When the patient continues to vomit after the third day and there is a rise in pulse rate, not due to a complication, he becomes anxious, nervous and restless. These bodies are usually found in conditions with symptoms from the acid intoxication. Why these bodies appear is not definitely settled. However, Joslin's work throws some light upon it. He starved some medical students at Harvard and found these acid bodies appearing in the urine. In all probability this is one of the reasons why they are present.

DOCTOR ALBION W. HEWLETT: The picture in the first of these cases was a striking one. She vomited continually and without any apparent cause and in addition there was great pain on swallowing. The latter was attributed to an esophagitis but at autopsy no cause for it was found. Too much importance should not be placed upon the appearance of acetone in the urine after operation as it occurs not infrequently at such times and may occur in any person who is suddenly starved after being on a full diet. When diacetic acid also appears the condition is more serious. Such cases as these occur more frequently after chloroform and have been spoken of as late chloroform poisoning but they may also occur after ether. The character of the second case was more doubtful for the reason that less of the acetone bodies was found and also because she had hyperthyroidism which might account for many of her symptoms.

ORIGINAL ABSTRACTS.

MEDICINE.

ALBION WALTER HEWLETT, B. S., M. D.

PROFESSOR OF MEDICINE IN THE UNIVERSITY OF MICHIGAN.

DAVID MURRAY COWIE, M. D.

CLINICAL PROFESSOR OF PEDIATRICS IN THE UNIVERSITY OF MICHIGAN.

DIGITALIS.

THE effect of digitalis and related drugs upon the heart and the circulation has been exhaustively studied by Mackenzie and his school and the results of these studies are summarized and discussed in Heart, 1911, II, 273. The British tincture of digitalis formed the basis of the study, although other preparations of digitalis and of related drugs were used. The drugs were pushed until some definite result was obtained either upon the heart rate or upon the stomach (nausea, vomiting). When the tincture was given in doses of about one drachm a day, nausea usually occurred after five to eight days. Mackenzie has never seen dangerous symptoms produced by such doses. Careful records were kept of the effects upon the general condition of the patient, the digestive and nervous symptoms, the urinary flow, the blood pressure and the heart rate and rhythm. The most striking digitalis effects, so far as the heart's rate was concerned, were obtained on cases of auricular fibrillation. Even large doses of

digitalis up to those producing nausea rarely slowed the heart rate. when the rhythm was of a normal character. In the latter group of cases also the improvement in the general condition was usually much less marked than in those with auricular fibrillation. The first digestive disturbances noted were loss of appetite and nausea, which were followed by vomiting if the drug was continued. Accompanying the nausea there was often headache and general malaise. Strophanthus and squills produced diarrhea much more readily than digitalis. Except in one case no appreciable effect upon the blood pressure was observed even though the drug was pushed to nausea.

As has been said the most striking effects of digitalis medication were obtained on patients who showed auricular fibrillation. clinical signs whereby we recognize this condition are: (1) The irregularity of the heart is usually continuous and is of a disorderly character, except in certain cases of slow heart action. (2) All signs of normal auricular contractions disappear-(a) in mitral stenosis the presystolic accentuation of the murmur attributed to auricular systole disappears, (b) no auricular waves appear in graphic records of the jugular pulse. (3) The fibrillation may be indicated on jugular tracings by small waves and are well marked on electrocardiographic tracings. It is in auricular fibrillation that marked slowing of the heart with great improvement is most liable to occur after digitalis. In a patient with temporary fibrillation digitalis caused slowing but was ineffective during the normal rhythm. The cases of fibrillation most susceptible to digitalis are those with a previous history of rheumatism especially in young individuals. In some cases the slowing is accompanied by a peculiar coupling of the rhythm due to ventricular extrasystoles. Occasionally auricular fibrillation may be produced by digitalis and disappear when the digitalis is stopped.

Digitalis increases the sinus irregularities of the heart. It may cause ventricular extrasystoles. Rarely it causes the pulsus alternans. The most characteristic irregularity produced by digitalis is partial heart block in which occasional ventricular contractions fail to occur after auricular contractions. The presence of a partial heart block is not an absolute countraindication to digitalis for some patients improve in spite of the partial block. A complete block is no contraindication, for it has not been definitely proven that digitalis can influence the automatic ventricular rate.

In tachycardias due to an increased number of stimuli at the normal site of origin, as in fever, alcoholism, and toxemias, digitalis is usually without effect upon the heart rate. Tachycardias due to auricular fibrillation are very susceptible to digitalis.

No definite change in the size of the heart as outlined by percussion could be made out even though the patient showed great general improvement.

The slowing of the heart under digitalis which occurred in fibrillation of the auricle as well as the slowing due to partial heart block could usually be removed by an injection of atropin, thus indicating that these effects were usually produced by stimulation of the vagus nerve by the digitalis.

A. W. H.

GYNECOLOGY.

REUBEN PETERSON, A. B., M. D.

PROFESSOR OF OBSTETRICS AND GYNECOLOGY IN THE UNIVERSITY OF MICHIGAN.

BENJAMIN ROBINSON SCHENCK, A. B., M. D.

CONSULTING OBSTETRICIAN TO THE WOMAN'S HOSPITAL OF DETROIT.

RADICAL EXTIRPATION OF THE CANCEROUS UTERUS. TWEEDY (The Journal of Obstetrics and Gynaecology of the British Empire, Volume XIX, Number IV, 1911) writes of his experience and reports his results with Wertheim's operation for cancer of the uterus. He considers that the modesty of Wertheim's claims is what has given his operation popularity over those of others. Berkeley considers that the use of the clamp on the vagina is the distinctive feature of Wertheim's operation, but Tweedy considers that the clamps are not necessary, and in fact, cannot be applied during some operations for radical extirpation of the uterus.

The writer prefers the use of loose untied silk ligatures around the ureter in order to be able to dissect them from their course. He considers that the danger of disturbing the ureters from their beds has been much exaggerated and in the past has led to incompleteness of operation.

Tweedy finds that the bladder is easily separated from the cancerous uterus if it be free from inflammatory and malignant infiltration. He also finds that the bladder, rectum and ureters are wonderfully resistant to uterine cancer, and he has often been struck with the extent of the infiltration above and below the ureter without its actual involvement. If it is necessary to resect the ureter he considers it all important to suture the ureter and leave no tension on the organ. Rather than have tension on the ureter he would pull up the bladder, or suture the ureter into the bowel, and he suggests that perhaps the Fallopian tube might be utilized as a urine carrier in some cases.

To prevent a pelvic hematoma from collecting the writer uses a plug of gauze which he places in the subperitoneal space leading into the vagina. Although it is not necessary in all early cases, he finds it almost indispensable in the more advanced cases.

The writer's experience is similar to that of others in that suppuration of the abdominal wound occurs frequently. A prophylactic stitching of the peritoneum to the skin takes too much time and is questionable as to its efficacy, which statement also holds true for other devices used to prevent wound infection.

Cystitis occurred in six out of forty-nine cases but yielded to treatment easily. Bladder injury likewise was not uncommon, three injuries occurring at the time of operation, and six cases obtaining sloughs later.

The writer operates on many cases where there is fixation of the uterus, pain, purulent discharge, infiltration of broad ligaments and cachexia. Extreme obesity he considers a hindrance but not a contraindication to the operation; even with involvement of the liver and other secondaries the writer considers it justifiable to remove a can

cerous uterus to afford relief from pain and discharge. One would be inclined to question the justification of such operations. Tweedy apparently performs abdominal operations on incurable cases with the hope that the patient's pain may be relieved. The idea that it may be wrong to subject a patient to the anxiety of a major operation which cannot prolong life is considered to be mere sophistry and is dismissed without discussion.

The writer's primary mortality is eighteen and seven-tenths per cent for all cases. For carcinoma of the cervix his primary mortality is twenty-four and one-quarter per cent, while it is nine and one-tenth per cent for carcinoma of the fundus. Of ten cases of carcinoma of the fundus, who survived the operation, five have died of recurrences and four are known to be alive after periods of from one to four years. Of twenty-five patients with carcinoma of the cervix who survived the operation nine have died since, and nine are known to be alive and four of these have recurrence. The five patients alive and without recurrences have been operated from two to five years ago. Apparently the author has not been doing the operation longer than five years. Of his three cases operated five years ago, one is alive without recurrence.

In four cases neither ureter could be isolated, and in six cases only the right ureter could be isolated because of the extensive involvement. This in itself proves that the operation was performed on inoperable

cases.

OBSTETRICS.

GEORGE KAMPERMAN, M. D.

G. K.

INSTRUCTOR IN OBSTETRICS AND GYNECOLOGY IN THE UNIVERSITY OF MICHIGAN.

HOWARD HASTINGS CUMMINGS, M. D.

INSTRUCTOR IN OBSTETRICS AND GYNECOLOGY IN THE UNIVERSITY OF MICHIGAN.

PLACENTAL ANAPHYLAXIS.

JOHNSTON (The Journal of Obstetrics and Gynaecology of the British Empire, Volume XIX, Number II) reports the results of his experiments on placental anaphylaxis. Anaphylaxis is the antithesis of immunity. Certain substances, complex protein compounds, when introduced in small nontoxic doses into an organism, have the property of producing excessive sensitiveness to subsequent very small doses of the same substance. This phenomenon explains the unpleasant results sometimes obtained after the repeated administration of antitoxic serums.

The writer's experiments were made in five groups. In the first group an extract of fresh placenta from an eclamptic patient was obtained and injected intravenously into rabbits. A subsequent injection eleven days later produced no symptoms except slight dyspnea and uneasiness, which lasted only a few minutes.

In the second group similar experiments using normal healthy placenta juice were carried out on twelve rabbits. After the second injection seven rabbits showed slight symptoms, dyspnea, blanching of the ears, loss of muscular tone, and subnormal temperature. In an

eighth case there were slight convulsions and profuse liquid diarrhea in addition to the other symptoms.

In the third group, pregnant animals were injected with the juice of the placenta from another of the same species. Two animals showed no reaction after the second injection and only one rabbit showed slight dyspnea.

In the next two groups a suspension of powdered placenta in normal salt solution was used. Liepmann believed that the eclamptic toxin is in the cell and might not be found in the juice. The suspension was injected intraperitoneally and two animals died of peritonitis. But of those that survived there was not the slightest appearance of any anaphylactic symp

toms.

Johnstone summarizes as follows: "Anaphylactic symptoms were obtained by the use of normal human placenta juice in eight out of twelve rabbits. This indicates that human placenta juice contains some complex protein body which is capable of acting as a toxin for other animals.

"No results followed the use of eclamptic placenta juice. So far as it goes, this may be taken to lend support to the view that the toxic element had passed out of the placenta into the patient's body.

"No results followed the use of extracts of animals of the same species. No results followed the use of a powder of placenta.

"The results of these experiments appear to support the view that there is no evidence of anything of the nature of anaphylaxis, so far as we at present understand that subject, in the common manifestations of the toxemia of pregnancy."

G. K.

PEDIATRICS.

ARTHUR DAVID HOLMES, M. D., C. M.

CONSULTANT IN PEDIATRICS ON STAFF OF WOMAN'S HOSPITAL AND INFANT'S HOME OF DETROIT.

HERBERT MATTESON RICH, B. L., M. D.

ASSISTANT IN INTERNAL MEDICINE AT THE DETROIT COLLEGE OF MEDICINE.

SHOULD ECLAMPTIC MOTHERS NURSE THEIR

NEW-BORN?

GODDALL (Archives of Pediatrics, Volume XXVIII, Number I, page 13) describes in full three cases of healthy or seemingly healthy infants, born of eclamptic mothers who showed no symptoms of illness until the first copious nursing, when they suddenly died without apparent cause. Referring to the literature on this subject, it appears that such children have often been found to show signs of general intoxication, and in a large percentage the lesions were identical with those of eclamptic mothers who had succumbed to the disease. Children born of such mothers are far from being healthy. Those which survive and those which die in whom the urine is examined show signs of renal injury; therefore one must consider the vast majority of these children born of eclamptic mothers more or less