ECTOPIC PREGNANCY

E. M. Stanton, in the Medical Record, thinks the really important point to be always borne in mind is that pelvic pain plus an unusual uterine bleeding spells ectopic pregnancy, in a very considerable proportion of cases. Whenever this combination of symptoms is present it becomes the imperative duty of the practitioner to rule out the possibility of extrauterine pregnancy before proceeding to entertain any other possible diagnosis.

Additional diagnostic data may be obtained from many sources. In the pretragic stage there is seldom any elevation of temperature commensurate with the amount of acute trouble evidently present in the pelvis. On the other hand, says Stanton, I have myself several times erred or come near erring because I did find a temperature of from 100° to 101° or even higher, and we should always remember that intraperitoneal hemorrhage is usually followed by a fever of the surgical type.

Treatment. In no other field of abdominal surgery were the advantages of operative treatment so promptly recognized. The excision of the appendage bearing the gestation sac is usually a very simple procedure, and except for the acute anemia and shock encountered in the tragic stage these patients are usually excellent operative risks. A good deal has been written about the advisability of delaying operation in cases of profound collapse. I am a firm believer in delay if the patient is in such collapse as to be oviously unable to stand any operation, but I do believe the fact should be very strongly emphasized that extrauterine pregnancy patients in the "tragic" stage of the disease stand anesthesia and operation better than any other cases presenting like blood pressure and pulse findings. The man reduced to an apparently similar state of collapse or shock by a traumatism such as a crushed leg is in no way comparable as an operative risk to the woman suffering from a ruptured ectopic, and the same may be said of the shock and collapse accompanying perforations and intraabdominal infections.

Nine of my patients were operated upon during the acute tragic stage in the presence of acute anemia and a rapid pulse. One I kept in a partial Trendelenburg position for about two hours before operation because she was quite pulseless when admitted to the hospital. Every one of my tragic cases actually improved from the time they

began to take the ether until they left the operating table. The operations were complete in from seven to ten minutes. No time was spent in removing clots other than those which presented in the wound and pelvis during the manipulations necessary to excise the gestation sac. All of these tragic stage patients made uneventful recoveries. I know of no other pathological condition capable of producing the degree of "shock" present in these nine patients, for which I could operate in the presence of the shock without expecting a mortality of from 30 to 60 per cent.

When operating in the non-tragic stage, procedures other than the simple excision of the First as regards the removal of blood and clots, affected appendage may be safely undertaken. I believe that the peritoneal cavity should be left reasonably clean, but this does not mean that the intestines should be much handled and endothelial surfaces injured by sponging in over-careful attempts to rid the peritoneal cavity of blood. If the loops of intestines are not displaced and are left to normal relationship one to another the remaining blood will do no harm other than to cause a few gas pains during the first days after operation.

There has been considerable discussion concerning the danger of a second ectopic in the opposite side if both tubes are not excised. Statistics on this question vary so much as to make them of little value from a percentage viewpoint. They do show, however, that if the opposite tube is not removed the woman who has had one ectopic pregnancy stands a fairly good chance of having subsequent normal pregnancies and a rather remote chance of a second ectopic pregnancy. own work I have not felt it justifiable to remove the opposite tube because of the danger of a second ectopic, yet for one reason or another (usually because of obvious disease of the other tube) I have excised both tubes in eleven out of twenty-three operative cases.

SURGICAL IMMUNITY

In my

Wayne Babcock, in the New York Medical Journal, admonishes that for the successful treatment of many surgical conditions the production of an artificial immunity is much less important than the maintenance of the normal bodily resistance. Too frequently we forget that vaccines and serums can never replace such timeworn aids to immunity as rest, support, noninterference, protection, and other important measures that have been reiterated and forgotten many times. It has been well said that surgery should be retaught every seven years, so that the useful things of the past are not forgotten and thrust aside by the innovations of the present.

It is my intention briefly to review a number of conditions in which attempts to produce artificial immunity are of secondary importance in the treatment of the affection. As surgeons no longer believe that disease is an evil to be scourged from the body by fire and other drastic measures, inflamed tissues are handled with greater gentleness, not because the handling is painful, but because we realize that traumatism may destroy the local immunity, or may diffuse infection beyond imperfectly erected tissue barriers. It has long been recognized that absolute, general, and local rest, frequently determines whether a contused wound leads to disorganizing infection, or a simple aseptic wound healing. A crushed hand treated by aseptization, and a careful dressing, but put back at once to work, is frequently followed by a disorganizing phlegmon that spreads up the arm. The same injury treated with a simple wet dressing, support, elevation, and complete local and general rest, may heal without inflammatory reaction. Against the handicap imposed by the first plan of treatment, no vaccine or other measure for the production of artificial immunity will avail. Again, many of us have seen a crushed and lacerated hand treated by painstaking aseptization, and the most accurate suture of the divided deep and superficial tissue, swell, become necrotic and disorganized from tension, infection, and secondary inflammatory processes. The same injury treated without suture of the divided tissues, especially the overlying skin, but by the free division of any skin that may cause constricting tension when the secondary swelling occurs, may heal with no sign of infection. No method of artificial immunity has been devised that will take the place of absence of local tension, or of local or general rest in the treatment of certain wounds.

Local traumatism has many examples as to its influence in decreasing tissue immunity. In the second stage of appendicitis a free incision with wide separation of adhesions, and especially the thorough scouring or mechanical or chemical cleansing of the peritoneum, opens lymph spaces, overcomes the local protective process, and is often followed by an overwhelming and fatal toxemia or bacteriemia.

sharp curette sows the bacteria into the deeper tissues and permits widespread invasion, and probably has been responsible for many tubal and pelvic infections.

In acute local infections how often puncture or ineffective incision increases the inflammatory process! The pustule that is punctured or squeezed becomes a furuncle, the furuncle that is traumatically irritated becames a carbuncle, the carbuncle that is massaged, punctured, and squeezed, may terminate in a fatal bacteremia.

The traumatism of a local anesthetic, or the general toxemia of inhalation anesthesia, may also seriously reduce a patient's immunity. An infection involving the root of the second or third molar treated by the usual simple dental methods, may resolve without serious symptoms. Extraction under nitrous oxide may be followed by a sharp attack of osteomyelitis of the jaw. If at the height of this osteomyelitis the patient is deeply etherized, the tissues are freely incised, the maxilla is thoroughly scraped, curetted, or gouged; the patient may be lucky if he escapes with his life. At the acme of an acute surgical infection operative intervention must be carried out with great care, and is often a source of great danger. An acute streptococcus or staphylococcus lymphadenitis of the groin, neck, or other parts of the body, in the acute stage when the fever is high, the pulse rapid, the tissues' defences as yet unerected, is often best let alone; if incised at all at this stage, it should be opened with the least possible local traumatism, and in the simplest manner. I have seen several deaths follow the careful enucleation of glands in such an acute inflammatory stage. At a little later stage, drainage or enucleation may safely be carried out. Likewise in an acute infectious phlebitis of the leg, I have seen massage followed by sudden pulmonary embolism and death, and in every case that has come to my knowledge in which an attempt has been made to remove the vein, or the clot from the vein, in such an acute septic condition, the patient has died of a general septicemia. On the other hand, for a suppurative inflammation within a vein, a simple sharp incision after the acute stage has subsided, carried out with the least possible handling or local traumatism, is a

HOW DO DIURETICS ACT?

If, says Clinical Medicine, we except the expectorants, no class of remedies is administered with as little real knowledge of their mode of action, of just how they operate as are the diuretics. In our student days, the professor once asked the class what division could be made of these agents. One volunteered the suggestion that they might

be divided into diuretics that increase the fluid (water) and those that increase the solid elements renally excreted. To the further query, as to what agents might be placed into the latter class, nobody replied. Reference to the textbooks gave no information upon this point. The teacher told the class that colchicum increased the output of urinary solids.

This statement directed our attention to the meadow-saffron. Turning to the books, we found that, of this plant, not less than six classes of fluid preparations were official, namely: the fluid extracts, wines, and tinctures of the seeds and of the corm. Upon our inquiring of our preceptor, which he considered the best, he said that neither of them was any good; personally, he used only an English wine (whether of seeds or corm, was not said).

Since that remote period, some progress has been made. We have become able to study the vasomotor conditions back of deficient urinary excretion, and have learned to apply our remedies in accordance with our finding. When the vascular tension is so high that the constriction of the renal arteries pinches off the blood supply to the glomeruli, the urine becomes scanty; and then we administer vasorelaxants, such

as veratrine. When, on the other hand, the capillary circulation has given way and general anasarca is present, the laboring heart vainly trying to propel the blood through this swamp, we endeavor to canalize the blood channels and, so, resort to the vasoconstrictors, such as apocynum.

It is obvious that in both conditions named success lies in securing an exact balance of circulatory tension, since overaction in either instance will induce the opposite fault and thus nullify the potential benefit.

This classification, however, leaves out of calculation the saline diuretics, for the action of which we never have met a satisfactory explanation; unless it be that they act as diuretics solely through the water drunk with them. They may, it is true, induce some form of irritation of the renal secretory structures, but this cannot be of a nature such as is exerted by the volatile oils, like juniper oil. This writer has found that small doses of the latter oil certainly do increase renal activity, but whenever the doses were increased the urine secreted became so scanty that he grew alarmed and stopped the experiment. He cannot conceive that such remedies are safe or that the delicate and vitally essential renal cells should be subjected to such forms of irritation. Besides, he has not been able to think of any form of disease in which such medication would be required and no other kind be available.

excretion as a whole; now we may ask as to what has been the progress, since the year 1870, in studying the effects of drugs upon the various solid constituents.

Widal was the first one to call attention to the importance of deficiency in the excretion of urea and of the significance of its retention in the blood. Busquet has presented the more recent work in this direction, in a paper in Le Monde Medical (No. 349, p. 195).

Drugs of the caffeine group stimulate the excretion of urea, and also of chlorides and water. Squill notably increases the urea output, but has scarcely any effect upon the volume of the water of the urine; that is, in healthy subjects. However, in those suffering from retention of urea, the effects are much more remarkable; for, even when theobromine and adonidin had failed in Busquet's hands, squill gave prompt and decided relief in this condition.

Chevalier has spoken of the diuretic action of mistletoe, in which he discovered an alkaloid. He and others found that mistletoe increased the excretion of chlorides and of urea; Busquet, however, has failed to verify this, using poplar or May-month mistletoe. The extracts used, however, were too crude and uncertain for modern testings.

Pic determined that the formiates and sugars also increased nitrogenous excretion, but confirmation has not yet been afforded.

A true diuretic of the class in question not only must increase the urinary urea, but must lessen the proportion of urea in the blood. Otherwise, the addition of a peptone solution to the ordinary diet would be diuretic. In two azotemic (nitrogen retaining) patients, Busquet found that the daily use of squill (15 milligrams thrice daily) reduced the proportion of urea in the blood, from 0.65 and 0.80 per liter, to 0.39 and 0.45, respectively, after 10 days' treatment. The first figures were obtained after these patients had been for two weeks on a hyponitrogenous diet, after which the squill was commenced. However, it was found that the increase in urea excretion lasted only during the first four days of administration of this drug. By that time the urea in the blood had decreased to the point where squill no longer acts, since it requires a certain proportion of urea for any excretory effect to be manifested.

LOCAL ANESTHESIA IN KIDNEY SURGERY

Allen, in the New Orleans Medical and Surgical Journal, recommends the following procedure in renal and ureteral surgery under local anesthesia:

A

selected and an intradermal wheal created. large syringe and long needle are now used. Onefourth per cent novocain or one-fifth eucain will suffice. The long needle is entered through the wheal and directed up subcutaneously over the last rib, injecting as the syringe is advanced as far as the eleventh rib. The point is now slightly withdrawn and directed close under the lips of the rib and an injection made here to reach the eleventh intercostal nerve. The needle is now withdrawn almost the entire length and redirected on a slightly deeper plane-always injecting the solution as the needle is being advanced, removing the syringe from time to time for refilling. The needle is now advanced in contact with the twelfth rib. The twelfth intercostal nerve, unlike the other intercostals, leaves the rib early in its course, running obliquely away from it downward and forward, and in the position encountered here about three inches from the spine, it lies from one-half to one inch from the rib. As the needle passes this point, a slightly larger quantity of solution is injected. The needle is now almost withdrawn and redirected down close in contact with the sheath of the quadratus lumborum and advanced up along it for several inches, distributing the solution. By changing the direction of the needle, the aponeurosis of the abdominal muscles at the point where they fuse with the sheath of the quadratus lumborum, is sought for; this is about two to two and one-half inches from the lumbar spinous processes. This is recognized as the first plane of resistance which the needle encounters. It is penetrated at several points and a few drams of solution deposited beneath it. The needle is now directed slightly deeper into the perirenal fat and about one-half ounce of solution deposited here, extending as high as a point well up under the last rib. If any uncertainty is felt in making these last deep injections, they can be omitted until the aponeurosis of the muscles is exposed and the deeper parts of the field brought closer within reach.

Having completed the above, the lower half of the area is now injected in a similar manner by directing the needle downward from the skin wheal toward the crest of the ilium, but on a slightly anterior plane approaching the anterior portion of the iliac crest to conform to the curve of the proposed incision.

The tissues here are injected in several planes as above the first injection being made subcutaneously. When proceeding by this method, it is unnecessary to inject the skin independently, as the subcutaneous injection has ample time to diffuse outward while making the deeper one.

A limited amount of injecting in the deeper parts will now be all that is needed. The advan

tage of practically completing the injection before making the incision is obvious. With the weak solution employed ample time is allowed for thorough saturation of the tissues and only the excess escapes when the incision is made. It is also much quicker and by following a methodical plan of this kind no portion of the field is left uninjected.

After dividing the aponeurosis of the abdominal muscles and the twelfth dorsal nerve, a large branch is encountered between their planes, giving off in this position its lateral cutaneous branch.

By gently following these two trunks proximately they are seen to approach each other and join on the anterior surface of the quadratus lumborum. In the depth of the wound, they can now be injected intraneurally, which should be done as deep down as they can be conveniently reached. They are the principal sensory nerves of the superficial parts and their thorough anesthesia insures a painless wound.

Having freely divided the aponeurosis of the abdominal muscles, the finger is gently passed inward through the cellular tissue along the anterior surface of the quadratus lumborum muscle. This tissue is loose and easily separated, searching the way for needle, which is now advanced in this direction toward the vertebral column and a few drams of solution deposited here in the tissues underlying the hylum of the kidney. If the kidney is adherent, this injection should be more liberal than in a simple case and should be carried well in toward the psoas muscle, which is easily felt and can be seen with reaction of the tissues. This deep injection is very easily made and is of much importance should the kidney be adherent or the abdominal cavity likely to be opened, as it controls the entire nerve supply of this portion of the cavity by blocking the sensory fibers of the rami communicantes.

MULTIPLE URINARY CALCULI Max Stern, in the Urologic and Cutaneous Review, describes an unusual case of this kind. A. L., male, unmarried, age 48 years. As long as this patient could remember he has had some ailment and though never strong was not known to have any positive disease until after his twentieth year, when it was discovered that he had a cardiac murmur. This probably had existed long before its discovery, as it had given no great trouble and the heart had compensated well. His prominent symptoms were annoying cough and insomnia.

Up to ten years ago there had been no symptoms relative to an irritative or inflammatory condition in the urinary system, when suddenly

upon urinating after a long walk he was seized with pain and passed a pea-sized calculus. He was again comfortable after this, so far as urinary symptoms were concerned and continued so for about a year, when the occurrence was repeated several times and the passing of stones gave him but little concern and medical aid was not sought.

Four years ago he had an attack of pain which was diagnosed as due to an inflammatory appendix, after which the patient had always felt some pain upon coughing or lifting. A similar seizure occurred two years ago and was again regarded as appendicular. During this time several small calculi were passed in the urinary stream, the last six months before his first visit to me, January 23, 1914.

Upon close questioning with the view of determining a specific cause, or the continued formation of the calculi, it was elicited that many years before, while a traveling salesman, he had acquired the habit of "salting" his food even before tasting it. This habit is still adhered to by him and is so strong that he applies salt to articles of diet which ordinarily are sweetened.

A cystoscopic examination was possible after many attempts and several small calculi were visible in the trigone and close to the vesical orifice. Ureteral catheterization was impossible in spite of local anesthesia because of the sensitive condition of the floor of the bladder. This is especially peculiar, though logical to the affair, because of the fact that the frequency of urination or other symptoms referable to the urinary apparatus were absent.

Because of the incomplete cystoscopic findings it was thought imperative to obtain X-ray plates and accordingly Dr. Friedmann's efforts cleared up the condition at that time, July 24, 1914, as follows: Roentgenograms show four small stones in right kidney, one small stone in left kidney, one stone in right ureter near base of bladder, and eleven stones in bladder, five on right and six on left side.

Since that time five calculi have been crushed and removed and two expelled naturally with the aid of the daily ingestion of large quantities of water. On September 15, at midnight, I was summoned to his bedside to attend him in his third attack of what he called appendicitis because of its similarity to the two previous ones. There was no temperature nor rigidity of the abdomen and the pain was not localized in the appendicular region. There was pain in the back and along the right side of the abdomen radiating down the leg of that side, but not to the penis. It was thought doubtful that this was appendicitis, and renal colic, though not typical, was regarded as the

cause of the pain. This was proven to be the case by the rapid subsidence of all symptoms in six hours and the appearance of the stone the following day in the urine. The previous attacks of socalled appendicitis were in all probability of the same nature, as no gastric or intestinal symptoms have ever troubled the patient and his descriptions of the onset and subsidence in all cases was similar.

The present condition of the patient is much better in every way. Just how much his insomnia can be ascribed to the presence of stones in the renal pelves cannot be stated and though there is still insomnia of a far lesser degree and in all probability some calculi present, he has shown a steady improvement. A future skiagraph will reveal the actual degree. In this case the etiological factor was in all probability the ingestion of large quantities of earthy elements with table salt.

MOVIES AND MORALS

A recent number of the Hospital Review calls attention to the effect of the moving picture shows as an evil influence upon home life and declares that any educational influence they exert is more than offset by the disturbance to normal home influence. The article maintains, and we think with justice, says the Long Island Medical Journal, that the craving for excitement, which can be so cheaply gratified by attendance at the moving picture shows, is one of the strongest influences at work in modern American life to destroy the home feeling and interfere with serious pursuits. It points out that, instead of providing wholesome intellectual entertainment for children at home, parents are permitting their children to frequent the movies to the exclusion of genuine intellectual pleasures. As this has long been our own feeling, it is a source of gratification to find that others are seeing a menace in the modern tendency to substitute cheap excitement for intellectual improvement.

It was the writer's misfortune not long ago to be so placed that for two weeks the only occupation available during the evenings was attendance at a free open air moving picture show, and if he may judge by the character of the films exhibited, he can affirm that while they were entertaining they were for the most part nothing else. Everyone can recall how in his boyhood he read "Old Sleuth, the Detective" and his impossible doings, on the sly, just as he smoked corn silk cigarettes where he was not likely to be caught at it. The ordinary film play is an insipid and often impossible portrayal of the penny dreadful variety that is unsuited to growing children, inasmuch as it presents situations that are often broad, to put it mildly, and not infrequently indecently suggestive