, 1913 , Vol. VIII, The sign is of particular diagnostic aid when the amount of fluid present is small. It must not, however, be regarded as pathognomonic, as evidence is accumulating to the effect that the triangle may be present in a number of subphrenic conditions associated with the massing of fluid. Diagnosis of Organic Heart Lesions.'-Bateson gives the following: 1. "In health, the cardiac dullness on percussion, immediately below the nipple, two inches across, and the extent of dullness beyond this measurement commonly indicates either the increased size of the organ or undue distention of the pericardium. 2. "In health, the apex of the heart may be felt and seen to strike the chest between the fifth and sixth ribs, a little below and a little to the inside of the left nipple. Any variations that may exist in the position of the apex are indications of disease, either of the heart itself or of the parts around it. 3. "A friction murmur synchronous with the heart's movements indicates pericardial or expericardial exudation. 4. "A bellows murmur with the first sound, heard loudest over the apex, indicates mitral insufficiency. 5. "A bellows murmur with the second sound, heard loudest at the base, indicates aortic insufficiency. 6. "A bellows murmur with the second sound, heard at the apex is rare. It indicates, first, aortic disease, the murmur being propagated downward to the apex; or, second, roughened auricular surface of the mitral valves; or, third, mitral obstruction (pre-systolic murmur at apex). 7. "A murmur with the first sound loudest at the base, and propagated in the direction of the large arteries, is more common. It indicates, first, an altered condition of the blood, as in anemia; or, second, dilatation or disease of the aorta itself; or, third, stricture of the aortic orifice, or disease of the aortic valve. 8. "Hypertrophy of the heart may exist independent of any valvular lesion, but this is rare. 9. "The pulse, as a general rule, is soft and irregular in mitral disease, but hard, jerking or regular in aortic disease. 10. "Cerebral symptoms are more marked in aortic disease; pulmonary symptoms in mitral disease." Von Pirquet Reaction. Michajlovskaja employed the following modification of the von Pirquet tuberculin test: The outer surface of the thigh was cleaned with ether and various dilutions of old tuberculin were deposited downward by means of a capillary pipette: 1. A drop of a solution of one part of five per cent. carbolic acid glycerin and two parts of normal 1J. C. Bateson, M. D., Med. Council, Nov. 1912. 'A. O. Michajlovskaja, M. D., Roussky Viatch, Aug. 18, 1912. saline, as control; 2, one drop of one per cent. solution of tuberculin; 3, five per cent.; 4, ten per cent.; 5, fifteen per cent.; 6, twenty per cent.; 7, twenty-five per cent.; 8, undiluted tuberculin. The skin over the deposits was slightly scarified, and in one to three minutes the excess was wiped off from above downward. The results in 164 cases showed that the majority of tuberculous patients gave the reaction with the higher dilutions (one to ten), while the nontuberculous as a rule failed to react. With the pure tuberculin fifty-two per cent, of nontuberculous individuals reacted. Symptoms of Bismuth Poisoning.'-From the cases reported, Warfield says, we can deduce a rather typical picture which differs from the poisoning of lead and of mercury. There are three stages: (1) Benign, where the violet-black line is the only manifestation; (2) moderately severe, where there is stomatitis, more or less acute, to which succeeds a chronic stomatitis characterized by discoloration of the gum margins and tattooing of the mucosa which extends to the buccal cavity; (3) a severe form characterized by a longer duration of the stomatitis, the margins of the gums and tattoo-like plaques ulcerate, secondary infections supervene, and general symptoms as fever, hiccough, vomiting, diarrhea, and albuminuria occur. Prodromal symptoms are slight or, if present, there is only malaise, slight salivation or tenderness about the mouth. There soon follows the line on the gums or tattoo plaques and ulcerations on the buccal mucosa. The bismuth line occupies a part or all of one or both jaws. It resembles the lead line but differs from it because of its really violet tint. In benign cases the gum margin is not swollen. In severe cases there may be swelling, ulceration, and loosening of the teeth. Cessation of the bismuth treatment brings about improvement but the gums still retain the discoloration for some time. The line on the gums is usually the first symptom of the poisoning, but occasionally there are plaques on the buccal mucosa like tattoo marks. The bismuth plaques may be found anywhere in the mouth but show preference for sites where the teeth and gums come in contact and the first plaque is often at or near the opening of the duct of the parotid gland. The ulceration is more apt to occur at this situation. The sides of the tongue are also frequent sites of ulceration. The color is the same in all, a violet black. The lesions rarely appear insidiously, but are usually preceded by salivation and erythematous stomatitis. At times the lesions come on rapidly with edema. The spots may be simply small areas of bluish violet-black color, in severer cases there is some swelling and a diphtheritic white membrane in the centre. This is characteris 1 L. M. Warfield, M. D., Milwaukee, Wis., Am. Jour. Med. Sciences, Nov., 1912. tic of bismuth. In very severe cases gangrene occurs with resulting loss of substance. The breath is usually foul, depending upon the state of the lesion. The spots appear simultaneously or in crops. They cause more or less functional disturbance and thus tend to weaken the patient. Mastication may become impossible. The swollen and painful tongue may with difficulty be protruded. Ulcerations on the soft palate and tonsils may cause hoarser ess. Salivation is marked and when healing of ulcers begins the saliva may Le so tenacious as to interfere with swallowing. The patient in these severe types naturally emaciates, and there is often fever due to secondary infections. There also may be dysphagia, vomiting, and diarrhea. The urine may even be blackish and frequently contains bismuth. Occasionally albumin and casts are present. These symptoms are produced by a pure bismuth salt. They are not the result of impurities, such as lead, arsenic, or antimony. Diagnosis of Nephritis.'-Engelbach in concluding his paper draws the following deductions: 1. Urine analysis alone is no criterion for the lesion or function of the kidney. having 2. In many cases of nephritis marked urinary findings the function of the kidney is not greatly diminished. 3. In probably 50 per cent. of the cases of secondary contracted or interstitial kidneys in which the urine may be practically normal, there is a marked decrease of renal insufficiency. 4. A diagnosis of nephritis or exclusion of such a diagnosis should never be made on the urinary findings alone. 5. Secondary changes in other organs due to nephritis are frequently diagnosed and treated as the primary lesion. 6. Complete general and physical examination, functional tests of the kidney, the course and the reaction to treatment should all be given consideration in the diagnosis of this disease. TREATMENT. Strangulated Hernia and Atropine.-Although many surgeons prefer to operate immediately in every case of strangulated hernia, reduction by taxis, especially in general practice, is always attempted, and frequently with success. There is not one practitioner who has not from time to time experienced the satisfaction of hearing and feeling the gurgling of the intestine as it slips into the abdomen. However, this happy result does not always obtain. In spite of repeated and patient efforts, the constriction cannot be overcome, and an operation seems inevitable. If the patient is within reach of immediate surgical interference, it 1 Wm. Engelbach, M. D., Jour. of Missouri State Med. Assn., Nov., 1912. makes little matter-relief is at hand. But it sometimes happens that there is some forced delay, and meanwhile the life of the patient is in jeopardy. For such cases a chance is afforded by placing a compress of ether on the tumour, or by injecting morphia or atropine, which is particularly successful. From 1 (children) to 5 milligrammes (adults) of atropine are injected under the skin of the pubis, and in a few hours the hernia is reduced spontaneously. Treatment of Cough in Pulmonary Tuberculosis. In a lecture at the Hôpital Beaujon, Professor Albert Robin pointed out that the cough in pulmonary tuberculosis is often useless, and ought to be treated. It may be laryngeal, tracheal, pulmonary, gastric, mediastinal, or pleural. The nervous cough is very common. It occurs as the result of a tickling sensation in the larynx, and does not depend upon any organic cause. It may be treated by suggestion, for example, in the course of sanatorium treatment. The patient educates himself by his own will. If this treatment is not enough, recourse must be had to the following: Swabbing the throat with a 30 per cent. solution of potassium bromide, or taking 1 g. (gr. xv) of that salt in water. The pharyngeal cough should be treated in the following way (the patient uses this gargle warm): , 1913 , Vol. VIII, The following draught may be ordered: 5. 6. Sufficient mastication. Regular hours. No hard and fast rules can be made as regards diet for each case will be influenced by the condition of the gastric secretion and motility. In general it should be said that food should be good, nutritious, as bland and nonirritating as possible and of sufficient variety not to become irksome. Cannon has shown that coarse foodstuffs are notably retarded in their exit from the stomach, and consequently act as irritants. When marked glandular activity exists as in the hyperacid stage, a diet rich in proteids, in spite of its high combining power with hydrochloric acid tends to further increase this activity. In Barclay's experience the best results were obtained by restricting or cutting out the coarse fibred meats, as beef, and prohibiting the use of such scratchy articles as cabbage, raw celery, graham bread, raw fruits, etc. Where atony is present water should not be allowed with meals or its amount limited as the extra bulk acts as a mechanical hindrance to the peristaltic action of the stomach. In the mechanical treatment lavage is a most useful adjunct. It not only removes the mucus, but in the expansion and contraction of the stomach wall stimulates the unstripped muscle fibres. In the milder degree of gastritis where mucus is not a continuous secretion, washing after a night's fast fails to reveal its presence. In these cases if it is practiced say four hours after an ordinary meal it can usually be demonstrated. The author has never seen that medicated lavage possesses any advantage over plain warm water. The presence of mucus is best shown by splashing a hook around in the washings and if it is present it can be drawn up in white glairy strings. Mere inspection as a rule fails to show its presence, as it is of the same color and held in solution by the water. A vast host of drugs has been advocated, but the majority of them are useless. In the well nourished cases, with normal or higher acidity use the alkaline saline waters, as Carlsbad in the form of imported salts. What their action is authorities seem to differ, but the general consensus of opinion is that they do exert a beneficial influence on the gastric mucosa by stimulating the secretion of bile, the motor function, dissolving mucus and reducing the acidity. In those cases of less robust constitution vichy salts may be substituted in place of Carlsbad, as its prolonged use is less debilitating. Where hyperacidity exists, the use of alkalies is indicated as soda bicarb. or magnesia oxide. In the subacid cases Kissengen salts have been advocated and as far as my experience goes, they have proven of benefit, but their use has rested largely on an empirical basis. Re cently Van Norden and Dapper have endeavored to determine thei- true physiological value. Their observations were carried out on a large number of gastric conditions, and one very interesting conclusion was that in many cases of gastric disorder, especially chronic gastritis, the use of saline waters leads to an active increase in the hydrochloric acid secretion. Again, that in case of hyperacidity a moderate use of the salines tends to decrease the hydrochloric acid secretion. This certainly sounds paradoxical, but the high standing of these clinicians leaves no room for scepticism. When constipation is present, the temperature of the saline should be reduced, as the cooler the water, the more laxative is the effect; where a tendency to diarrhea is present they should be given as hot as possible, slipping .them preferably through a tube. Those cases where there is no free hydrochloric and a total acidity of 20 or under; hydrochloric by itself or in combination with resorcin, especially where atony is present, is of decided benefit. The Kissengen salts should be given a half hour before meals and the hydrochloric not earlier than half an hour after meals. In those cases where overwork and worry are prominent factors, a trip to some of the European or American spas will often prove of great benefit, not so much on account of the waters, as the regular life, simple diet and the freedom from care. Treatment of Epistaxis. Let the patient always sit up before an open window-never lie down-so as to keep the head higher than the trunk. Ice may be used locally and to the back of the neck. The lower extremities should be immersed in hot water up to the knees, or the lower limbs bound with hot cloths, and small doses of digitalis with ergot may be given every three hours. The best method of using powerful astringents is to illuminate the nose by a good light and speculum, and attempt to detect the spot from which the blood flows. Then apply such remedies as adrenalin, turpentine, sulphate of iron, hazeline, and other astringents directly to the bleeding point, a probe being tipped with sponge for the purpose. This is a better practice than blindly swabbing the whole of the nasal cavity and membranes with caustic agents. It is sometimes necessary to plug the nares, which must be plugged posteriorly with a piece of lint, fastened with silk through the nose. The silk may first be passed with a Pellocq's sound, or, better, a soft gum catheter. These plugs should always be soaked in antiseptic solutions and covered with boracic acid, or they soon become foul. They should always be removed within twenty-four hours. serious objection to their use is the setting up of acute inflammation of the middle ear, which A 'Dr. J. L. Morse, Am. Jour. Med. Sciences, Nov., 1912. , 1913 , Vol. VIII, is very apt to occur if the pernicious practice of plugging the posterior nares with lint soaked in a strong solution of perchloride of iron is followed. Transplantation of Bone in Treatment of Fractures.-Dr. Murphy has demonstrated beyond a doubt that transplantation of bone, if done in a certain class of cases, and under certain conditions, is perfectly feasible; and a most satisfactory method of dealing with ununited fractures, or fractures where there is loss of much bone tissue, and especially in cases where malignancy or traumatism has caused the loss of a considerable section of a long bone. The following rules must, however, be observed: First, the bone must be taken from the same individual, preferably from the spine of the tibia of the well leg; second, that there must be direct contact of both ends of the graft with the bone, and preferably the graft should be driven snugly into the rimmed out medullary canal at each end. Nails may be driven in to prevent undue shortening and to make the contact more accurate if there has been much loss of bone substance. The site of reception of the transplant must be free from infection or disease of any kind, and must not have sustained a recent trauma. After placing the transplant, the wound must be closed so as to exclude the air. Reasonable fixation of the limb must be maintained, and the usual treatment for simple fracture be instituted. The size of the transplant should be as large as can be taken conveniently from the tibia, provided the same is not larger than the place to be filled. In chiseling the slip from the tibia it is his custom to leave the periosteum attached to one side of the transplant, but he is not at all certain that this is necessary. He is certain that he has demonstrated that bone regenerates from bone and not entirely from the periosteum. He is not yet certain whether the transplant simply acts as a stimulant to the osteogenic process, the Haversian canals with their lacunae, canaliculi, lamellae and Haversian spaces, serving as carriers of the osteoblasts and osteoclasts, the compact tissue eventually being entirely absorbed, its place being taken by new bone; or whether it remains after complete regeneration has taken place simply as a part of the new bone. It will be remembered that both osteoblasts and giant cells are found in great abundance on the walls of the medullary canal, also that the canal does not exist in early fetal life. To what extent it reforms later in these cases is still unknown. This, however, is not a matter of great importance from a clinical standpoint. 'C. P. Thomas, M. D., So. Cal. Practitioner, Los Angeles, Cal.. Nov.. 1912. , 1913 , Vol. VIII, Mixed Narcosis.-Embley in his useful paper states that the purposes of administering morphine in conjunction with ether or chloroform in general anesthetics are: (1) To diminish the quantity of chloroform or ether necessary to maintain surgical anesthesia, thereby lessening the liability to overdosage and the severity of after effects. (2) To cut out as far as possible the liability to reflex syncope and to diminish shock in prolonged operations. (3) To diminish "psychic shock." (4) To diminish the secretions of the mouth and airway in ether narcosis. The addition of atropine to morphine in mixed narcosis was made for the following reasons: (1) To further diminish the secretions of the mouth and the airway in ether narcosis. (2) To cut out the cardio-inhibitory function of the vagi, and thus to prevent syncope, especially in chloroform narcosis. (3) To compensate the defective lung ventilation due to morphine. The addition of scopolamine to the morphine in mixed narcosis was made for the following reasons: (1) To further diminish the secretions of the mouth and airway in ether narcosis. (2) To further diminish the amount of ether or chloroform necessary to maintain surgical anesthesia, by summing its own anesthetic effect with that of ether and morphine or chloroform and morphine. (3) To compensate the defective lung ventilation, due to morphine. His conclusions, which should be read in connection with the remarks in the "Univ. Med. Record," September, 1912, No. 697, and October, p. 335, are that: (1) The use of morphine, atropine, and scopolamine in mixed narcosis appears to be justified; with the exception of the employment of atropine and scopolamine to compensate the respiratory depression caused by morphine. (2) Neither atropine nor scopolamine compensates the respiratory depression caused by morphine. In the severe form of depression they are incompetent, whilst in the milder forms the augmentation is of too short duration to be of service in clinical usage. (3) During employment of the closed method of mixed narcosis, respiratory depression does not occur. When marked depression occurs in the open ether method of mixed narcosis, the closed method should be substituted. Should marked depression be found to continue after the operation and to cause anxiety, CO, should be administered, much diluted in the inspired air. (4) If the dosage be confined to the lowest useful limit-say % to 1% grain of morphine for adults and 1/100 to 1/150 grain of atropine or scopolamine-and the anesthesia by open ether be not carried to too deep a level, 1C. P. Embley, M. D., Australasian Med. Jour., Aug. 17, 1912. marked respiratory depression will rarely oc cur. (5) In the small minority of cases in which morphine causes marked respiratory depression, it is due to abnormal innervation of the respiratory mechanism, when even the smallest serviceable quantity of morphine will bring it about. (6) Omnopon appears to offer a way of obtaining the advantages of morphine in mixed narcosis with a diminished risk of respiratory depression. (7) In the mixed narcosis of chloroform, respiratory depression is apt to be absolute and persistent in cases of abnormal innervation. Such cases are not necessarily dangerous, providing that artificial respiration be maintained till autonomic breathing returns. The administration of CO, during artificial respiration is the best treatment. The CO2 of course, should be used so that some approximation to 5 per cent. be inspired intermittently. (8) Clinical experience of omnopon, scopolamine, nitrous oxide and oxygen, with ether, favorably impresses. The after effects are much less and the patient less unhappy on recovery. Much less ether is used than by other methods. Treatment of Erysipelas by Tincture of Iodine.'-Binet reports the results of a series of cases of erysipelas treated by swabbing over the affected area with tincture of iodine. He points out that the disease is a dermatitis, and consequently that if the streptococci, which swarm in the compact meshes of the skin, are to be destroyed, it is necessary to use an antiseptic which can be absorbed. Iodine answers this want, but its absorption varies considerably, according to the conditions under which the swabbing is made. Faults of technique are responsible for the most part of the failures of this method. It is absolutely necessary to follow up the application of the antiseptic with a dressing composed of sterile compresses or of simple sheets of wool. The tincture of iodine dries up and forms a pellicle on the surface of the epidermis. It is, therefore, necessary also, when a fresh swabbing is required, to begin by removing this iodic pellicle, and clean the epidermis with either a little absolute alcohol or glycerine. The skin must be quite dry before the iodine is applied. To avoid excessive concentration, Binet dilutes the tincture of iodine with alcohol, and adds a small quantity of guaiacol. R Guaiacol Tincture Iodi, Alcohol Absolut. Misce. . gr. xlv. .aa zi. The guaiacol is absorbent, analgesic, and antithermic. The first swabbing with iodine is made freely over the whole surface of the erysipelatous area, even going beyond its borders to prevent serpiginous invasion of the in1 Revue Medicale. |