Reports on Progress.

COMPRISING THE REGULAR CONTRIBUTORS OF THE FORTNIGHTLY DEPARTMENT STAFF

GENITO-URINARY SURGERY.

BY BRANSFORD LEWIS, M. D.,

Professor of Genito-Urinary Surgery, Marion-Sims College of Medicine.

Assisted by J. L. BOEHM, M. D.,

ST. LOUIS.

[Translations from Centr. fur die Krkheiten d. Harn und Sexual Org., Bd., XI, Hft. 6.]

Causes and Treatment of Prostatic Abscess.-A, Routier (La Presse Med., No. 13, February 14, 1900) points out how seldom prostatic abscess occurs in cases of a healthy urethra; most commonly it is a result of gonorrheal infection, very seldom from other infections. A previous trauma is often the cause for the formation of this abscess. Catheterization during the course of a urethritis, unskillful and careless injections, sexual excesses or direct strain on the perineum, as in sitting in long railway journeys, or riding on a wheel, is often an exciting cause. The treatment, according to Routier, is deep incision with a guide.

Treatment of Prostatic Tuberculosis.-(Sarda, Toulouse, Archiv. provincial de Chirurg., No. 3, March, 1900.) –In treating prostatic tuberculosis by local medication there is little success. Often surgical treatment is not desirable. It is best to incise the perineum in front of the rectum deeply, and then curette. If an abscess points in the perineum, an incision one finger's breadth anterior to the anus should be made. In tuberculosis of prostate without abscess formation, it is desirable to establish a perineal fistula. If a fistula exists it should be extended into the prostate. In performing prostatectomy, especially if the seminal vesicles are not to be removed, the long incision is recommended.

Herpes Genitalis.-(M. Gaucher, Paris, Independence Med., 1899.)— According to the author, herpes caused by external irritants must be differentiated from that due to internal neuroses. Herpes following some internal disease may be localized on the gentalia. The common causes are, ordinary coitus, sexual excesses, blenorrhagic or chancroidal discharges of the female genitalia. As a modification the constitutional condition must essentially be considered. A local predisposition due to previous venereal disease of the genitalia need not be considered, since many suffer with herpes who never had any venereal disease. For treatment the author uses starch or talcum and alum mixed together. As a systemic treatment, arsenic and sulphur baths.

Treatment of Surgical Tuberculous Affections.-(W. Cheyne, Lancet, December 30, 1899.)-Of the male reproductive organs, tuberculosis of the epididymis is the most common. With this as a nidus the process extends to the testes, seminal vesicles and prostate. A contraindication to operation exists when the disease is of a chronic character, showing a tendency of healing. In such cases attention should be given to the hygiene and building up of the constitution; and when suffering much pain inunction of belladonna ointment is desirable. Operations of curetting, epididymectomy and castration are performed. In the early stages epididymectomy is a satisfactory, radical procedure, and should be followed by curetting. Since castration in most instances is bilateral, and there is a probability of mental depression following, it shold only be performed in case of absolute necessity. Tuberculosis of the bladder is usually secondary to renal tuberculosis, and goes on to ulceration. The treatment may be medical and surgical; in neither method is there ony positive result. Injection of iodoform emulsion is of little avail, silver nitrate is often painful and injurious. Opening and draining the bladder is often followed by good results. On the other hand, curetting and cauterizing may be tried. Cheyne treated five cases by this method; in one there was an undoubted cure. Renal tuberculosis is common. Before every nephrotomy, we should determine the seat of the lesion and the condition of the other kidney. Nephrotomy is only a temporary preparatory measure for an ultimate nephrectomy. The latter is contraindicated if other organs are affected. Partial nephrectomy in the early stages has produced good results.

Renal Tuberculosis.-(König and Pels-Leusden, D. Zeitschrift f. Chirurg., Vol. 55, No. 12,)-In the clinical report of this article, which is very instructive, Konig concludes: There are two forms of incipient renal tuberculosis, which are observed by the physician, viz., the isolated tuberculosis of the glomeruli with no communication with the renal pelvis, and that tuberculous process found in the renal pelvis. The first form often passes into the second. The diagnosis of the first form is often very uncertain. In comparison with this is the clinical diagnosis of the second form. It is to be regretted that the diagnosls is not commonly confirmed by the finding of bacilli. We cannot be absolutely certain of the normality of the other kidney; the most practical and surest diagnostic means is the cystocopic and ureteral examination. [ At present, the inoculation of a guinea-pig with the urine of the patient, is probably the most reliable procedure. If possible, it should be drawn from the two kidneys separately by ureteral catheterization.-B. L.] The operative treatment of tuberculous kidney is on the whole only to be undertaken when signs of wasting appear. Nephrotomy and renal resection do not suffice in renal tuberculosis. The field of nephrectomy is much larger now than formerly; whilst formerly we thought the absolute safety of the other kidney demanded an extirpation of the phthisical kidney, we now know that following extirpation patients live for years, and survive tolerably well even with disease of this remaining kidney. Furthermore, patients who have bladder disease at the same time are greatly benefited by an extirpation of the phthisical kid

ney. Corresponding to these two forms of renal tuberculosis, there are two classes of results from operation. In the first class by extirpating the diseased kidney the disease is totally removed. Patients of the second class are not absolutely cured. They still have one tuberculous kidney, vesicle tuberculosis, the testicle and urinary tract are abnormal, but nevertheless this class is remarkably benefited by removal of the phthisical kidney. Part II of the article contains a macro- and microscopical description of 16 of Prof. Konig's extirpated kidneys. Dr. Pels-Leusden concludes his observations with the following: 1. In all cases of renal tuberculosis in which the diagnosis can be positively made, an extirpation of the kidney is absolutely necessary. 2. In the majority of cases the pelvis and ureter are affected. The extension of the disease in the parenchyma and pelvis is as a rule so diffuse that a partial resection does not appear sufficient to stop the morbid process. 3. A spontaneous cure of renal tuberculosis is not to be expected. 4. The dissemination of tuberculous foci in the kidney occurs very commonly in the form of lines of tuberculous deposits along the course of the uriniferous tubules, having a similar course as pyelonephritis.

The Clinical Significance of Casts.-Kobler, Wiener Klinische Wochensch., No. 14, 1900).-At the present time the finding of granular and epithelial casts does not absolutely signify the morbid condition of Bright, whilst formerly this was considered as proof positive. Kobler studied this question carefully, and concluded, that the presence of casts does not always justify a diagnosis of Bright's disease. The true significance of hyaline casts is not known. Granular and epithelial casts are often found when no morbid condition of the kidney exists, but when there is gastrointestinal disease, especially when the latter is accompanied by violent diarrhea. This causes a lowering of the blood pressure on account of the rapid loss of water; hence a faulty metabolism of the renal epithelium and formation of casts and albumin. On the other hand, Kobler has found these casts when obstipation exists. This conditien is preceded by pain, which at times is very severe; this pain is considered as a reflex to the contraction of the kidney capsule, which consequentiy deprives the renal epithelium of its proper nutrition.

Operation for Tuberculosis of Seminal Vesicles.-(M. Moullin, Edinburgh Medical Society, January 8, 1900.)-Moullin reports two cases of tuberculosis, in which he excised the testicles and the seminal vesicles through a transverse incision in the perineum. Both cases improved; in one a urinary fistula remained for several months. Moullin recommends this operation for all cases of tuberculosis testes, in which the seminal vesicles can be plainly palpated in the rectum.

Treatment of Chronic Urethritis with Instillations of Picric Acid.(Desnos and Guillon, Journal des Maladies Cutanees et Syphilitques, Vol. 10, 1899.) The author used this method in 29 cases; it is only to be used in chronic cases, and not in primary attacks, and in acute exacerbations of old cases. By means of an instillator and a four-grain Guyon syringe, from 20 to 80 gtt of a 1⁄2 to I per cent solution is used. This must be repeated every second day. Tuberculous cystitis may also be influenced by picric acid.

MEDICINE.

BY FRANK PARSONS NORBURY, M. D,

Formerly Resident Physician Pennsylvania Institution for Feeble-Minded Children; Formerly Assistant Physician Illinois Central Hospital for the Insane; Physician to Oak Lawn Sanitorium, Passavant Memorial Hospital, and Physician to the Illinois Institution for the Blind; Neurologist to Our Savior's Hospital; Lecturer Psycho-Physics, Illinois College.

AND EGBERT W. FELL, B. S..
JACKSONVILLE, ILL.

Some Points in the Therapeutics of Heart Disease.-( Thompson, Med. Record, March 17, 1900.)-In all chronic heart diseases every function of the body should be kept in the best condition to help the laboring organ. Only temporary relief can be obtained from such remedies as digitalis, strophanthus, strychnine, spartenil, etc., and permanent improvement must come from measures which improve nutrition, and not those that stimulate function. Fresh air systemtically and continually provided without effort by the patient is the most important of these measures. The author always uses iron. Bichloride grain three times a day for a week is efficient in endocarditis. He has also used sodium iodide 5 grains three times a day in chronic cardiac enlargement accompanied by arterial disease.--From abstract in Med. Age.

The Heart in Life Insurance.-(Upshaw, Atlanta Jour. Rec. of Med. April, 1900.)--Policies are often refused unjustly, and on the other hand, are often issued when they should not be. An applicant with a functional murmur, either hemic or fron reflex irritation from overwork, indigestion, etc., should be re-examined at short intervals to determine the true condition of the heart. A bruit without hypertrophy or displacement to the right does not affect the risk. Cases in which an acute endocarditis with valvular lesion in childhood was recovered from with perfect compensation, and a normal circulation should not be rejected. In obese persons past middle age any irregularity should be looked on with suspicion. No risk is first-class when the sound of the valves fail in clearness and is muffled, showing rigidity and loss of elasticity. In applicants who are reformed. alcoholics the chance of changes in the heart walls allows them to be rated as fair only. Tobacco heart is a practical entity, and sudden death from heart failure is not so uncommon as to preclude the gravest consideration in determining the value of such a risk.

Myocarditis in Infancy and Childhood (Koplik, Med. News, March 31, 1900). Any autopsy on a child dying of an infectious disease will show changes in the heart muscle sufficient to cause death. Foci of degeneration exist, other portions of the muscle being quite normal. Experiment has shown that the myocarditis is not produced by the prolonged high temperature, but by the action of the toxins directly on the muscle cells; the nerves show no change whatever. These myocardial changes are not necessarily fatal, the infant's or child's heart seeming to be particularly capable of restoration to the normal. It is impossible, with our present

knowledge, to formulate a table of symptoms which in infectious diseases could be traced to myocarditis. The original disease masks the heart symptoms. We have, however, a certain definite set of symptoms which supervene after the myocarditis has become developed, pointing to functional weakness in the muscle, as evinced by the feeble, disordered action of the organ. Antitoxine in diphtheria will prevent myocardial changes, if used before the third day, but if later these are likely to appear. The toxins developed by a strepto- or staphlococcus throat disease may also by their action on the heart muscle cause weakness and irregularity. Malarial poisoning may have the same effect. In pneumonia derangement is apt to occur at the onset, at the appearance of crepitant rales, at the crises, or during convalescence. There is oftcn evidence of poor heart action in the beginning, and it is sometimes impossible to say whether the heart was primarily fatty, or whether myocardial changes were caused by the toxin. The presumption of the latter is very strong. Weakness of the myocardium may be caused in prolonged cases of pertussis, not only by the strain, but also by toxic influences. Infectious diseases occurring during a subacute endocarditis following rheumatism is apt to affect the heart badly. Degeneration of the myocardium extending from the pericardium is the most serious condition, as there is actual destruction and replacement by connective tissue. Although we cannot always make a positive diagnosis of myocarditis during an infectious disease if we have attacks of faintness, pallor, vomiting, disturbed and very irregular heart action, and distortion of the respiratory and pulse ratio, we should suspect myocardial degeneration. An examination of the heart reveals extreme weakness of apex beat, weakness of first sound or loss of its muscular quality, and greater intensity of second sound at apex and pulmonic orifice. In the treatment powerful drugs should not be employed, but the strength fostered with the object of healing the diseased foci.

Recent Methods in Cardiac Therapeutics by Baths and Exercises (Satterthwaite, Med. News, March 10, 1900). -The exercises are chiefly voluntary, and consist in flexion, extention, adduction, abduction and rotation of the limbs, neck, and trunk by the patient, while the operator opposes graduated resistance. Passive respiratory movements are also used. The exercises should at first be short, and gradually increase in length and force. The patient should at the same time take exercise in the open air, but avoid physical or mental strain and overeating. For a six weeks' course the baths are given as follows: First week, half per cent salt bath at 98 F., duration four minutes. Second week, threefourths per cent salt and one-fourth per cent carbonic acid gas, temperature 97 F., duration six minutes. The strength is gradually increased until oh the sixth week the bath is two per cent salt and one per cent carbonic acid gas at 93° F. for fourteen minutes. Baths and exercises are omitted every third or fifth day. The exercises and baths improve the superficial and deep circulation, the blood is invited to the skin and limbs, preventing congestion of internal organs, relieving the heart of the internal pressure and given an opportunity to contract. The muscular movements act by