Abstracts CONNOTATIONS H. J. SIMS Denver, Colorado Pohl, in 1737, gave a fairly accurate description of prostatic calculi. As late as 1838, Civale stated: "Their origin is very dark; they have not been studied accurately enough so that it can be said under what pathological conditions they are formed, nor what

organic changes lead to their formation." Biliary peritonitis of obscure origin was first reported by Saunders, in 1783. A fourteen year old boy, after falling from a tree was bled and purged for four days because of severe pains in the abdomen. His abdomen gradually enlargened and on the twenty-fourth day two gallons of

T h e loss of water from the tissues which is so frequently s y m p t o m a t i c of s u m m e r diarrheas a n d other hot weather affections tends to carry with it a depletion in alkali a n d m i n e r a l reserves. You can meet this deficiency successfully a n d in a convenient, pleasant form for your patients by prescribing Alka-Vess. Each tablet contains the buffer salts c a l c i u m - d i - h y d r o g e n phosphate 3 grs.; p o t a s s i u m b i c a r b o n a t e 1 gr.; m a g n e s i u m sulphate (dried) 1 gr.; s o d i u m chloride 1 gr.; citric acid 19 grs.; sodium bic a r b o n a t e 31 grs. I n c o n v e n i e n t t u b e s of 25 tablets.

392

bile was removed through a trocar. On the thirty-seventh day he: was again tapped. The trocar entered the intestine and he died of peritonitis five days later. Drainage of the abdominal cavity as now practiced was developed after McDowell began performing ovariotomies. It was found in most of the fatal cases a collection of serosanguinous fluid formed in the pelvis. Drainage through the cul-de-sac was first attempted by Keith, in 1864. He also introduced intraperitoneal drainage through the rectum. Celsus, so far as is known, first drained the abdomen for the removal of ascitic fluid. His tubes were made of lead and brass and tapered to prevent slipping into the abdomen. Galen, in the second century, a n d A v i c e n n a , in the eleventh, used the same technique as Celsus. Adenoma of the liver in young infants suggests the congenital origin of these tumors. Wagner, in 1861, described such an instance in a nursling. The first detailed description of fibrous osteoma of the jaw was published by Menzet, in 1872. The tumor was noted by the patient over a period of twenty-five years. It was removed because of partial obstruction of the air and food passages. Bennett, in 1881, exhibited before t h e D u b l i n Pathological society a series of fractures of the metacarpal bones. Such fractures are recognized as Bennett's fracture. John Hunter transplanted cocks' spurs into their combs. The spurs grew to an enormous size. He attributed the excessive growth to inflammation, believing t h a t an increase in the blood supply stimulated healing by giving power of action. Diverticulosis of the colon was described by Cruveilhier, in 1849, Virchow in 1853, by Rokitansky in 1856. These investigators are usually given credit, however, Ballies' Morbid Anatomy published in 1794, recognized sacculations of the colon. Trephining for depressed fractures of the skull was done in ancient Egypt. Hippocrates observed t h a t fractures with depression were not particularly dangerous u n l e s s the membranes were ruptured. Lanza and Higgins were the first Americans to make a comprehensive report on silicosis. The disease is not a recent one for Ramazzini, in 1700 described the condition. Richter, in 1778, gave a complete s c i e n t i f i c description of a hernia which now bears his name. Treves

ABSTRACTS suggested that this type of hernia be called Richter's hernia to differentiate it from the hernia of Littre. WHYTE, DAVIDAND O'REGAN, ROLLAND

Complete Prolapse of the Rectum. N e w Zealand Med. Jour., 36:381382, Dec., 1937. The injection method of treatment of rectal prolapse is not entirely safe. A case is reported in which sloughing of the rectal wall occurred with severe and repeated secondary hemorrhage. Temporary colostomy and six blood transfusions in the course of seventeen days were considered necessary in treatment. The end result was complete cure. Hanes M. Fow]er, Fort Wayne.

Hahn in 1881, conceived the idea of sewing the perirenal fat to the walls of the lumbar incision. He named his procedure nehprorrhaphy. In 1870, Gilutore m a d e the deliberate and successful effort to remove a kidney during pregnancy. The first case of ilopectineal bursitis was reported by Fricke of Germany, in 1834. Joly, in 1847, recognized the second case. As far back as 1874, Carl Reuber demonstrated t h a t certain definite changes occur in the synovial mem-

393 brane in immobilization of normal joints. Gastrostomy was first suggested by Eggebert, in 1837. Blaudlot, in 1843, performed this operation on a dog. In 1843, both Sedielat and Nelaton independently and successfully carried out this procedure in man. Only a few less than forty modifications of the original procedure has been offered. Scoliosis is one of the oldest conditions described in medical literature. Hippocrates used this term to describe any twisted spine.

CARMALT-JONES, D. W. Disorders of the Pituitary Gland in Relation to Circulatory and M e t a b o l i c Disturbances. M e d . J o u r . o f Australia, 1:$39-440, March 5, 1938. Anterior pituitary excess leads to overgrowth, hypertension increase in basal metabolic rate, with at present an imperfectly traced influenced on the other endocrine glands. No medication is of any service in these cases. A defect of the anterior lobe of the pituitary leads sometimes to wasting, sometimes to obesity and a low basal metabolic rate. Patlents with these conditions may be capable of treatment with anterior pituitary extracts. Water metabolism is controlled by the hypothalamus and posterior lobe of the pituitary, and persons suffering from excessive loss of water may be treated by posterior pituitary extract. Hanes M. Fowler, Fort Wayne. CONNOTATIONS H. J: SIMS Denver, Colorado Placenta accreta, a comparative rare condition was known to the older obstetricians. Morgagni made mention of the condition and commented that it was difficult even with a bistoury, to separate the placental tissue from the uterine muscle. Ried, of Erlangen, a German surgeon, was the first to recognize tuberculosis of the flat bones of the vault of the skull. His article appeared in 1842, hov~ever, the c a s e s were observed in 1838. Carcinoma of the male breast was mentioned in the writings of Arcaeus (1493-1573). Hildanus (1537-1619) described a similar case. It was not until 1872 t h a t a systematic study of this disease was made by Horteloup. Le Gallois, in 1812, Knox in 1839, and Barlow in 1854, reported rupture of the symphysis pubis articulation in p a r t u r i e n t g u i n e a pigs, seals and COWS.

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AMERICAN JOURNAL OF DIGESTIYE DISEASES

William Turner, in 1886, wrote "with the exception of the skull no portion of t h e s k e l e t o n presents greater individual variations than the pelvis". Vesalius' drawing of the pelvis showed the sacrum to consist of six segments. Oddly, the writings of Deventer published in 1725, also describes the sacrum as consisting of six segments.

SPRAGUE, E. W., SCHAAF,R. A., MACARTHUR, C., HAWKES, S. Z., HAUTM A N , H . , AND HALE~, P. W. A Study o/ Appendicitis. S. G. 0., Vot. 66, No. 2, pp. 166-172. Feb. 1, 1938. The authors present a review of

1463 consecutive cases of acute appendicitis, all of which were operated upon. The technique was practically the same in all cases; the appendix being crushed, ligated, then severed with a cautery and inverted by means of a purse string suture. A row of Czerny-Lembert sutures is used to cover this and the raw edges of the meso-appendix. The appendix was not removed in three cases, which were complicated b y general peritonitis. In septic cases great care is exercised to protect the healthy peritoneum. Abscesses are drained without entering the general peritoneal cavity if possible. The history of chills or the presence of a remittent type of fever

curve was taken to indicate the presence of the thrombophlebitis of some extent. The authors have not used the socalled expectant treatment in any of these cases because they feel unable to judge which cases may localize safely and which ones may extend and continue to spread. The conclusion is apparent from this study that operation is comparatively safe during the first 18 hours after onset. After that time the danger rises in direct proportion to the time elapsing between the onset and the time of operation. The mortality in this series of cases is 2.73 per cent. Ten tables accompany the article. Nelson M. Percy, Chicago. G A U N T , W I L L I A M E., I R V I N G , J A M E S T . AND T H O M P S O N , W I L L I A M .

Calcium and Phosphorus Deficiencies in a Poor H u m a n Dietary. British Med. Jonr., 770-773, A p r i l 9, 1938. Experiments are cited in which it was shown that the nutritional value of a poor human dietary can be greatly improved by the addition of milk, and green food supplements. Experiments reported here demonstrate that in rats bred from stock this improvement is due largely lo the calcium and phosphorus contained in the supplements. This conclusion is based upon a comparison of the rate of the growth, calcification of bones a n d t e e t h , a n d reproductive performance in various groups of rats, all bred from stock. Hanes M. Fowler, Fort Wayne. VAUGHAN, WARREN T.

l t t d i v a t l o n s . T h e l i t e r a t u r e shows GLUTAN H-C-L (Glutamic Acid ltydrochloride) to be a superior source of free hydrochloric acid in the treatment of gastric achlorhydria, hypochlorhydria, n e r v o u s anorexia, and in s e c o n d a r y anemias requiring a high protein diet, or whenever it is necessary to supplement or replace gastric hydrochloric acid.

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Food Idiosyncrasy as a Factor of Importance in Gastro-enter.dogy and in Allergy. The Review of Gastroenterology, March, 19~!'8. The first reference in all literature which might be taken as pertinent to the subject of food idiosyncrasy was the statement of Lucretius, a Roman - - " O n e man's food may be highly poisonous to another," since corrupted into "One man's meat is another man's poison." Allergy and idiosyncrasy mean precisely the same thing today, although perhaps the term "sensitive" in connection with foods might be considered more general. Wolff-Eisner's suggestion in 1906 that hay fever might be an allergic disease first showed that there might be a connection between experimental anaphylaxis and spontaneous clinical disease, but it was not until 1910 that Doerr suggested a common basis for food idiosyncrasy and anaphylaxis. The first book on clinical allergy, by hlinet and LeClercq in t913, devoted only nine pages to food allergy and concluded that the phenomenon mus~ be quite rare. Schloss in America in

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AMERICAN JOURNAL OF DIGESTIVE DISEASES

1912 applied skin tests and showed that while explosive instances of food allergy were not common, that a wide variety of milder symptoms could be attributed to the same cause. Allergic symptoms referable to the digestive tract may result from food or drugs. The two commonest manifestations in the lips and mouth are angioneurotic edema and stomatitis following the ingestion of foods or drugs or the use of dental powders, pastes, mouth washes or even chewing gum. The recurrent form of herpes labialis is not infrequently associated w i t h f o o d allergy, and the same applies to many cases of recurrent canker sores in the

mouth. The classical allergic reaction in the stomach is associated with nausea and vomiting soon after the ingestion of the allergic excitant: if the latter is not vomited, the colon may later react with diarrhea and even true mucous colitis. Even perianal eczema may be due to food allergy and it seems that about onethird of cases of pruritis ani and perianal eczema, which are not due to pathologic conditions in the rectum can be relieved by a carefully studied plan of food avoidances. It is probably true that at times symptoms of gall bladder disease are due not to gall bladder infection but to the

effects on the gall bladder of food allergy, for it has been shown that in a sensitized animal, the local chemical irritation of a tissue may result in the accumulation of antigen at the point irritated: and it is recognized that the empirically-discovered gall bladder diets usually eliminated such definitely allergy-producing foods as strawberries and sea foods. Thus allergy may become a local complication superimposed upon the basis of an infected gall bladder. F o r the same reason, some cases of peptic ulcer have superimposed upon the ulcer a definite tendency to local allergic reaction, and in such cases the avoidance of the allergy-inducing food (notably milk) may result in symptomatic improvement very p r o m p t l y At times the symptoms of appendicitis may be imitated by food allergy. Some patients with characteristic history of chronic appendicitis, but who did not improve after operation, were found to have marked eosinophilic infiltration of their amputated appendices, and it was considered t h a t this "appendiceal allergy" was but a part of an allergic colitis. The Walzer reaction suggested that possibly proteins are often absorbed from the digestive tract in a sufficiently unaltered state to be antigenic after absorption, but the further work of Thiers and Chevallier indicated that even after gastric digestion and after removal of protein by ultra-filtration food could still be allergy-producing. Possibly the active factor is not the protein but an associated hapten. The leukopenic index is more reliable than the skin tests in determining allecgic substances in individual cases, but both ought to be used. The elimination diets of Rowe or the food diary of Vaughan are useful in detecting the offending food in many obscure cases. At the lowest estimate ten per cent of the population of the United States is frankly allergic, and for that reason it becomes evident t h a t allergy must play a considerable part in the siiudy of gastro-intestinal symptomatology. LEVINE, A. L. AND SHUSHAN, MORRIS.

The Value of the Medical Plan of Treatment in Intestinal Obstruction. The Review of Gastro-e~terology, March, 1938. A middle p o s i t i o n may be discovered between those who believe that intestinal obstruction is invariably a surgical emergency and those who do not, and careful study, undertaken for the purpose of creating distinctions may persuade medical nihilists that medical treatment has a definite place, not only because many cases ought to be operated upon (rely as a last resort but because medical treatment forms a vital pre- and I~)stoperative requirement, none too well

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AMERICAN JOURNAL OF DIGESTIVE DISEASES

is N O N - I R R I T A T I N G and t e n d s toward Normal Physiological Activity of the Bowel Doctor, have you used KONSYL to promote peristalsis by bulk and lubrication in your cases of chronic constipation?

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recognized at the present time. Since obstruction is at times due to fecoliths and encrusted gall stones attempting passage through the bowel, operation ought to be delayed until the colon can be flushed out and the stomach and duodenum drained by catheter in a double effort to relieve obstruction and intoxication, because so frequently operation results in death from surgical shock even though the cause of the obstruction be very simple. Whether the cause be obstruction, paralysis or reflex ileus, the symptoms depend largely on the position of the block, high blockage being the most dangerous and rapid in development, and resulting in a quick dehydration and chloride deprivation. Frequent lavage of the stomach via the nasal catheter, the introduction of fluids and dilute HCI through this catheter at intervals, oil enemas, interstitial injection of 2,000 cc. of glucose in saline each 24 hours, the heat tent over the abdomen, cardiac stimulants and morphine for rest are suggested, both preoperatively and postoperatively. Complete cooperation between surgeon and gastro-enterologist s p e 11 s a h i g h measure of success. DE RIVAS. DAMASO. The Rational T r e a t m e ~ t o f Amebic Dysentery with Sioecial Reference to the Eradicati,)n of th~ Parasite by the Intra-e,)lonic Thermie Method. The Revi~,,w of Gastro-enterology, March, 1938. The author uses colonic instillations of a 1-5000 copper sulphate in saline solution with glycerine and laudanum added, keeping the temperature very close to 45 to 47 degrees C. It is a procedure which is non-effective or e v e n dangerous in inexperienced hands and depends for its efficacy upon the critical death point o[ endameba histolytica. He relies upon the sufficiently frequent use of this method more securely than upon the use of any drug, and checks the progress by the presence of amebae or cysts or occult blood in the stools, and the healing of the ulcers, but not by the presence or absence of symptoms. He quotes Smithies as support in the idea of ceasing to rely upon many expensive drugs with claimed specificity of action, and compares Amebiasis to syphilis, in that both diseases are more efficiently cured by prolonged careful application of simple and known remedies than by the erratic use of new and much vaunted o~es. HARTZELL, J . B.

The Treatment of Fistulas ~f the Small Intestine. S. G. 0., V~l. 66, No. l, pp. 108-116, Jan., 1938. The author discusses the treatment of small fistulas by means of pastes, buttons, discs and other devices and presents his modification of the r~bber

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AMERICAN JOURNAL OF DIGESTIVE DISEASES

in Chronic Cholecystitis Toxic Hepatitis Stone-Free Cholangitis Duoehol (Plessner) provides the specific pharmacologic influence needed in many affections of the biliary passages. Containing highly purified bile salts and sodium salicylate (2 gr. of each), it intensifies bile secretion by the liver and increases cholecystic evacuation. Drainage of the bile ducts and gallbladder is thus encouraged, leading to rapid subjective and objective improvement in chronic cholecystitis, t o x i c hepatitis, and stone-free cholangitis. Samples and literature Sent to physicians on r e q u e s t .

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disc. The efferent and afferent limbs of the fistula are probed and a wax model of the interior of the bowel is made. This is long enough to extend well into healthy bowel. This model is then east in pliable rubber, which is inserted into the limbs of the fistula. Into the exposed portion of this rubber mold a heavy silk suture is placed. If necessary two sutures are inserted at different points in the mold and fastened to a crossbar on the surface of the abdomen. As the fistula heals a smaller rubber mold is made and inserted. Finally after the fistula is completely healed the sutures may be cut and removed and the mold will pass through the intestinal tract. Prerequisite to the success of this method is the complete absence of any degree of intestinal obstruction below the fistulous opening. Eighteen figures from ease reports and a bibliography accompany the article. Nelson M. Percy, Chicago. HAWKES, STUART Z. Thrombophlebitis of the Appendiceal V e i n Complicating Ac~te Appendicitis. S. G. 0., Vol. 66, No. 1, pp. 62-78, Jan., 1938. Thrombophlebitis of the appendiceal vein occurs when the infection tends to spread through the tissues. This thrombus serves to stop the spread of infection, but if the infection is so virulent as to cause enlargement of the thrombus and extension of it proximally in the appendiceal vein small emboli may break off and lodge in the liver. Such a happening is usually denoted by the occurrence of a chill and a sharp rise in the patient's temperature. This is frequently the beginning of a liver abscess and marks that case of appendicitis as one with a more grave outlook. If the thrombus has extended beyond the appendiceal vein and is giving off small emboli from a point in the ileo-colic vein it should be excised or ligated at the time the appendix is removed. If simple appendectomy without excision or ligation of the thrombosed vein is performed the patient will continue to have chills post-operatively and the possibility of the development of a liver abscess becomes much greater. The author describes the course of the appendiceal and the ileo-colic vein and points out that the ligature should be placed at a point distal to the juncture of that vein with the right colic vein. E a r l y recognition and proper treatment of this type of appendicitis the author believes may contribute to lowering the mortality rate of appendicitis as a whole, Three figures and a summary of eight cases accompany the article. Nelson M. Percy, Chicago.

BERMAN, ft. K. Congenital A n o m a l i e s of the Rectum and Anus. S. G. 0.: Vol. 66, No. 1, pp. 11-22, Jan., 19~8. Congenital anomalies of the rectum and anus are rare. Their diagnosis presents no difficulty but recognition of the type of anomaly present requires a complete knowledge of the embyological d e v e l o p m e n t of t h e mesenteron and proctodeum. Anomalies of the anus arise from ma]development of the proctodeum, while those of the rectum result :from maldevelopment of the mesenteron. An accurate anatomical classification as proposed by Fraser, follows: 1. Congenital narrowing o f t h e anal canal. 2. Congenital occlusion of the anal canal. 3. Abnormal location of the anus. 4. Congenital absence of the anus. 5. Total absence of the rectum. 6. Atresia of the lower end of the rectum. 7. Membranous occlusion of the rectum. 8. Recto-vaginal, recto-urethral and recto-vesical fistulas. The symptoms are those of complete or partial intestinal obstruction with distension of the abdomen. In the fistulous types the parents will have noted that there is an abnormal opening with an absence of the normal anus. The diagnosls ~s difficult. X-ray examinations with the baby held in an upside down position will reveal the position of the bind gut if it contains gas. Gas is rarely present beyond the hepatic flexure during the first 24 hours of life. Fluoroscopy with massage of gas into the bind gut is a valuable method. Injections of 121/~ per cent sodium Iodide into an external fistula will reveal the course of an internal fistula if one is present. Colostomy and digital exploration of the bind gut is dangerous. Treatment depends on the type of anomaly present and the accurac:~ of diagnosis. C o l o s t o m y should be avoided if possible. Dissections shquld be made from below through a longitudinal incision from the perineal body to the tip of the coccyx. This will be through the sphincter muscle which develops independently in the regional mesenchyma. Local anesthesia should be used as the straining and crying of the baby tends to push the bind gut down in the desired position. If a fistula is present it should be left alone until the child is older. The author uses No. 0 catgut to suture the mucosa of the bowel to ~he skin. A brief summary of 23 cases of congenital anomaly of the rectum and anus with eleven figures and two tables accompany the article. Nelson M. Percy, Chicago.

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AMERICAN JOURNAL OF DIGESTIVE DISEASES

MULHOLLAND, H. B.

Intravenous Liver E x t r a c t in the Therapy of Pernlcious Anemia: Report of a Case. Ann. Int. Med., Vol. 11, No. 4, p. 671, Oct., 1937. The author states that some cases of pernicious anemia will not respond to liver or liver extract and ventricuIin when given orally but will respond to intramuscular injections of liver extract. The author cites a very comprehensive case history, over a period of eighteen months, in which oral administration of liver extract was efficient for a period, then failed; intramuscular injections reacted similarly and was then followed by five intravenous injections of 20 c.c. of specially prepared liver extract, with less reaction to each successive dose and causing such improvement that the patient was able to leave the hospital for his home. Since then he has used one intramuscular injection of liver extract each week. Over a stay of 120 days in the hospital both the blood picture and general health were much improved. In his comments Dr. Mulholland reviews the literature of other authors in which liver extract was administered intravenously. B. B. Vincent Lyon and C. H. Aronld. VAUGHAN, JANET M.

Anemia and the Gastro-intestinal Tract. British Med. Jour., 57-59, July 9, 1938. It is recognized today that the commonest cause of anemia is a lack of one or other of the essential hemopoietic principles. The known hemopoietic principles are iron, the P.A. substance in liver effective in Addisonian pernicious anemia, and vitamin C. Minute quantities of such minerals as copper, cobalt, and manganese may be

For

required but are usually present in adequate amounts even in the poorest diets. An adequate supply of hemopoietic principles may be rendered inadequate due to certain disturbances of the gastro-intestinal tract such as, hemorrhage, deficiency of gastric digestion, deficiency of intestinal absorption, and production of toxic substances. The commonest sources of gastro-intestinal hemorrhage are bleeding gastric and duodenal ulcers and hemorrhoids. In all cases of anemia of unknown etiology an analysis of the stools for occult blood is an essential investigation. Deficiency of gastric digestion may be due to organic lesions, diminished secretion of hydrochloric acid, or diminished secretion of the intrinsic factor of Castle,. By organic lesions of the stomach are meant new growths and complete or partial gastric resection. The anemia in such cases is due in part to the diminished gastric secretion and in part to altered intestinal frmction. It usually responds well to treatment with iron and liver extract. There is a high incidence of achlorhydria associated with all types of anemia, but the exact etiological r~!ationship of gastric acid secretion to anemia has not been established because of conflicting evidence in the literature. Some cases of Addisonian pernicious anemia also show an iron deficiency. In such cases large doses of iron must be given along with the liver extract to secure a satisfactory hemotological response. This point should be remembered in order to combat the onset or f u r t h e r development of subacute combined degeneration of the cord. Deficiency of intestinal absorption may be due to changes in pH, increased motility, abnormalities of muscle tone, or abnormalities of the mucosa. The anemia seen in such conditions is often of a mixed t y p e - - t h a t is, there is a deficiency of both the iron and the P.A. principle.

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