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living in small but densely populated villages. The Chinese who constitute the greater part of the population live in small houses of two rooms and in many of these houses from 10 to 20 people live. According to the inhabitants of this district the plague has been an annual visitor for at least 10 years. It usually appears in August or September and disappears when the cold weather comes on. The author saw clinically a small epidemic in one of the villages and he also identified the disease bacteriologically. It was noted in this epidemic that the pneumonic form of the disease was unusually prevalent. The anti-plague serum was used in 16 cases of which 4 recovered. The author describes a form of the disease which he had never seen in India, i. e., the pustular form. In this form numerous pustules appear on the surface of the body which are surrounded by a hard red zone of skin.
The author calls attention to the resemblance between the plague and a disease of rodents which also occurs in Mongolia and which is called the plague of tarabaganes. These tarabagenes are closely related to rats and he mentions the fact that individuals who eat the rodents without cooking them are attacked with the disease which resembles plague, both in its symptoms and its unusually high mortality. He thinks that there is very little doubt that this disease is the true plague and that it has probably been endemic in Mongolia for a long time.
Concerning Auto-Digestion of the Pancreas.-PFÖRRINGER in Virchow's Archiv for October 1899 discusses the subject of the agonal and postmortem digestion of the pancreas by its own secretion. He refers to the well known work of Chiari and tabulates 100 unselected consecutive cases in which he made microscopical examination of the pancreas. Of these 100 cases 45 showed evidences of digestion necrosis. Of this number 1 showed almost complete, and the remaining 34 small necrosis. 13 of the cases were women, 32 men. The shortest time post-mortem at which the necrosis was discovered was four hours. The youngest individual showing the change was two and one-half years of age, the oldest seventy-seven years of age. The change was found both in acuțe diseases and after sudden death from accident as well as in chronic diseases. There was no particular distribution of the foci of necrosis which was sometimes associated with hemorrhages.
The author believes as a result of his examinations that in a large number of cases the pancreas either post-mortem or even during the death agony is able to digest itself. This digestion is more probable the nearer to normal the organ is and is more apt to take place when digestion hyperæmia of the mucous membrane of the stomach and duodenum is also found. As in artificial digestion experiments, so under natural circumstances the transformation of the pancreas zymogen into an active ferment takes a number of hours. Where the auto-digestion takes place during life it begins in the glandular tubercles and there is always reactive inflammation about the affected area. Such an intravital auto-digestion can be precedeä by a fat necrosis, which necrosis allows the escape of pancreas secretion thereby leading to a wider area of auto-digestion. The author
suggests the possible relation of these areas to pancreatic hemorrhage and abscess.
Lipase in Pathological conditions.-ACHARD and CLERC in the Gazette des Hopitaux for November 23, 1899, discuss the relation of lipase, the fat saponifying ferment of the blood, in different conditions. The test is an easy one to make as the lipase can be quantitatively determined from relatively small quantities of blood serum. The authors fixed the normal saponifying power of the lipase at from 15 to 20. Above 20 they considered that a condition of hyperlipasis was present and below 15 a condition of hypolipasis.
Hyperlipasis was present in seven cases of diabetes and in one obese and one myxædematous individual. In the diabetic patients, however, the excess of lipase disappeared when cachexia became pronounced.
Hypolipasis was found in almost all instances in severe and generally fatal diseases. These were sometimes acute, as pneumonia, rheumatism and septicæmia, and sometimes chronic, as tuberculosis, new growths and brights disease. The authors have been unable to satisfactorily explain the variations in the activity of the lipase. They state that their experience leads them to believe that extreme diminution of the substance has a certain prognostic value, and must be regarded as a sign of grave omen.
The Use of Phloridzin in Determining Renal Insufficiency.—DELAMARE in the Gazette des Hopitaux, October 28, 1899, reviews very fully the physiological action of pholoridzin, and after noting the well known fact that it produces a renal glycosuria, he cites the number of cases in which he used it in order to determine the presence or absence of renal insufficiency. His method consists of injecting a dose of 5 milligrammes subcutaneously. The patient empties the bladder at the time of injection. The urine is collected half an hour after the injection, one hour after it, and after that every hour for seven or eight hours. The author finds that as a rule, in healthy people the sugar appears in the urine at the end of half an hour or an hour and remains present for from two to four hours. The amount excreted varies from 50 centigrammes to 2%2 grammes. The author tested the method upon a large number of cases and in 55 found either diminution or an absence of glycosuria. Several of these cases subsequently came to autopsy. The changes in the glucose excretion were not always alike. In some cases there was merely a prolongation of the time during which the glucose was excreted, and in other cases there was no prolongation of the time, but an unusual amount of glucose was excreted. As a result of his experiments the author states that this method of determining changes in the kidneys is of value combined with other well known methods as the estimation of albumin and the methylene blue method. He regards the phloridzin method as only determining changes in function, and not necessarily denoting changes in structures, even when positive. In his autopsies he found that the prominent disease contained in the kidneys was in connection with the cells lining the tubules and he thinks that it is these cells which probably have to do with the glucose formation.
OBSTETRICS, GYNÆCOLOGY AND PÆDIATRICS
Edited by James P. Boyd, M. D. Surgical Treatment of Fibromyoma. — Baldy in the American Journal of Obstetrics, December, 1899, gives a report on this subject read at the meeting of the International Gynecological and Obstetrical Congress held at Amsterdam, August 8–12, 1899: "Hysterectomy may be performed by either the vaginal or abdominal route; it is complete or incomplete as the operator may prefer. Performed by way of the vagina it is always complete—a panhysterectomy. Performed by way of the abdominal incision the operation is completely as a panhysterectomy or as an amputation at the cervical neck. Ligature of the stump, the most common and only thoroughly tested method of treatment. Amputation at the cervical neck after the method of the old Serre-Neud operation has fallen into disrepute. Universally ligatures are applied to the vessels, and after suturing the peritoneum over the cervical stump it is dropped back into the pelvis and drainage dispensed with. This is the best method because it is applicable to all cases; it makes a shorter operation; it requires less manipulation; it opens up less connective tissue space and consequently makes less traumatism. There is less liability to septic infection, as the opening of the cervical canal is infinitely smaller and consequently more easily controlled than is the opening into the vagina when the cervix is removed. During the manipulation the fingers enter neither the cervical canal nor the vagina. The anatomical relations of the vaginal vault are kept intact and the vagina is in no degree foreshortened. There is better opportunity to prevent sagging of the vaginal vault in closing the wounds than where the cervix has been removed. On the other hand no possible good can be obtained by the removal of the cervix.
Hysterectomy is the operation of choice in fibrous tumors of the uterus. Myomectomy is only indicated when special reasons for so doing exist. The whole question of the propriety of surgical interference with fibrous tumors of the uterus rests largely on the consideration of each case. The disease is essentially a benign one. The question to be decided is the one of health and future possibilities. That of health is largely determined by the pain, hemorrhage, rapidly of growth, size, pressure symptoms, recurring attacks of peritonitis, mental condition, expediency. As to the future of fibroid disease of the pelvis, it is well established that:—there is no natural cure other than the menopause; there is no medical cure; the menopause will relieve a cartain proportion of cases only; in others, at the time of the menopause the symptoms are frequently redoubled; in still others, the establishment of the menopause is indefinitely postponed; at some time or other during their existence the large majority of these cases will give rise to symptoms of sufficient gravity to demand surgical interference.”
Cysts of the Ovary Complicating Labor.-Two cases of this rather rare condition were reported in Obstetrics, December, 1899, by Drs. PETERSON and LEWIS. The case described by the latter was a dermoid cyst which persisted in blocking the passage of the foetal head. Under chloroform the author succeeded in pushing up the tumor until the head became firmly engaged. The presentation was L. O. P. but by means of the Tarnier forceps, it rotated fairly easily into the anterior position and was delivered after a left sided episiotomy. The cyst was removed some time later. Dr. Peterson's case on vaginal examination revealed a large mass in Douglas' cul-de-sac resembling in size, shape and contour a fætal head. The cervix was pushed forward and upward above the pubes, the os was dilated about half an inch. The child's head could be easily felt through the abdominal wall above the pubes. Fætal head tones were not heard. Foetal movements had ceased two weeks previonsly. An incision was made in the vagina, the cyst punctured and about a quart of thin serous fluid was evacuated. The wound was closed with silk wormgut sutures. The cervix now resumed its normal position. Pains began about two hours after operation and seven hours later she was delivered of a still-born macerated fætus.
The Influence of Prolonged Standing in the Production of Women's Diseases. -Narne in the British Medical Journal, September 2, 1899 (American Gynecological and Obstetrical Journal, December, 1899), says that many years ago his attention was called to this subject and that during the past thirteen years as surgeon to two large hospitals for women in Glasgow, he has been able to ascertain the relation of occupation to disease in a vast number of cases. He was convinced that where women stood for many hours each day, the hyperæmia of the uterus and ovaries at the menstrual period, and the influence of gravity upon the temporarily enlarged organs, led not only to prolapsus uteri, but to other uterine and ovarian derangements. Not only so, but the veins became varicosed and, after a time, various forms of neuritis manifested themselves, due in part, perhaps, to the continuous contraction of dorsal muscles. Anæmia, arising from lack of outdoor exercise and to the long continued strain of standing, leading to deterioration of the blood cells, sets in. Special organs lose their tone, suffer from passive congestion, which passes into acute inflammation in time. While only a comparatively small number of shop girls break down at early age, 40 per cent. of married women, who have been shop girls, come under medical attention for pelvic troubles under thirty years of age. The girls are broken down and wearied, but keep at their work by force of circumstances. After marriage the former conditions tell on them, and marriage instead of giving them rest, adds fresh congestion to organs already more or less diseased. The same statistics apply to girls and women working in factories where they have to stand all day.
Suprapubic Subperitoneal Total Hysterectomy. – JABOULAY (Lyon Med., September 1899) aims in his operation to protect the peritoneal cavity and intestines from all the manipulations of ablation of the uterus, whether fibromatous or cancerous, and to secure complete hæmostosis. The operation comprises three stages :
1. Sub-umbilical median incision, down to, but not through, the peritoneum, extending as far as the pubes.
2. The operator thrusts his hand in front of the bladder under the peritoneum, stopping and pushing back the latter so as to reach the broad ligament, the ureter first identified, then the uterine artery, which is tied. Continuing always close to the peritoneum one reaches the ovary and tube, and the anastomosis of the utero-ovarian and uterine arteries is sought and ligated. Should the round ligament be in the way (though this had not occurred in the writer's experience) it could be easily cut subperitoneally and freed from its connection with the inguinal canal. The same manæuvres are repeated from the opposite side. To separate the utorus from the bladder, it is necessary to penetrate into the interior of the broad ligament above the umbilical artery and push the latter downwards and forwards. The finger profits by the denudation of the broad ligament to reach downwards to the vagina and with the scissors one opens the cul-desac, liberating the cervix wholly or in part from its attachments. Sometimes the writer has proceeded differently; after conflicting with the hæmostasis of the broad ligament, the vagina was opened with scissors and the cervix seized with forceps; and after completely reversing the uterus with the cervix upwards, he performed the denudation and hæmostasis of the opposite broad ligament, then ligation and excision of the annexa.
3. The dissection of the broad ligament having been accomplished, and the peritoneum being still intact, the cervix is seized with uterine forceps, and drawn away from the broad ligament, forward and upward to the side where the operator stands, or upon the median line; the rest of the uterus follows, detaching itself from its surroundings and vessels, until finally it remains in intimate contact only with the annexa (which are tied and cut) and with the peritoneum as its fundus. The denudation is continued until one has the entire uterus with a little of its serous covering. Sometimes the serous coat tears transversely, opening an escape for the small intestine, but they are easily held in place. In case of omental or other adhesions it would be well to attack them at the end, after a deliberate opening of the pelvic peritoneum; after breaking them up the cavity remains exposed to infection only during the extirpation of the uterus. The transverse peritoneal opening is sutured and the subserous anfractuosity has a sufficiently free drainage through the vagina to protect the overlying peritoneum. The author has employed the same proceeding in cases which demanded the removal of diseased annexa, as well as that of the uterus; and in these cases the preliminary mobilization of the uterus and hæmostasis of the pelvis make the necessary intra-peritoneal manœuvres very simple. This method corresponds to the embryological origin of the uterus, taking into account the fact that it is an organ of subserous development.
The Presence of a Living Fætus as a Cause of Eclampsia.-VAN DER HOREN in his thesis on “ The Etiology of Eclampsia” published in 1896, was one of the first to attribute the cause of eclampsia to the presence of the living foetus in the uterus. In L'Obstetrique, September, 1899, he again reviews the subject. One of tho two conditions must prevail: ist, during the gestation it is the secretory organs which are altered in their