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First, we have in the aqueous extract of suprarenal glands a powerful local vaso-constrictor agent and a contractor of erectile tissue, which is safe to use in very considerable amounts without any dangerous or deleterious effects locally, or to the general constitution of the individual.

Second, these local effects can be reproduced in the same individual apparently any number of times without entailing any vicious habit, either to the tissue or the individual.

Third, the use of the extract seems to rather heighten the effects which may be expected from any given drug which may be locally used after it.

Fourth, in acute congestions it has its widest application and greatest opportunity for good, but also in certain chronic conditions of the hay fever type, where edematous tissue seems prone to develop, it can be relied upon as one of the most helpful adjuvants which we have at command. The only difficulty seems to be in producing it in quantities and in preventing decomposition on standing, which objection will be probably easily overcome by laboratory experiment.



Consulting Gynecologist to St. Joseph's Hospital, Memphis, Tenn.

Ovarian Cyst Protruding Through the Inguinal Canal.

Baldy (Amer. Jour. Obstet., etc., vol. 38, no. 252) reports the following case: A woman was sent to him for diagnosis and treatment. About two years previous to her coming to Philadelphia she had noticed a small, pedunculated tumor in the right inguinal region, which continued to grow until as large as an egg. She was placed under an anesthetic by her physician and the tumor removed. The growth had a reasonably small pedicle, which came from the inguinal canal, and he amputated it as low down as possible. One year later the growth had again returned, much larger and with a shorter and broader pedicle. A second time she was placed under an anesthetic and the growth removed, as in the first instance. When seen by Baldy the growth had returned at its former site, and was as large as one's fist, with apparently no pedicle at all. Palpation showed it well above the large vessels on the thigh, although it hung suspiciously near them; yet could readily pass fingers between the lower margin of the tumor and the vessels. A pelvic examination revealed a mass filling the right side of the pelvis, indefinite as to its outlines and consistence. The uterus had a limited amount of mobility. The general health of the patient was quite good, and no general signs of malignancy existed.

The patient was prepared for both an enucleation of the tumor in the groin and an abdominal section. An incision was made directly over the growth and the tumor freed from all surrounding connections down to a thick, broad and short pedicle which led into and through the inguinal canal. The attachments of the pedicle in the canal were freed, and the finger forced into the abdomen, where it was found that the tumor was a continuation of a large intra-abdominal mass. The abdomen was opened in the median line, and the pedicle of the

inguinal growth found to spring from a large intraligamentous tumor of similar character. The opposite uterine appendage was healthy. It was at once observed that the most feasible way to make the removal was to ligate the left broad ligament and amputate the uterus at the neck. The woman being at or past the period of the menopause, this course was pursued, and the tumor lifted out of its bed with little or no effort -- in fact, after the uterus was amputated the tumor was enucleated by its own weight and a slight amount of sponging. All oozing points were covered over with redundant peritoneum by means of catgut sutures, and the abdominal incision was closed without drainage. The inguinal canal was of course enormously dilated. Its edges were freshened with knife and scissors, and approximated with several rows of continuous silk sutures, which were allowed to remain permanently. The skin was united by a subcutaneous silk suture.

The patient made an uninterrupted recovery, and left the hospital for her home four weeks after the operation.

Large Fibroid Tumors of the Uterus.

Lewers (Obstet. Soc., London; Med. Press & Cir., vol. 66, no. 3010) showed two large fibroid tumors of the uterus, weighing nine and one-half and eight pounds, respectively, removed by laparotomy, with intraperitoneal treatment of the stump. In the one case the tumor was a solitary subperitoneal fibroid growing abruptly from the left side and anterior surface of the body of the uterus, which was of normal size. There was no pedicle. The area of attachment to the uterus was about equal to that of a five-shilling piece. Peritoneal flaps were stripped down, the left uterine artery was tied in two places, and the oozing surface of the uterine tissue left after removal of the tumor was constricted by several silk sutures passed rather deeply; the peritoneal flaps were then stitched over the stump. At the end of the operation the patient was left with the uterus practically intact, and both ovaries. She made a good recovery.

In the second case the specimen consisted of the body of the uterus with multiple fibroids and one set of the uterine appendages · the appendages on the other side having been left. She made a good recovery.

Dr. Lewers observed that cases of large solitary subperitoneal fibroid tumors of the uterus, as in his first case, differed in many important particulars from the ordinary cases of multiple fibroids, of which the second case was a typical example. In the first case the patient had been married ten years, and had had five children and two miscarriages—the last, ten months before the operation was performed. Menstruation had always been scanty. There had been absolute amenorrhea for the ten months preceding the operation. In regard to the physical signs, the uterus was of normal size, and in no way deformed, except where the tumor grew from it. In the case of multiple fibroids the patient had been married five years, and there had been no pregnancy. Menstruation had always been profuse, and for three months preceding the operation there had been a daily loss of blood. The uterine cavity was greatly enlarged in this case, the sound passing seven or eight inches, and removing the tumors involved removing the whole of the body of the uterus.



Hysteria and Nervousness in Childhood.

Sänger recently contributed an article on hysteria and nervousness in childhood to the Berliner Klin. Wochenschrift, which, being translated and abstracted by the Berlin correspondent of the Medical Press and Circular, we take pleasure in here reproducing:

As regarding the frequency of these diseases he remarks that among 30,759 cases of disease of the eyes in the General Hospital, Hamburg, 1029 children suffered from asthenopia. It could be shown in these cases that the disturbance of vision was part of a general nervous disturbance. He divides the cases into four groups:

1. The hemasthenic. These were mostly anemic children, easily excited, readily crying and easily tired; they complained of angioneurotic troubles, palpitation and giddiness. Occasionally they suffered from true phobias.

2. Among the hysterical group, they were mostly intelligent children, who gave an impression of precocity. Child hysteria is generally monosymptomatic, but by careful examination other points could be discovered (anomalies of attitude, hysterical scoliosis, torticollis, hysterical cough, aphonia, tremor, etc.)

3. Mixed forms of hysteria and neurasthenia. Along with nervous asthenopia there was limitation of the field of vision, analgesic or hyperalgesic zones on the body, absence of pharyngeal and corneal reflexes, and sometimes illusion of vision and hearing-such children were generally indolent and physically dull. 4. Hereditary neuropathics, which were met with more frequently in private practice.

As regarded treatment, psychical influence and electrical treatment were of importance.

He considers overdriving in school to be the provocative agent in these cases. Overstudy and exhaustion sometimes lead on to a fatal issue; of 289 suicides in Prussia 179 were of children in the lower schools. This fact demanded greater watchfulness on the part of the school physician than had hitherto been bestowed.

Clinical Types of Infantile Pneumonia.

Carmichael (Pediatrics, vol. 6, no. 11) says that clinically we can differentiate the following four types of infantile pneumonia:

(1) Complete consolidation, with lobar distribution and absence of signs of bronchial catarrh.

(2) No sign of consolidation; bronchial catarrh generally distributed over one or more-frequently both-lungs.

(3) Bronchial catarrh, with small areas of incomplete consolidation, lobular distribution.

(4) Bronchial catarrh, with larger areas of incomplete consolidation, lobar distribution.

The first form, or type (1): The true fibrinous or croupous variety, is distinct and definite, both in its clinical relations and pathology. The main factors are complete consolidation, sudden invasion, rapid crisis in from seven to ten days,

symptoms not always proportionate to the degree of lung involvement, but rather to the toxemia.

Type (2) Clinically the features are those of bronchial catarrh, involving the minute bronchial ramifications (capillary bronchitis). The type of fever is similar to the other varieties of broncho-pneumonia. No evidence of lobular involvement can be made out by physical examination. Post mortem examination shows catarrhal inflammation of the alveoli and smaller bronchi.

Type (3): Signs of bronchial catarrh, sometimes chiefly confined to one lung, often to both; small areas of incomplete consolidation (lobular distribution). The type of temperature is irregular compared with the fibrinous form; the onset is gradual, not sudden, the duration of the disease from ten to fourteen or twenty-one days, ending by lysis, rarely but occasionally by crisis. The pneumonic areas can only be detected with certainty by the stethoscope, percussion being unreliable. The auscultatory signs are limited areas of broncho - vesicular breathing, with increased crying resonance and crepitations, heard both during inspiration and expiration finer than those heard over the other portions of the lung.

Type (4): Signs of bronchial catarrh, with larger areas of incompetent consolidation. These cases usually are classed under the "mixed type." The auscultatory signs are similar to those of the former type (3), with this difference, that the percussion is impaired in proportion to the extent of lung involved. The note shows dullness, not so absolute as in the fibrinous form, as the lung is more or less vesicular. Of 142 of Carmichael's hospital cases during the last five years, 107 showed the clinical features of broncho-pneumonia of various types, 35 showed all the features of the fibrinous form.



The Diagnosis of Non-Venereal Syphilis in Its Early Stages.

Van Harlingen (Int. Med. Mag., vol. 7, no. 12) refers to the difficulty and oftentimes impossibility of getting a history of lesion of the genitals in many cases of undoubted syphilis, especially in women. The well-marked indurated chancre as depicted in textbooks is often absent, and in its place we find a small, hardly-perceptible papule or erosion, which is almost concealed among the folds of mucous membranes, and readily escapes detection. The initial lesion is more frequently extra-genital than was formerly supposed.

When a doubtful case of eruption of the skin is brought to one's notice, however, and an examination is had with a view to making a diagnosis, this is oftentimes a very difficult matter. The early eruption of syphilis, that known as the maculo-papular syphiloderm, is extremely varied in its manifestations. The skin affection most apt to be confounded with the early syphiloderm is that known as pityriasis maculata et circinata—a not very uncommon skin affection, but one with which the average practitioner is apparently unfamiliar.

When confronted with a supposed syphilitic eruption, every part of the surface, from head to foot, should be examined where this is at all practicable. Think of the variety and multiplicity of the lesions which may attack any por


tion of the integument or its appendages. The hair may fall out, the eyes may show iritis, the mouth, tongue, fauces, any or all, may show the tell-tale mucous patch, and thus one may get a side-light on the case which may be invaluable. Now, too, in connection with these early eruptions, we have a right to expect some trace of the initial lesion. When the patient has had a chancre of average character on the genitals, the trace of this almost always remains visible until the early generalized eruption is pretty well developed. But if there is no sign of any lesion in that locality, we should look elsewhere. The mouth is son times the seat of the initial lesion, perhaps most frequently so in syphilis of the innocent, or family syphilis, as it may sometimes occur. In physicians the finger is sometimes the seat of infection; but the disease may find entrance at any point. Fournier, out of 1124 cases of extra-genital chancres, found 849 about the face and head, 78 on the upper part of the body, 77 in the anal region, 59 on the breasts, 33 on the thorax, abdomen and thighs, 14 on the lower limbs, and the same number in the cervical region. Unfortunately for diagnostic purposes, most of these escape observation. A chancre of the lips, tongue or tonsils is usually such a marked lesion that it can scarcely escape observation; but in some other regions, unless the lesion is large, it may entirely escape observation, or it may be confounded with some simple pimple or other ordinary lesion. However insignificant the initial lesion may be, it is invariably accompanied by involvement of some of the neighboring glands, and a thorough examination of the principal glandular regions will often put one on the track of an almost forgotten initial lesion. Genital chancres-that is, chancres of the penis, scrotum, labia majora and minora, fourchette, meatus urinarius, urethra, opening of the vagina, etc.—involve the inguinal glands. The same is the case with perigenital chancres - chancres of the perineum, genito-crural region, mons veneris, anus, buttocks, thighs, etc. Chancres of the lip and chin involve the sub-maxillary glands; chancres of the tongue, the sub-hyoid glands; chancres of the eyelid, the preauricular glands; chancres of the finger, the epitrochlear glands and the axillary glands; chancres of the arm, the axillary; chancres of the heart, the axillary and sometimes the sub-pectoral glands. Chancres of the cervix uteri involve, theoretically, the pelvic glands; in general there is no engorgement of the groins exceptionally, inguinal bubo.

By applying these rules conversely we can often get at the seat of the initial lesion, and thus aid in making out a diagnosis in doubtful cases.

Peculiar Forms of Syphilis.

At a recent meeting of the Medical Club of Vienna, Weidenfeld (Cor. Med. Press & Cir., vol. 66, no. 3010) showed a patient who had suffered for eight years from syphilis without treatment. The external parts of the nose were quite eaten away, leaving nothing but the remnants of some of the smaller muscles of the septum. The soft palate had almost disappeared. Such cases of total neglect were rarely to be found in a Christian land. The patient was a Hungarian.

He also showed another with rhinoscleroma in the posterior nares, which was quite blocked up. The disease was presumably syphilitic in origin, and had commenced in the posterior portion of the fauces as a hard scar, and extended up the larynx.

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