ted cells, or conglomerates of cells, takes place when it MEDICAL REVIEW.comes in contact with the epithelial layer of cells of the L. T. RIESMEYER, M.D., Editor. Department Editors: Dr. F. J. LUTZ, General Surgery. Dr. E. C. RỤNGE, General Medicine, Published Under the Auspices of the Yearly Subscription, $3.50. Single Copies, 10 Cents. To Contributors and Correspondents. All letters, whether intended for publication or not, must contain the writer's name and address, not necessarily for publication. No attention will be paid to anonymous communications. Secretaries of medical societies will confer a favor by keeping us informed of the dates of the meetings of their respective societies, and of officers elected. Members of the profession, who send us information on matters of general interest to our readers, will be considered as doing them and us a favor, and we shall take pleasure in inserting the substance of such communications. Communications, Medical Books (for review), and all letters containing business communications or referring to the publication, subscription or advertising_department of the MEDICAL REVIEW, must be addressed to O. H. DREYER, Publisher, 112 N. Fourth Street, St. Louis, Mo. Entered at the St. Louis Postoffice as Second-Class Matter. ST. LOUIS, MO.: JANUARY 28, 1899. EDITORIALS mucous membrane of the stomach, or any other mucous membrane. When distilled water enters the stomach the superficial layers of epithelial cells die and are thrown off. Recently Dr. Hans Koeppe has again called attention to this phenomenon in a paper entitled "Pure Water-Its Poisonous Action cnd Its Existence in Nature." The author states that the poisonous action of "pure water" would have often been noticed in a much more pronounced measure were it not for the fact that even so called chemically pure water is usually not absolutely pure. Even recently prepared ordinary dis tilled water of the shops is in reality not pure water, and this is much more the case after such water has been standing in vessels which have not been well sealed and in apartments where chemicals are kept and gases of various description have access to the water. The most sensitive and best indicator of the degree of purity of water is its capacity of conducting electric currents. Admixtures of impurities that can not be de tected in water by the most delicate chemical analysis are amenable to a quantitative estimation by the electric conductivity, and it is by the application of this test that the differences in impurity among various specimens of (from a chemical standpoint) pure waters are determined. The access of air alone and, after water has been kept for some time in a glass vessel, It is a phenomenon which is well known to micro the infinitesimal quantity of glass dissolved by it inscopists that cells of fresh animal tissues swell and be creases its electric conductivity. The electric conducting come opaque when they are examined under the micro power of the purest water which can be artificially proscope in a medium of distilled water. This action of duced with the aid of the most careful precautions has chemically pure water is one reason why a small been calculated to be 0.0425. Carefully preserved ordi. amount (0.6 per cent) of chloride of sodium is added to nary distilled water in which the ordinary impurities as the water which is used for microscopic purposes. determined by chemical tests were absent was found by These changes in the cell are due to the fact that, in the author to possess an electric conductivity of 49 2. harmony with a well known natural law, some of the Water which is considered sufficiently pure for physicosalts and other soluble constituents of the cell pass into chemical investigations has, according to Oswald, an the water. These constituents are necessary to the life electric conducting power of 2.13. Three specimens of of the cell which dies when they are withdrawn by the well water examined by Koeppe were found to possess water. Distilled water is therefore a poison to the pro. an electric conducting power of 344.0, 654 0, 701.0; an toplasm of the cell. It is for this reason that physicians 0.73 per cent solution of chloride of sodium has, acshould warn their patients against drinking chemically cording to Oswald, an electric conducting power of pure water in any form. The at first sight paradoxical, 11050.0. The figures express only the comparative con but nevertheless perfectly correct statement, that water ducting power (at 18°C.) and represent ohms multiplied which is too pure, i. e., chemically pure, is a poison, be by 1010. comes at once plausible to the person who is practically A consideration of the fact that chemically pure water familiar with the rudiments of histology and physiology. hss poisonous qualities is of practical importance to the An action, similar to that observed under the microscope The Poisonous Quality of Chemically when chemically pure water comes in contact with isola 1 Deutsche medicinische Wochenschrift, No. 39, 1898. physician who, for instance, wants to prescribe ice pills for nausea and vomiting. It is, what would appear at first sight paradoxical, the artificial ice which has a greater electric conducting power, i. e., is less pure, than the natural ice, and therefore less poisonous, in the above sense, than the latter. Artificial ice is less apt to cause a burning sensation in the stomach, nausea, vomiting and catarrh of the stomach, because it is less pure than natural ice, although it is made from distilled water. In the artificial ice all impurities of the water are con tained in the ice, while ice as it occurs in nature where it forms in the upper portion of the water-the impuri ties sinking to the bottom-is relatively free from im purities and hence more poisonous with regard to its cell-destroying action. A still less objectionable ice for medicinal purposes would, of course, be obtained if a slight addition of chloride of sodium, say 0.60 per cent, or some other salts were added to the distilled water before it is subjected to the artificial freezing process. Natural ice is relatively pure even if it is gathered from very impure water, and the water obtained in Koeppe's experiments by melting natural ice was purer than boiled distilled water; the electric conducting power of the former being 8.0, that of the latter 10.0 to 10 5. The ice of glaciers and mountain snow is particularly pure and its injurious effects are well known to moun tain guides. The reason that pure ice is not offensive to the taste is that the cold benumbs the taste. As a consequence, ice is not spit out like a mouthful of distilled water taken by mistake in the laboratory. The belief that the cold temperature is the cause of the in jurious effects of swallowing ice is a fallacy. It is, on the contrary, the cold which prevents the detection of the injuriousness of ice, or chemically pure water, like that obtained from rivulets of the high mountains, by paralyzing the sense of taste. The idea, too, that the symptoms of gastric irritation which sometimes fol. low the administration of ice pills are due to bacteria, attached to the ice from contamination by exteral sources, is an erroneous one. As above pointed out the gastric irritation is due to the absence of impurities (salts) in the water. There is a well in Gastein which has been called for several centuries the "poison well." The citizens of Gastein do not drink its water, because they consider it poisonous; yet it contains not a trace of any known poison, its poisonous qualities evidently consisting in the fact that it is "too pure." ABSTRACTS MEDICINE AND THERAPEUTICS. The Treatment of Pneumonia.-An essay on the "State of the Vasomotors in Lobar Pneumonia, and its bearing upon Treatment," which appeared in the New York Medical Journal for October 8, 1893, presents the important subject of treatment in an interesting light, because it differs widely from the usual crude or empirical views found in in our literature The paramount import of the vasomotors is clearly set forth by the author, and an attempt is made to deduce a correct treatment from the ascertained condi tions, viz, the relaxation of the peripheral vessels. The able author refers to Romberg's and Paessler's experi ments with injections of pneumococci into the circulation of rabbits, which demonstrate the import of vaso motor involvement. This is of special interest to me, because he confirms my clinical observations of the past ten years, which were offered to the New York Academy of Medicine not long ago. In this essay the following statement was made: "Romberg has recently confirmed what I have several years ago and repeatedly since that time insisted upon, that in acute infectious diseases we encounter disturb. ances of the circulation which manifest themselves clinically as reduced tension and diminished filling of the arteries, and which are commonly described as heart failure. Undoubtedly the condition of the peripheral vessels bears a very large share of the production of cardiac inadequacy, as I have sought to impress when explaining the rationale of cold applications in typhoid fever and pneumonia. Romberg has shown by experi ments with injections into rabbits of Fraenkel's diplo cocci that the circulation is damaged by a paralysis of the vasomotor, while the heart itself remains unaffected" That the same condition of the peripheral vessels exists in lobar pneumonia is demonstrated by the clinical observations of Van Santvoord, who found that "chloride of barium in doses of four grains every four hours produced in one case a material contraction of the very much relaxed arteries, the pulse slowed, and the marked delirium and prostration of the patient disappeared, although the temperature and pulmonary lesion remained unchanged. In other cases no material result followed the same treatment." The fact that "strychnine, which is now so widely used, not only has a tonic effect upon the heart, but also causes contraction of the peripheral vessels, through its action upon the spinal vaso motor centers, which, according to Romberg, are not affected by the pneumococcus," is also cited in support of the theory that a relaxation of the peripheral vessels in pneumonia exists. The author states that "the most obvious method of combating extreme dilatation of the peripheral vessels” (to which he justly attributes cardiac failure) "is to ad minister drugs which cause their contraction." Inasmuch as he clearly states that in only one case out of several the drug, "which has been proved to act on the peripheral vasomotors," really produced any improve ment, there seems to be little hope of discovering a more efficient one. Shall we confine our search for such remedial agents to drugs whose action at best is either unreliable or connected with some undesirable effect? Clinical ob servation has already demonstrated conclusively that we may find outside of pharmacy a most potent agent for this purpose in cold applications to the cutaneous surface, which presents an enormous "peripheral circu lation." My advocacy of this therapeutic agent is, how ever, not based upon clinical experience alone. I agree with Horatio Wood that "therapeutics developed by empiricism or clinical experience alone can not rest upon a secure foundation. Experiments upon the lower animals or upon healthy human beings are the only rational scientific groundwork for the treatment of diseases." Roehrig has shown by experiments on frogs that feeble cutaneous irritants enhance the normal tone of the circular muscular fibers of the vessels, and that in tense irritants permit a relaxation of these muscular fibers. This has been confirmed by Naumann and others. These observes have shown that weak cutane ous irritants produce a narrowing of the small arteri oles, with a rise of pressure, in consequence of which the resistance at the periphery is enhanced, and thus the heart is made to contract more rapidly. Intense cutaneous irritants, on the other hand, fatigue and par alyze the normally existing innervation of the blood vessels, which emanates from the medulla oblongata, and therefore produce a relaxation and dilatation of the peripheral arterioles, with diminution of pressure That the toxic agents circulating in the blood in certain infectious diseases belong to the latter class has been demonstrated by Romberg and Paessler. That the ap plication of cold water to the cutaneous surface belongs to the former class (fesble cutaneous irritants) has been demonstrated by Winternitz. From these demonstrated facts a rational treatment of pneumonia has been deduced, to which the attention of the medical profession needs to be directed. The application of cold water to the skin produces, like other mild cutaneous irritants, a narrowing of the cutaneous vessels, which, followed by their tonic dilata tion during reaction, causes the blood pressure to rise and improves cardiac action. increased contractility of the walls of the fine peripheral vessels, relieving the heart enormously, and freeing it from the added labor which threatens to exhaust it in infectious diseases, in which there is a loss of this propulsive power, due to passive relaxation of the peri. pheral vessel walls, by which normal resistance is removed. Prof. Hobart A. Hare demonstrates his great aptness as a teacher by the ingenious comparison of the heart to a locomotive. He says, correctly, that the vasomo· tor system is made up, on the one hand, by the vaso motor nervous apparatus, and, on the other, by the blood-vessels themselves. The resistance offered to the heart by the properly acting vasomotor nervous system, through its influence on the vessels, is identical with the friction offered to the driving wheels of a locomotive. The locomotive is intended to meet and stand any resistance, but when the latter is removed by slippery rails the wheels fly around ineffectually, racking the machinery and destroying its usefulness. He maintains justly that "a rapid pulse may be due in no way to a disordered heart, but to vasomotor relaxation, and that the proper treatment is to put sand on the track to increase the resistance, and not to make more steam-or give digitalis-which will only cause the engine or heart to work away on slippery rails, with more wear and tear and no progress." The cold bath increases the re sistance. That the explanation of the action of cold hydriatic procedure in infectious diseases which I have given is correct, has recently been confirmed by Dr. Woods Hutchinson, Professor of Comparative Physiology in the University of Buffalo, who argues ingeniously from comparative anatomy the existence of elasticity in the peripheral vessels, which aid in propelling the blood onward, and states that the caliber of the arteries and arterioles, particularly the latter, varies very considerably from time to time, so as markedly to influence the flow of blood to the part supplied by them, and that these changes of caliber are brought about by the vital contraction or relaxation of the firm and powerful mus. cular wall, which extends from the largest arteries down to the mouths of the very capillaries them selves. Hutchinson concludes: 1. That the existence of active contractility upon the part of the muscular wall of the arteries and arterioles, and in less degree of the veins and lymphatics, and of the capillary epithelium, is something which we have the strongest reason to expect upon ancestral ground in even the highest aninals. 2. That the beneficial effects of cold water upon the circulation, accompanied by friction, as in the Brand method of typhoid fever, are adequately to be explained only upon the ground of the persistence of such a power in our mammalian "skin heart." I have for many years expressed the belief that this tonic effect upon the heart is due to the fact that the peripheral vessels posses the power of propelling the blood through these fine tubes, and thus bear a larger share in the circulation than is commonly suspected. 8. The occurrence of this sort of contraction is alThis effect I have long claimed is enhance by the appli- most universal in invertebrates (having been seen even cation of cold water to the skin, which produces first in the higher vertebrates-the wing of the bat, and the a contraction and subsequently a tonic dilatation, with ear of the rabbit), so that we have abundant ground for the possibility and some even for the probability of its occurrence in our own species. Essential Paroxysmal Tachycardia.-Dr. S. B. Laache (Deut. Med.-Zeit.; Med. Rec.), makes the Thus theory, experiment, and logical reasoning have following remarks: The disease may in general be confirmed the clinical observation of those who resort looked upon as a neurosis, but not infrequently it is asto cold hydriatic procedure in infectious diseases. Even sociated with evident changes in the heart valves or if the temperature is not materially reduced by them, myocardium. The attack begins snddenly as a rule. the pulse almost always demonstrates improved heart In spite of the increased frequency, the pulse is regu. action. The application of these principles to the lar. Perhaps the lowering of the blood pressure plays therapy of pneumonia has been of great interest to me. an important part. The temperature is normal as a Careful observation at the bedside during the past ten rule, though at times a febrile condition exists. The years has brought me to the abandonment of the cold, attack stops as suddenly as it began, whereby the pa full bath, chiefly because it is too disturbing to the patient experiences a precordial concussion, which Martius tient, and the latter does not require it, because there considers a sign of the sudden contraction of the heart is not usually a serious involvement of the nervous sys- following a previous dilatation. The duration of the tem, and also because the body cools very rapidly in attack varies from a few minutes to hours or even days. this disease after any decided cold procedure. I have The prognosis for a single attack is good. Recurrences therefore substituted a more mild procedure-the wet will very likely take place. Instances of cure have been chest compress. The latter consists of several layers of recorded. The diagnosis is generally easy. The neuold linen cloth, wrung more or less out of water at 60° ralgic pains of angina, as well as the dyspnea of asthma, or more, and repeated every half to two hours, accord- are lacking. Abdominal pain without the existence of ing to the patient's condition and temperature, applied any symptoms of abdominal diseases is very striking. snugly around the entire chest, and covered with flan The pathologico-anatomical condition of the affection is nel. This has in my hands proved quite sufficient to thus far but little understood. Changes in the valves produce all the effects of cold water. The first effect or myocardium have been found. The disease attacks of such a compress is a shock to the peripheral nerves, men most frequently, but quite often too women and followed rapidly by a reaction which is conveyed to children. Nervous influence, infectious diseases (diph the central nervous system, and thence reflected to the theria, rotheln, syphilis), disturbances of the sexual and lungs, causing deeper inspiration and increased expec gastro-intestinal apparatus, and, finally, dreams, plays toration; to the heart rendering the pulse slower, more an important râle in the etiology of the affection, tense, and resisting. When the compress becomes which is also observed in several members of the same family. Martius looks upon the paroxysmal tachycardia as a very acute cardiac dilatation, which disappears as suddenly as it began. Laache considers this dilatation as secondary, and seeks for the cause of the disease partly in a neurotic, partly in an anatomical change of the heart muscle and cardiac vessels. Therapy consists No drug is capable of accomplishing the same result. of absolute rest during the attack, and application of an I am not averse to the use of drugs, and often resort to ice bag. Sceott prefers local warm applications. Digihypodermics of strychnine to tide over temporary car- talis is too slow in action. Subcutaneous injections of diac inadequacy, but I depend almost entirely on the morphine tend to alleviate symptoms, but do not cold compresses to meet the most pressing indications shorten the attack. Suggestion therapy is often folof improving the circulation and respiration, increasing lowed by good results. Of the nervous sedatives, the renal elimination and reducing temperature. Since al- salts of bromine are recommended. In organic disease, coholic stimulants produce in large doses the same con- digitalis is the sovereign remedy. ditions of the cutaneous vessels as the injection of the pneumococcus produces, I do not resort to them, except in alcoholics to whom they have become a daily necessity. heated by contact with the hot skin, evaporation through the flannel covering ensues, causing heat diffusion and consequent local cooling. Removal of the compress produces a repetition of the shock and reas tion, with the same effect upon the respiratory and vasomotor centers. The lessons of Dr. Van Santvoord's admirable essay are that drugs are demanded to counteract the danger ous relaxation of the peripheral vessels, and that drugs have thus far failed to accomplish this desirable result. The lesson I desire to emphasize is that the cold, wet compress, judiciously adapted to each individual case of pneumonia, not only restores the tone of the relaxed peripheral vessels, but possesses other therapeutic qualities which render it the most useful agent in the treat ment of this disease.-SIMOM BARUCH, M.D., in New York Medical Journal. A Case of Diphtheria of the Floor of the Mouth.-Isolated diphtheria of the mouth is a suffi ciently rare condition as to deserve more than a pass ing notice. In the following case, which came under my observation, the diagnosis was established by micro scopical examination of a portion of excised tissue: The patient was a female, 36 years of age, married, with negative previous history. Present illness. Last evening while in her usual good health, she noticed a gradually increasing thickness of speech, together with a swelling of the floor of the mouth, coming on without apparent cause, and attended by marked salivation. Swallowing became almost impossible. Movements of the tongue were difficult, but not painful. Examination twelve hours after onset of the symp lene blue, a considerable number of bacilli are found, toms showed the patient to be a fairly developed evenly dispersed throughout the region of the fibrinous woman in apparently good health, except for the lesions exudate. These bacilli have the characters of bacilli of within the mouth. The floor of the mouth exhibited a diphtheria, appearing as small, short, straight or slightly marked diffuse swelling of soft elastic consistence. On curved rods, from two to three times longer than broad either side, a fold of membrane running antero-poster- with rounded ends, and often staining unevenly through, iorly appeared as a reddened prominent ridge, on a out their length. They decolorize by Gram. level with the top of the inferior incisors, firm and elastic in consistence, translucent except on the anterior margin and extreme summit, which was covered with a white exudate. This exudate on close inspection was seen to consist of a fine delicate tracery of white lines, roughly parallel to each other, arranged in undulating waves and in places aggregated to form white opaque ares. A few cocci in pairs and short chains, staining by Gram, are found lying upon the mucous membrane, but not below the surface of the fibrinous exudate.-J. L. GOODALE, A.M., M.D., in The Laryngoscope. The Effect of Aniline Upon the Bladder. -Professor Rehn (Lancet; N, Y. Med. Jour.) at the German Surgical Congress, described some cases of Moderate salivation was present. No foul odor was growths of the bladder occurring in workmen employed apparent beyond that which might naturally proceed in chemical factories, especially those where fuchsine is from several carious teeth. The gums were reddened, moderately spongy and swollen. The glands below the jaw were moderately enlarged but not tender. The general condition of the patient was not effected. turia. He refers to similar observations made by Dr. Grandhomme, of Hoechst, Dr. Stark, of Chicago, and Dr Bachfeld. Aniline and toluidine are especially liable to produce irritation of the bladder. The patients in question were employed in the so called reduction made. He expressed his opinion that the vapors devel. oped in the manufacture of fuchsine produced an irritation of the uropoietic system which finally led to the formation of malignant growths. Dr. Leichtenstern, MICROSCOPICAL EXAMINATION.-A wedge shaped piece chief physician to the Cologne General Hospital, writwas excised from the summit of the ridge at a point ing in the Deutsche medicinische Wochenschrift, states covered microscopically with a white exudate. Alcohol that long ago he also observed urinary troubles in these hardening. Sections stained in hematoxylon and eosin workmen, especially in the form of strangury and hemashowed the epithelial cells to be widely separated from each other by the penetration between them of great numbers of leucocytes and an abundant mass of mesh like exudate. In places these epithelial cells are ex foliated in coherent masses. In most places the individual epithelial cells exhibit no change in their department of the factory, where nitrobenzol is con protoplasm or nuclei, but here and there where a few are surrounded by an especially large mass of exudate and leucocytes their nuclei stain faintly or not at all. The submucous connective tissue is scarcely to be per ceived, its place being occupied chiefly by numerous leucocytes and masses of exudate. The leucocytes are less abundant than in the mucous membrane. Except for their wide separation from each other the individual fibres show no abnormality. A considerable number of red blood corpusles are seen intermingled with the leucocytes in the meshes of the exudate. verted into aniline, amidotoluol converted into toluidine, and fuchaine produced from these two compounds. In this department, therefore, the workmen run great riske, and prophylactic measures should be taken. Free ventilation is essential in order that they may not be ex posed to the influence of concentrated vapors of the above substances. They should be instructed to give immediate notice to the medical officers whenever any urinary troubles occur, and men suffering from a disease of the uropoietic system ought not to be employed in aniline works. Dr. Leichtenstern in conclusion de On staining by Weigert, the exudate is found to conscribed two cases of tumors of the bladder lately ob. sist of fibrin. This is chiefly found in the deeper por- served by him in workmen from a well-known Rhenish tions of the mucous membrane, where it is spread out chemical factory. The first patient was a man, 31 in a well-defined fairly even line from which finer pro years of age, suffering from symptoms of chronic longations are given off to the surface and to the sub- aniline poisoning-yellow green color of the hair and mucous tissue. There is also seen a separate fibrinous nails, together with anemia. He had also for several mesh diffused throughout the deeper layers of the sub-weeks complained of anorexia and strangury. By rectal mucosr, increasing in density with the depth. palpation a glubular and very painful tumor was recog Examination of sections stained in polychrome nized in the bladder. The bladder itself was so small methylene blue and eosin show that the leucocytes that only seventy cubic centimeters (two ounces and a above referred to, consist of small mononuclear and or half) of fluid could be injected by irrigation. The daily dinary fine granular polynuclear cells in about equal quantity of urine was from five hundred cubic centiproportion, together with a considerable number of meters to seven hundred and fifty cubic centimeters eosinophiles. The relative proportion of these cells is (seventeen fluid ounces to twenty-seven fluid ounces); about equal throughout the specimen. There are no it was of a dark green color and contained a small cells found resembling plasma cells or matzellen. quantity of blood. Casts were never present and the In course of time other tumors In specimens stained with Loeffler's alkaline methy. reaction was acid. |