The problem throughout was the element of infection and each time that a focus was removed or cleared up there was a lowering in the leucocyte count, less fever, less distress in the affected joints and improvement in the general condition. The infection manifested itself as periodic pharyngitis, cystitis, nephritis, and infected teeth. As further complicating the condition was the periodic hyperthyroidism, angio-neurotic oedema, impaired blood coagulation, with associated bleeding tendency, marked secondary anemia, lowered renal function and sugar tolerance. In spite of all, the outcome was very gratifying both as to the general state and the arthritic While the removal of the infective foci should be of first importance, the general care of the patient should have an equal place in any plan of treatment. Every case is a matter of individual study. Much depends upon the attending physician. His heart must be in it, and this interest must be manifest at all times, if the fullest confidence of the patient is to be secured. The handling of chronic arthritis resembles in many ways the care of a neurasthenic patient. J. W. MYERS, M.D., Sheldon Entrance and Complaint-William J., first appeared in the office on the evening of April 15, 1919, complaining of weakness, loss of appetite, inability to sleep, skin rash and vague indefinite, mental symptoms, chiefly concerning his sexual life. Personal History-Patient was male, age twenty, farmer, moderate user of tobacco, denied lues or gonorrhea. Family History-Patient comes from a large family whose members have all been healthy, with the exception of the father who has had gas tric ulcer for years. The family is in very comfortable, financial circumstances and live in good sanitary surroundings. Past Medical-Negative. Present Illness-Patient went to bed feeling perfectly well on the evening of April 8th. During the night he was seized with violent cramp, diarrhea and fever, the pain being so severe that it required the use of a hypodermic of morphine to relieve. In the interval between the 8th and 15th, the patient was not seen, but when he appeared for consultation, said that the diarrhea had only persisted that night and since then he had been obstinately constipated, a condition very unusual for him. His appetite had been gradually These cases naturally come first to the attenbecoming poorer, due to a dislike for food and tion of the orthopedist, yet the problems involved because of the soreness of his mouth. Insomnia in diagnosis and treatment, bring them properly believed this was due to worry over his condition. formed one of his most bitter complaints and he within the sphere of internal medicine, although believed this was due to worry over his condition. the advice and cooperation of the orthopedic sur- Weakness, especially of the lower limbs, comgeon is a necessary factor in the successful treat-pelled him to quit work altogether and to express Chronic arthritis can only be properly treated in a hospital where every facility for examination is available and all possible forms of therapy can be properly carried out. it in the patient's own words, "I feel as weak and limp as a dish rag." About four or five days after the initial diarrhea an eruption appeared on both hands extending up as high as the wrists. This he said, was very annoying because of the itching and burning, especially the latter. At this time the patient appeared to be laboring under great emotional stress and had forebodings that he was going to lose his mind. Delusions of persecution were present even within this early period. He imagined that he had been poisoned by a powder which had been placed on a billiard *Read before the Northwestern Iowa Medical Society, October 27, 1920. cue by a party who had taken offense at a remark which the patient had made and this powder or "cow itch" as the patient described it, had been given to him for the purpose of making him a sexual degenerate. He was also considerable worried that he was afflicted with syphilis, that he was only reaping the results of his own misconduct and that he would never become a well man again. He seemed to be living in an atmosphere of hopelessness and depression and could see no help for himself in the future but misery and utter despair. At times he would become very offensive to other members of the family with his sexual delusions and his indifference to the exposure of his person. His speech was slow, studied and tremulous, and it was difficult for him to comprehend what you desired in the simplest questions. Other nervous manifestations of the disease were an unsteadiness, almost an ataxia of the lower limbs, a jerky inco-ordination of movements between upper and lower limbs, and an unsteady, shuffling gait. A coarse tremor was present which was more pronounced in the upper extremities, especially the hands and tongue. These symptoms along with insomnia were the most pronounced nervous symptoms of the disease and continued until November of the same year. The cutaneous symptoms were also a prominent feature in the case and formed one of the chief diagnostic aids in solving the disease. It was characterized by a symmetrical erythema involving the backs of the hands and ending with a sharp line of demarcation at the level of the styloid process. It closely resembled a sunburn and could be easily mistaken for it, especially as a few days later the neck was covered with an erythema, limited above by the hair line and below by clothing. This eruption gradually assumed a brownish tint soon followed by a very fine exfoliation of the epidermis. The gastro-intestinal symptoms were ushered in by cramp, diarrhea, and fever which persisted for a few hours. The diarrhea was replaced by an obstinate constipation, a large dose of saline or castor oil being necessary to secure a daily evacuation. The mucous membrane of the mouth and tongue was reddened and inflamed and presented a few aphthous ulcers on the under surface of the tongue and gums. The patient complained of a dry and burning sensation in the mouth and of painful deglutition. Anorexia and disgust for food was present in the early weeks of the disease but the appetite seemed to improve far more than the other clinical manifestations of the dis ease. Cachexia was present to a marked degree and seemed not to bear any definite relations to the blood examination, nothing being noted in the blood count or hemoglobin estimation, which could account for such an extreme degree of cachexia. The blood serum gave a negative Wassermann. Urine examinations on three occasions were negative. R-The patient was immediately put on a nourishing, well balanced diet, with abundance of milk and medication in the form of sodium cacodylate, a three grain ampoule given twice a week and continued until November, at which time the patient began to improve in all respects and the drug discontinued. He was advised to report January, 1920, for further arsenic treatment but failed to do so. In April, 1920, we expected this man to have a relapse but it did not However, after studying the work on pellagra by Wood, we have taken a more hopeful view of the case and thought possibly the intensive arsenic treatment and liberal use of milk and proteids in the diet, would result in a perma occur. nent cure. DETACHMENT OF ADHERENT PLACENTE AND DELIVERY IN ABORTION C. E. RUTH, M.D., F.A.C.S., Des Moines The great frequency of abortion from whatever cause, together with its frequent grave complications gives the subject sufficient importance to justify its careful consideration. Complete detachment of the placenta is at times difficult, and in many cases it is imperfectly accomplished, and at others much needless trauma is done, besides increasing the danger of infection and sterility by the manipulation intended to detach and remove the secundines. Were the index finger of sufficient length, it would be the ideal instrument with which to produce detachment of the placenta because its tactile sense makes it an ideal instrument of precision, able to practically see and know the condition. Unfortunately the longest finger is almost, but not quite long enough for the work, in many cases, as I have abundantly verified on frequent occa sions. Placental forceps on the market are absolutely worthless as detachers of the placenta and any ordinary forcep can remove a placenta which is already detached. The impossibility of effecting detachment of the placenta by the finger in many cases, the uncertainty and danger of the auger and curet, even in the most skilled hands has caused a large percentage of the profession to abandon all attempts of removal of secundines in abortion cases with adherent placenta. These physicians allow the secundines to come away by putrefaction as safer than manipulation of any kind. Not one physician in one thousand would seriously consider leaving the bedside of a patient for more than a few moments until the placenta was delivered, in a case of labor at term. The placenta has as certainly lost its function. in the case of abortion as in labor at term and its being allowed to remain in abortion is only an admission on the part of the surgeon that he cannot safely remove it. Failure to remove the placenta following labor at term would by most physicians be considered criminal. The surgeon should, can and usually does prevent infection in wounds elsewhere and he should be as able to do clean work here and give his patient protection against infection by emptying the uterus at once thus saving her from the dangers Figure 2. Diagrammatic sketch of uterus in early months of pregnancy, showing globular character. inches in length (figure 2), it follows that any appliance to be of service in detaching an adherent placenta must be capable of application to every part of the interior of a spheroid. If such instrument is to be of the forceps type, it must be capable of being made small enough to be introduced through a long cervical canal; it must be capable of expansion entirely within the globular uterine body cavity entirely above the narrow cervical canal; must be so constructed as to be made to reach every portion of the interior of the uterus and clear it of attached placental tissues and membranes; and when that is done it. should be capable of being closed and withdrawn, bringing with it the placenta and membranes in such manner that no harm is done to the patient, and with the minimum of pain. Such an instrument I devised in two sizes, and have used for many years with satisfaction, though I have never until within the last year at of death, prolonged illness, permanently impaired tempted a public description, of its virtues and health and sterility. I am convinced that the uterus can always be safely emptied if done promptly, before putrefaction changes have begun accompanyed by pyrexia, septicema and abscess formation. The method presented to you herewith is not use. The stage of gestation and resulting size of the uterine cavity, will determine the size of the instrument to be used, in detaching the secundines in any individual case. In some cases while abortion is inevitable the cervix is not sufficiently dilated for instrumentation of the uterine contents. In such cases the use of the hard rubber dilator with elastic pressure will accomplish the dilation. Proper care in the use of the instrument will usually result in a complete detachment and delivery of the placenta and membranes at the first trial. There is however no objection to repeating the performance, if there is any question as to complete removal. Steadying of the fundus with one hand, while the instrument is rotated on the interior produces very active uterine contractions materially aiding separation of the placenta. The instrument was originally made to present a dull margin against the uterine wall while rotating to the right. When rotated to the left brought a sharp angle in contact with the area from which the placenta and membranes are to be detached. At the present I should never recommend the use of a sharp-edged or angled instrument in detaching the placenta. Great harm has resulted from the use of the sharp curet in these cases. in a few hours, without trauma, without anesthesia, and without abrasion of the mucosa. Then with or without anesthesia the detacher is introduced under aseptic precautions with the jaws closed, while the fundus uteri is depressed and the handles of the detacher are carried backward, so as to bring the uterine and vaginal canals in as nearly as possible a straight line. The fundus uterine is steadied by the left hand above the pubes, while the right hand spreads the jaws of the detacher and holds them firmly in contact with the lower internal surface of the uterus. In this position the detacher is rotated and the lower segment is swept by a complete rotation. The detacher is then inserted an inch farther and again rotated in the same direction; this farther insertion and rotation always in the same direction is repeated until every part of the interior of the uterus has been cleared, then the jaws of the instrument are closed and instrument, placenta and secundines are gently withdrawn while the rotation is continued until all is delivered. Figure 4. Detacher further introduced and sweeping the midportion of the uterine wall. I have twice perforated the uterus with a curet and I have seen septic uteri through which the finger could be passed with very slight resistance being encountered. A case of performation of the uterus during curetage was reported to me which occurred within the last four weeks. I am convinced that thousands of women have been rendered sterile by the curet with no compensating benefits. The auger principal of detachment is scarcely less dangerous than the curet and its use in detachment and delivery is principally in the stimulation of the uterine contraction. Thorough disinfection as possible should accompany all instrumentation of the uterine cavity and be followed by tubal drainage in all septic cases. THE DIETARY TREATMENT OF NEPHRITIS* R. L. FENLON, M.D. At the present time there are many dietary treatments of nephritis. The object of this paper is to present a convenient dietary therapy that is applicable to the disease, particularly of the chronic interstitial type. The very low protein intake has many advocates, as has also the high protein diet of Epstein. Rather recently, an editorial appeared in the Journal of the American Medical Association questioning the advisability of an extremely low protein diet in nephritis. The diets given in full below, are the diets that have been in use at the University Hospital for the past year and a half. These all conform with the requirements of the needed protein intake as given by the Chittenden standard. The following test diet is used to determine the degree of renal injury. This test is a readjustment of the original appearing in German. The urines are collected at regular intervals on the day of the test, these separate voidings are measured, and the specific gravity of each recorded. The noon and the five P. M. meals contain the bulk of the carbohydrate, and at these hours for a normal kidney, there should be a prompt period of diuresis as shown by the lowered specific gravity and the increased urinary output. The night urine should not exceed one-half of the day amount and the specific gravity of this specimen should be at least 1.019. The abnormal urinary findings, as shown by this test follow: (1) a constantly high specific gravity with variation in the readings; (2) nycturia or excessive night urine, which is generally accompanied by a low specific gravity; (3) a delayed or prolonged period of diuresis; (4) no diuresis demonstrable, and (5) a fixation of the specific gravity, that is, the readings on all of the specimens do not vary more than one or two points at the most. This is the most severe picture. As evident from *From the Research Laboratory of the Department of Internal Medicine, University Hospital, Iowa City, Iowa. |