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danger of tetanus, infection, ulcerative fistula and sec ondary hemorrhage is obviated. Acute aseptic inflammation follows after the hemorrhoids are replaced, which ends in resorption of their contents, so that in a short period nothing remains to mark their former site but short, atrophied stalks.

3. Shortened Convalescence.-By this manner, as there are no sequellæ to be feared, the after-treatment is al most nil. As a general rule our patient may be about in a few days, or a week, though it is always well that the body be kept in a state of rest and the parts be daily bathed for two or three weeks in severe cases.

4. This method has something more than speculation and theory to support it, for in my hands, in a large. number of cases of every type of hemorrhoids, during the past two years, it has invariably succeeded, and in no single instance with which I am acquainted, has it failed, or has it been followed by relapse. I add, may however, that in females it is not as satisfactory as in the opposite sex because they are commonly so refrac tory to the action of cocaine.

Iodide of Potassium in Actinomycosis in the Human Subject.-Buzzi and Galli-Valerio (Rif. Med., Brit. Med. Jour.) prompted by the successful experiences of Thomassen and Nocard, in veterinary practice, and of van Iterson in the case of actinomycosis in a human being, applied the treatment by potassium iodide to a case which came under their observation. In their case, that of a healthy laborer, the disease af fected the whole right side of the face from the temple to the clavicle. It had been of some mounths' duration before it came under close observation, and had undergone treatment by poulticing and free incision without being in any way favorably influenced. It was then that the diagnosis of actinomycosis was established, and the iodide treatment commenced. On January 9th, 1893, daily doses of 30 g. of pot. iod. were commenced, and save for a slight cutaneous eruption which ap peared on the fourth or fifth day, no untoward effects followed its use. On the contrary improvement rapidly became manifest. The incisions which had previously been discharging quantities of yellow pus, secreted less freely, and showed distinct signs of healing; the swell ing became less marked, and patient could soon open his mounth. All pain disappeared, and by March 5th, the patient was well enough to leave the hospital. Seen again on April 4th, the cure was pronounced complete; all swelling had disappeared, the fistulæ had cicatrized perfectly, and the skin' was freely movable over the subjacent parts save in one small spot. The movements of the jaw were normal, and the patient appared to be in perfect health. The authors therefore recommend highly the treatment of this disease by large doses of iodide of potassium, kept up till all signs of the affection have disappeared.

EDITORIALS

L. T. RIESMEYER, M.D., Editor.

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Retention of Urine After Operations. Retention of urine is a symptom so often observed after operations that it appears strange that text-books have so far paid little or no attention to the same. Ac. cording to A. Guepin who has looked up the literature upon this subject and published the result of his re searches in the Gaz. des. Hop., urinary retention may occur at every age after puberty, it never has been ob served before the fifteenth year. It is most frequently observed after operations upon the belly and the lower extremities and it becomes rarer the farther away from those parts the operation took place; after operations upon the face and upper extremities it has been ob served very rarely. There are two forms of retention which differ distinctly in a clinical sense, these are the indolent and the painful forms; the former occurs in individuals with healthy urinary organs and the latter in individuals whose urinary apparatus is diseased. The duration of retention varies a great deal.

The indolent form usually disappears after the first catheterism; the second form may last from eight hours to three days and sometimes longer.

Various hypotheses have been advanced to explain the production of this kind of retention, some of them being of a rather adventurous nature. Swelling of the urethra, the dressings, pain, paresis of the abdominal muscles, anesthesia, etc., have been made responsible for the occurrence. Guepin mentions three different causes of retention after operations:

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1. Spasm of urethra particularly of the bulbous por- in the lightest cases, it was found merely in the first

tion.

2. Paresis of bladder.

3. Posture of patient, many persons not being able to urinate in the attitude of lying immovably upon the back. The treatment consists in change of posture and, if this is insufficient, a warm clysma, and as a last re sort catheterization.

Diagnostic Value of the Diazo Reaction.

three or four days of observation. In measles it invariably appeared at the commencement of desquamation, i. e., about the crisis, and usually, though not invariably, during the eruptive stage. In acute phthisis it was, as a rule, markedly present during the whole course of the disease. In chronic phthisis it was present during periods of varying duration and this was the only disease in which it was found absolutely unconnected with febrile disease.

From these and similar data Ehrlich drew the following conclusions, amongst others:

1. The reaction is one of the most constant symptoms of enteric fever from the middle of the first week on, so that its absence renders the diagnosis doubtful.

2. The reaction cannot be used for the diagnosis of enteric fever from diseases of the second group. 3. The occurrence of the reaction in croupous pneumonia indicates the supervention of complications. 4. The presence of the reaction for a length of time. and in the absence of fever points to phthisis.

Dawson concludes his able paper by saying: The conclusions then, which seem to be warranted by this investigation, are briefly these:

Dawson, Dublin University, presents an instructive article upon the above subject and the following points may be specially noted (Pac. Med. Jour.): A saturated solution of sulphanilic acid in strongly acidulated water is first made; hydrochloric acid is now employed in the proportion of one to eight. To this solution is added, just before use, a few drops, about five minims, to the 2 ounce, of a very dilute solution of sodium nitrite (1 in 200). The test is applied thus: A test tube is filled to about one third of its height with urine and an equal quantity of the test solution is added. The resulting fluid may assume a yellow color, which constitutes the first part of the reaction, but this does not invariably occur by any means. If now, however, some liquor potassæ be added, a more or less deep blood or portwine color at once appears. This constitutes the sec- twenty-first days, and is more constant in that disease ond and really significant part of the reaction. The third and last part consists in the separation of a green ish black precipitate, which forms a layer on the surface of the high-colored sediment when the tube has been allowed to stand twenty-four hours. Urine which does not show the reaction assumes some shade of yellow or orange on adding the alkali, and on standing throws down a precipitate which is of no particular color.

Having tried the test with a great number of different diseases, Ehrlich came to the conclusion that, with the exception of phthisis, the morbid conditions in which the reaction is obtained are always of a febrile nature, and these he divided into three groups:

1. The diazo is found in the great majority of cases of enteric fever at some period between the fifth and

than in any other (of those tested), except measles, and perhaps acute phthisis, so that, with these reservations, its presence affords a presumption in favor of, its absence a much stronger presumption against, such a diagnosis.

2. That the reaction cannot be used either positively or negatively to distinguish enteric fever from phthisis or measles, and that the presumption which it affords. against typhus is small.

3. That it is nearly or quite constant in measles, but absent in at least many cases of roetheln, and may, consequently, be used to distinguish between them.

4. That the substance causing it does not indicate its

1. Diseases in which the reaction is constant, as en presence by any peculiarity in the color, odor, deposit, teric fever and measles.

2. Diseases in which it occurs with greater or less frequency, according to the nature of the attack, as erysipelas, miliary tuberculosis, septicopyemia, pleurisy, intermittent fever, etc.

3. Diseases in which it is scarcely ever seen.

The three diseases in which it was found constantly in a great number of cases, are enteric fever, in which Ehrlich failed to obtain it in only two out of many cases, one of the two being a very mild attack; measles, in which it was never missed, and phthisis in which it occurs constantly in the acute form, and also, though with long periods of intermission, in the chronic. In enteric fever it was found in many cases all through the attack, and one or two days over the time of the subsidence of the fever, in others it disappeared at the beginning of the remissions, or more rarely from three to five days before, whilst very seldom, and that usually

reaction or specific gravity of the urine, nor by the presence of albumen, sugar or indican.

5. That it is not due to free acetone, nor to a direct product of the bacillus typhosus of Eberth.

Catheterization of the Ureters.

Howard A. Kelly, M.D, Professor of Gynecology and Obstetrics in the Johns Hopkins University, has contributed a valuable article upon this subject in the Annals of Gynecology and Pediatrics, of which we take the liberty to reproduce the essentials:

Prof. G. Simon was the first to indicate a way by which we might collect the urine as it came from the kidney by a catheter introduced into the ureter, thus eliminating vesical contamination and differentiating between the two kidneys both as to the quality and quantity of urine. Prof. Simon's method involved in

cision of the external meatus, followed by dilatation of the urethra sufficient to admit the index finger into the bladder, by means of which the ureteral orifice was sought out, and under its guidance a slender catheter introduced into the bladder and guided up the ureter. The serious objections to this plan are that the catheterization thus becomes a rather formidable opera tion, and the stretching of the urethra in women to a sufficient size to admit a finger will certainly be followed by incontinence in a large number of cases. Pawlik, now professor in Prag, obviated all these objections by demonstrating landmarks in the vagina which serve to locate the ureters, and also by greatly improving the catheter. He thus made it possible to catheterize the ureters "free-hand," by sight alone, without any preparatory operation.

Prof. Saenger, of Leipzig, about this time had demonstrated the fact that the terminal extremities of the ureters could readily be palpated per vaginam in almost

all cases.

The writer has devised an improved ureteral catheter, sound and bougie. I have performed various ureteral operations, such as opening and draining the ureter into the vagina while treating ureteral stricture, ureterectomy, etc., but I have no claims of originality in this field which deserve to be mentioned along with the names above cited.

INSTRUMENTS AND ACCESSORIES.

Two Kelly's ureteral catheters.

One small calibre female catheter.

fold: in the first place it does away with all the rugosi. ties of a contracted bladder, which hinder catheterization, if they do not render it impossible. The only rugosities left are the prominences on either side, through which the mouths of the ureters open into the bladder by a little slit, running obliquely backward in a line with the course of the ureters.

The second reason is well exhibited pictorially by Prof. Pawlik, who was the first to demonstrate that the curved folds which cross the anterior vaginal wall out to the lateral walls and around toward the cervix are valuable landmarks in finding the ureters, which lie parallel to and just above them. These are appropri ately called for this reason the "ureteral folds." They are brought out distinctly by moderate distension of the bladder.

An assistant should determine that the catheter is clear by placing the end in water and blowing through it without touching it with his lips. The metal plug, attached by a short chain to the catheter, is coated with a little vaseline and inserted in the outer end, thus keeping the aniline solution from filling the lumen of the catheter when it enters the bladder.

It is now evident that if clear or straw colored fluid escapes through the catheter it must be urine, as the deep aniline color of the fluid in the bladder renders de ception from that source impossible. When the catheter is introduced as far as the bladder, touch and sight assist in its further introduction into the ureter.

By turning its point forward and elevating the han die, a slight prominence is produced on the anterior va

One syringe, with a graduated barrel, of 4 or 5 oz. ginal wall. Throughout the manipulations of the cath (120-150 c.c.) capacity.

Eight ounces of a decided blue aniline solution.

One Sims' or Simon's speculum.

eter this is the constant guide to the vesical orifice of the ureter. The first step after the introduction of the catheter into the bladder is to try to locate the ureteral

Two minim or cubic centimeter graduates of about eminence by the sense of touch communicated from the 60 minims capacity.

tip of the catheter.

To this end the movements of the point on the ante. rior vaginal wall are closely watched as it plays over the base of the bladder. It is made to gently glide in a fore and aft direction from the neck of the bladder to cervix, in the median line, a little to one side, a little further out, and so on until it reaches the ureteral emi. nence, when it is distinctly felt to trip, jogging the thumb and finger in which the catheter is held.

Many patients can be catheterized without anesthe sia. The buttocks should be brought to the edge of the table, and the legs flexed upon the abdomen. The operator then catheterizes the bladder. This urine is set aside in a conical glass vessel for comparison with that to be obtained from the kidneys. The value of this will be seen when I say that I have repeatedly been able, upon drawing purulent or bloody urine from the bladder, to produce the same shade of red or yellow as The same movement is repeated until this point is that of the vesical urine by mixing pure urine obtained exactly located. The attempt is now made to introduce by the ureteral catheter from one kidney with the the catheter into the ureter by carrying the handle to bloody or purulent urine drawn from the other. By the opposite side, thus directing the point toward the careful palpation the ureters are located anteriorly posterior lateral wall of the pelvis, when the catheter is through the vaginal wall, noting especially whether withdrawn slightly, and with its point still down, but they are well forward under the bladder, or, as often turned a little more toward the side, is swept down found, abnormally far back in the pelvis. ward, outward and backward in the direction of the ureteral prominence. With each of these sweeping mo tions the catheter is rotated until the point is directed fully outward or slightly upward.

The bladder is then distended with from 5 to 7 oz. (150-210 c.c.) of the aniline solution. The posterior vaginal wall is retracted with a speculum, exposing the anterior wall up to the cervix, while the bladder is being injected.

This movement, employed in engaging the catheter in the ureter, may very appropriately be called fishing

The object of this distension of the bladder is two- for the ureter.

CORRESPONDENCE

Acute Dyspepsia.

As soon as the catheter enters the ureter its course is fixed, and the tactile sense at once recognizes that it no longer lies free in the bladder as before. If the catheter is released for a moment the handle does not drop, but remains in a fixed position and forms an angle, of about thirty degrees, with a line projected from the urethra. The catheter should be introduced into the ureter until its point reaches the wall of the pelvis, Editor MEDICAL REVIEW.—I take this opportunity to when the plug is removed from the end. A catheter question my brother M.D.'s through the columns of may now be introduced into the opposite ureter and your valuable paper, of which I acknowledge I am a both thus catheterized at the same sitting.

On account of the partial occlusion of the urethra by the first catheter the second is slightly more difficult to introduce.

If it is desirable to carry the catheter higher, even over the brim of the pelvis and up to the pelvis of the kidney, the bladder can be emptied by introducing a small glass catheter under the two ureteral catheters. The contracted bladder now forms a movable organ, which can be displaced upward without harm in manipulating the ureteral catheters.

reader and great admirer, in regard to a case which it has been my fortune to have had care of during my life as

a physician and which as yet I have been unable to cure, in fact, the patient has gradually been getting worse since 1888. Her history is about as follows: A very healthy, robust young girl of 18, whose weight was about 130 pounds, became poisoned by eating canned fish, salmon, and was confined to her bed for about three weeks. On getting up she had every symptom of acute dyspepsia, and was treated with dilute hydrochloric acid before, With an index finger introduced into the rectum the and pepsin after eating, which relieved the condition catheter is lifted up and guided while it is pushed on up excepting a severe headache which would come on at over the pelvic brim and up to the pelvis of the kidney. intervals and only be relieved by the use of morphine As soon as the plug of each catheter is withdrawn an followed by a laxative aud for such has been used cas. assistant notes the time so as to be able to tell after-cara sag., calomel and sodii phosp., U. S. P. comp. cath. ward just how long the urine has been flowing from pille, R. tr. bellad., tr. hyoscy..cascara sag. et ol. anisi. each kidney. The minim graduates are held below the M. Sig. Pro dose, sufficians. Then has followed a catheters to catch the urine. An average of 1500 c. c., tonic of iron, of quin., and of both combined with the or about three pints is the normal daily excretion of addition of phosp. and strychnine, of stout, of port wine, urine. If from both catheters one cubic centimeter of malt, potassii iodidi, and of the change of climate from one catheter is passed, the number of minutes in and residence at Mineral Springs, and mineral waters, a day multiplied by this amount gives 1440 c. c., which also electricity and a milk diet exclusively. And with is practically the normal excretion. I have frequently all this medication she suffered for a period of found just this proportion upon estimating the day's five years, during which time she has become a mother, urine by the amount collected in a few minutes by the which relieved the menorrhagia and dysmenorrhea of catheters. lieved by bromide and chloral or anything else. which she complained bitterly, which could not be re

Oftener the amount falls much below normal. In disease there is frequently a marked difference in the amount of urine collected from the two sides. One With so much of the history and treatment I ask side may flow freely and the other discharge no urine, your suggestion for any treatment for her at present. although this may be due to stricture, which I have A mother whose weight is 110 pounds, whose appetite demonstrated by pushing the catheter up beyond the is extra, but who is punished severely with the increase stricture and over the brim of the pelvis, when immedi

ately several ounces escaped. One side may be alka- of a constant headache by eating anything, yes, by even line and the other acid; one may be bloody or pure taking a drink of water, tea or milk, who complains of blood and the other clear urine; one may be pus and no fullness after eating unless a very hearty meal is the other urine. I have demonstrated all these varia- eaten, when she takes one-half teaspoonful of table salt, tions a number of times. which relieves the fullness better than pepsin. She has

minute or more.

The urine evidently flows from the kidney in little wavelets, for it does not appear at the end of the cathe no acid eructations, she has a tendency toward constiter in from one to eight or ten minutes, and then it only pation, she has no soreness at any point, no cough, no escapes by drops at intervals of a few seconds to a difficulty with her water, no vomiting nor nausea at any Fifteen minutes is an average time for the duration time, sleeps well, but she constantly complains of achof the catheterization. The urine of each side is thening of knees, a tired feeling and headache. marked and set aside for examination The catheters I would be pleased to answer any question in relation are plugged and withdrawn and the urine in each of to this case which may be asked and I would be overthem is added to that in the graduate from the same joyed to read in the MEDICAL RENIEW a line of treat side. A little patience and tact, as I have said, are all ment that would cure my patient. that are needed to succeed in this little maneuver, which adds so much to the possibilities of gynecology, as it brings into this special branch of surgery renal Ex President Santa Cruz County Medical Society,

diseases in the female.

Soquel, Santa Cruz County, Cal.

H. O. BRINK, M.D.,

ABSTRACTS

sicians might be required to be summoned to determine the sanity or insanity.

long-established criminal practice in this class of cases, which is based on human experience from earliest times The Legislature might, very appropriately, pass an Act permitting the State or the accused to have the question Insanity from Intoxication as a Defence of insanity tried before the main trial upon the into Crime. The rule laid down by the Supreme formation or indictment. In such a case a jury of phyCourt of Kansas (Med. News) concerning the responsibility of a person who, at the time of the commission of an alleged crime, has sufficient mental capacity to understand the nature and quality of the particular act or acts cnnstituting the crime, and the mental capacity to know whether they are right or wrong, that he is generally responsible if he commits such act or acts, whatever may be his capacity in other particulars, was forcibly challenged in the case of State v. ONeil, just re ported (33 Pacific Reporter, 287). The theory of irre sponsibility from an irresistible or uncontrollable im pulse was ably presented. Several authorities were cited and the Court also referred to a lengthy article "On the Legal Aspect of Insanity," published in 1 N. W. Law Rev. 1, which stated, among other things, that "it would be difficult to crowd into the same compass more erroneous ideas than are found in the charge of the Court in the Guiteau case." The Court said that it had examined these authorities and had also read simi lar articles in the magazines upon legal or forensic medicine, which support and even go further than the views expressed in the Law Review.

In the case under consideration evidence was offered upon the part of the accused showing that he had inherited an appetite for intoxicating liquors; that he had indulged that appetite during life; and that the habit for drink had grown upon him so that he had the reputation of being an habitual drunkard. It was further insisted, the evidence tended to prove, that at the time of the killing he was insane from alcoholism. The Court, however, instructed the jury, among other things, that voluntary intoxication is no defence to murder in the first degree, unless such intoxication should be so extreme as to rob the mind of the power of premeditation and deliberation. Hence, if it was found that the accused committed the act of killing as charged, and that at the time that he did so he was in a state of intoxication caused by his voluntary action, he was guilty of murder in the first degree, unless it should be further found that such intoxication was so extreme as to prevent his mind from the exercise of deliberation or premeditation; in which latter case he would be guilty Some of the articles in the medico-legal journals of murder in the second degree, or manslaughter in assert that all crimes result from heredity, and, there some of the degrees. If the jury should believe from fore, that all persons committing alleged offences the evidence, beyond a reasonable doubt, that the acshould be considered irresponsible, and be subjected to cused did the killing at the time that he was so drunk treatment for disease only; not for crime. The decis- as to be incapable of entertaining deliberation and preions cited were called sporadic cases, and against the meditation, and also was incapable of entertaining the overpowering weight of authority. As declared by this elements of purpose and malice, and that he had no Court early in the State's history: "It is possible that previous knowledge that when intoxicated that he was an insane, uncontrollable impulse is sometimes sufficient liable to commit acts of violence upon his wife, whom to destroy criminal responsibility, but this is probably he was charged with murdering, or others, as a conso only where it destroys the power of the accused to sequence of such drinking, it could not find him guilty comprehend rationally the nature, character, and con- of murder in either the first or second degree. sequences of the particular act or acts charged against him, and not where the accused still has the power of knowing the character of the particular act or acts, and that they are wrong. Indeed, it would seem dangerous to society to say that a man who knows what is right and wrong may, nevertheless, for any reason, do what he knows to be wrong without any legal responsibility intoxicated, then, and in such a case, such person would therefor. The law will hardly recognize the theory that any uncontrollable impulse may so take possession of a man's faculties and powers as to compel him to do what he knows to be wrong and a crime, and thereby relieve him from all criminal responsibility. When ever a man understands the nature and character of an act and knows that it is wrong, it would seem that he ought to be held legally responsible for the commission of it, if in fact he does commit it." And in a later case the Court adopted the views thus expressed upon uncontrollable impulse. Nor is it now inclined to adopt the Bishop, in his work on Criminal Law, says: "When theories of psychologic enthusiasts to overthrow the a man voluntarily becomes drunk, there is the wrong.

When a person is shown to have been in the habit of becoming intoxicated, and it is further shown that when intoxicated he is likely to commit acts of violence upon his fellows, and endanger their lives or safety, and such person is shown to have knowledge of such fact, and, having such knowledge, voluntarily becomes

be as fully and entirely responsible for acts of a criminal nature committed by him while in such state of intoxication as though the act had been committed by him while not intoxicated. When insanity is set up as a defence to crime committed, the rule that the jury must ever keep before their eyes and minds in determining the responsibility of the accused is this: "Was the accused, at the time of doing the act complained of, conscious of the nature of his act, or did he know that it was wrong to do it?"

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