoneal duplication over the fundus. And this had She did not seek medical aid until she came to the been a real difficulty in a suprapubic section when the hospital, where an examination revealed two openings, stone was large and the peritoneum descended rather one on either side of the median line, and each opening lower than its classic limitations, but we now know plugged by a calculus. The calculi were united at the that if proper care and technique are observed, the top in horse-shoe shape and a catheter could not be in

troduced into the bladder. She also has a tear in the perineum of the third degree. The stone was crushed through the fistulous opening with heavy forceps by Dr. Crossen. She has a cystitis from which she still suffers, although doing well otherwise.

THE PRESIDENT asked whether no urine was passed through the urethra before the stone was removed. DR. ZIMMERMAN said some urine was passed as the stone did not, apparently, close the opening entirely. DR. P. J. HEUER asked Dr. Gorin if a microscopical examination had been made of the tumor removed.

DR. GORIN, in closing, said the urinalysis at first re vealed nothing except a low specific gravity. About two weeks after the operation the urine was slightly alkaline. The cause of the irritability in this case was the fact that the wound did not have an opportunity to heal on account of straining at micturition. As to why the dilatation was not resorted to at first he said he thought it probable that the caruncle was the cause of the irritability and that its removal would give the patient relief without the necessity of further operative procedure. The cautery was made strong, as he thought the patient would recover the normal use of the bladder, while the wound was healing under a firm, protecting eschar. A microscopical examination of the growth had not as yet been made.

for he knew full well that the most skillful artists some times blundered.

In this case, he said, he did not attempt to scrape upward the pre-vesical cellular and fatty tissues as is advised in the old stereotyped operation, but made a clean cut through it to the bladder wall, inserting the hooks into the muscle and lifting it up for puncture. When these tissues were not lacerated and contused there was little, if any, danger from sepsis by virture of urinary extravasation, whether the bladder be left open for drainage or closed by suture. He did not close the bladder in this case on account of the cystitis that ex isted at the time and because daily irrigation was desired. The bladder responded promptly to the irriga tions after removal of the stone.

THE PRESIDENT asked what solution was used in irrigating.

DR. BOND said he used warm two and one half per cent boracic acid solution.

The case described by Dr. Zimmermann, the speaker said, showed how important an etiological factor cystitis was in the development of stone in the bladder.

THE PRESIDENT asked if Dr. Bond thought only four per cent of all cases of urinary stone were seen in women.

DR. BOND replied that such was the case, according to the best information he had been able to obtain. THE PRESIDENT asked if they were as subject to

DR. BOND thanked the members for their interesting renal calculus as men. and generous discussion of his paper.

The stone, in his bladder case, was not encysted but occupied nest at the base of the bladder and was freely movable. This nest was a simple rounded indenture produced by the long presence of the stone and the manner in which it had rested in the organ.

The cutting operation was selected in preference to litholapaxy because he knew the stone was very large and because the crushing of a stone of its size consumes a great deal of time and not infrequently particles were left in the bladder in washing out the reduced subHe thought litholapaxy in such cases was a more or less dangerous and unsatisfactory procedure, since a fragment left was very liable to be retained and form a nucleus for the redevelopment of stone. The danger from prolonged anesthesia should also be con sidered.

Another reason for selecting the cutting operation was that, after explaining the two methods to the patient and showing him the dangers attending each, he was very decided in his choice of the clean-cut pro cedure.

Of the cutting operations the suprapubic was se lected because, he said, some of the best surgeons of to day caused serious injury to the ureters, perineal ves sels, the recto vesical space, or to the urethra or bladder itself in operating through the perineum, and especially for the removal of large stones.

He did not mean to cast any reflection on the anatomical knowledge or surgical skill of these operators,

DR. BOND replied that his information tended to show that a greater number of men suffered from renal calculus, and that it was his opinion that such was the case because of habits and physical indiscretions peculiar to men; but that he was unable to say what the exact proportion of cases of renal stone was between the male and female.

He said that women seldom suffered from vesical stone on account of the shortness and greater caliber of their urethra, and their freedom from causes of urethral obstruction so common in men.

ABSTRACTS

MEDICINE AND THERAPEUTICS.

Protonuclein in General Practice.—Dr. G. W. Sherman, of Detroit, Mich., in a paper read before the Detroit Medical and Library Association, and which appeared in The Physician and Surgeon for October, 1898, says:

My first practical experience with protonuclein was on myself. About two and a half years ago I was taken with a severe attack of acute catarrhal inflammation of the nasal mucous membrane which rapidly extended down the trachea into the bronchi. It began on a Friday morning with an almost incessant sneezing accompanied by blocking of the nose, fullness in the head and

headache, followed later in the day by a thin, copious protonuclein and ordered that the dose be repeated every two hours. The next day there was hepatization of the lower half of the right lung, with a temperature of 102°F., and a pulse of 108. The protonuclein was now increased to nine grains, repeated every two hours. The third day the temperature was 101°F, and the pulse 100. He felt better, and on examination the lung was found to be clearing up. The protonuclein was continued. On the fourth day the temperature was 98°F., the pulse 84, patient had enjoyed a night's rest, appetite return. ing, and lung much improved. The fifth day I found my patient dressed and sitting in a chair. He said he felt well, but I persuaded him to go back to bed fearing something might happen. I continued the protonuclein four times a day for a few days, when he made a complete recovery.

discharge from the nose, and an irritating cough. By 5 o'clock P M. the same day my headache was severe, my limbs all ached, and on taking my temperature it regis tered 101°F. I had had similar attacks before, none apparently quite so severe, which always run a course of from one to three weeks. I had tried quinine and other remedies without any appreciable benefit, and was a willing subject to try something new. I had a few samples of protonuclein and began to take them ad lib. itum, starting about 5 o'clock in the evening. By Sat urday morning I felt some better and continued taking the preparation through all that day, still ad libitum, and by evening, twenty-four hours after I began its use, felt considerably improved. I continued taking more during Sunday, when my nose cleared up, and the head ache, fever, cough, and soreness in my limbs disap peared. By Monday evening, after three days' treat ment, I was practically well and attended a meeting of the Detroit Medical and Library Association. Since then I have always prescribed protonuclein in these acute catarrhal affections with the same happy result. Experience has taught me that the proper dose for such cases, in the adult, is from six to twelve grains repeated every two to three hours. The treatment should be continued with smaller doses for a few days after the disease has disappeared to prevent a relapse.

I have found protonuclein especially useful in the treatment of broncho-pneumonia in infants and children. In these cases I usually give from two to four grains, according to age, repeated every two to three hours, and find that a recovery takes place in from three to five days. I have had remarkable success in treating pneumonia with this preparation and will briefly report

two cases.

CASE I. My mother, aged 72 years, on April 8, 1897, suffered a severe chill about 9 o'clock in the evening. Two hours later when I first saw her she complained of pain in the right side; was coughing up bloody mucus, and was very uneasy. Her heart had been irregular for some years but now the pulse was 130 and her tempera ture 103°F. Physical examination revealed pneumonia of the right lung. I prescribed two grains of phenacetin and six grains of protonuclein to be repeated every two hours. By 10 o'clock the next day her temperature was 99 6°F. and her pulse 108; the pain in her side was less and she felt much better. The phenacetin was discontinued and the protonuclein continued. By the third day her temperature was normal and she felt so well that in spite of my protests, she was determined to sit up. She coughed up rust colored sputum for six or seven days but otherwise felt quite well. She has had no trouble with her lungs since.

I have treated ten cases of typhoid fever with protonuclein, all of which made an unusually early recovery considering the severity of the early symptoms of some cases. I will briefly report a few cases:

I was called to a family in which one of the city phy. sicians had charge of two typhoid fever cases; one, aged 20 years, who had been sick three weeks, and another, aged 6 years, who was just convalescing after seven weeks' illness. By the time I made my second call a few days later, two other children of the family had taken sick. A boy, aged 7 years, had not been feeling well for a few days, had no appetite, felt tired, tongne dry and coated, temperature 101°F. I gave him four grains of protonuclein every three hours. He began to feel better in a few days, and by the eighth day had entirely recovered. I will leave the members to decide whether this was typhoid fever or not. The other case was a girl aged 10 years. She had the usual symptoms of typhoid fever, with a temperature of 102.5° F. Protonuclein, six grains, and phenacetin, two grains, repeated every three hours, were prescribed. The temperature continued to rise until the fifth day when it reached 104.2°F., pulse 130. The phenacetin was dis continued and the cold pack substituted (which was poorly dispensed) and protonuclein increased to nine grains, repeated every two hours. The temperature from the fifth to the tenth day ranged between 102 5°F. and 104.5°F., and considerable diarrhea set in which was controlled with bismuth and turpentine emulsion. From the tenth day the temperature gradually declined until the fifteenth day, when it became normal and remained so thereafter. It will be noticed that larger doses of protonuclein were used in this case than in the first case and a more decisive recovery ensued.

I have recently treated two other patients, one aged 6 years, and the other 12 years, both girls, with large doses of protonuclein, in whom the fever ran a course CASE II.-C. G., male, aged 63 years, had not felt almost identical with the above case. The one unusual well for several days, and was taken with a fever the feature in these three cases was the early appearance of day before I saw him. Patient complained of pain in the appetite. About the twelfth or thirteenth day they his right side, and difficulty in breathing. His temper- began to ask for food, and in a few days the desire to ature was 102.6°F., pulse 110, and the lower portion of take nourishment became so keen that it was difficult to his left lung was inflamed. I prescribed six grains of refuse them something more substantial than milk. All

these patients lost their hair during convalescence. Protonuclein has a wonderful effect in maintaining the spirits and vitality of a patient during fever and has no depressing effect, while it reduces the temperature. This is particularly noticeable in typhoid cases. They do not lapse into that stupid condition which is so characteristic of this disease.

MISCELLANY

Health Reports.-The following statistics concerning small-pox, yellow fever, cholera and plague, have been received in the office of the Supervising Surgeon-General of the U. S. Marine Hospital Service during the week ending December 30, 1898:

When protonuclein is taken in large doses, say ten to fifteen grains repeated every two or three hours, it pro duces a deafness and ringing in the ears very similar to that produced by large doses of quinine. In such doses COLORADOit may also cause an unsteadiness of the nerves aud an increased frequency of the heart's action. If this condition is observed during the treatment of a disease it is well to withhold a few doses, when these symptoms will readily disappear without leaving any bad effects.

I have given protonuclein in scarlet fever with the effect of having the temperature decline and the swell ing of the glands of the neck disappear, while the rash is coming out. I have given it with great success in puerperal fever, erysipelas, infected wounds, and in fact consider it a valuable remedy in all infectious diseases. Protonuclein also has quite marked tonic effects which are particularly noticeable when given in cases of gen eral debility resulting from advanced age. As a tonic it should be given in from six to nine grain doses, after meals and at bedtime. In neurasthenic cases it is of benefit, restoring a normal tone to the nervous system I have given it in a few cases of whooping cough with benefit. I have given it to a few tubercular cases, but can not say that it was followed by especial improvement. In cases wherein the temperature is high I usually prescribe small doses of phenacetin as a palliative rem edy to assist in bringing down the temperature until the protonuclein has time to produce results. I consider protonuclein a very valuable addition to our remedies in combating disease, and feel that all who use it in large doses will be gratified with its results.

Sporozoa of Carcinoma.-Jurgens has succeeded in isolating from the mucus surrounding the neoplasm a micro-organism evidently belonging to the Gregarinidæ in a number of cases of cancer of the stomach and one cancer of the bronchi, in which the air-passages were occluded, resulting in a collection of several generations of the sporozoa. It is much larger than the usual Gregarina, which he explains by the discovery of the fact that the micro organism develops by the conjugation peculiar to this species, the two bodies blending to form a single large one which invades the cell until the shell of the cell enclosing the micro or ganism is all that is left of it. In this condition it re sembles Miescher's tubes and Rainey's bodies, and he queries whether they may not be developed Gregarinidæ. Farther particulars are given in the Klin. Therap. Woch; Jour. Amer. Med. Ass'n.

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