ABSTRACTS e d e m a t o u s s t a g e s w h i c h r o s e t o n o r m a l or above a f t e r t h e d i s a p p e a r a n c e of the edema. N a k a z a m a (5) and c o - w o r k e r s r e p o r t e d a s e r u m a l b u m e n values seldom below 4 p e r c e n t a n d colloid osmotic p r e s s u r e of only one p e r cent below n o r m a l . T h e y f o u n d t h e m o l e c u l a r w e i g h t of a l b u m e n g r e a t e r in t h e e d e m a t o u s f o r m s a n d s u g g e s t t h e h y p o t h e s i s t h a t t h e blood b u i l d i n g m e c h a n i s m is d i s t u r b e d in b e r i b e r i . M c C a r r i s o n (6) f o u n d t h a t t h e a d r e n a l s of fowls s u f f e r i n g f r o m " B " a v i t a m i n o s i s a r e c o n s i d e r a b l y e n l a r g e d , and t h a t t h e s e c r e t i o n o f a d r e n a l i n by these e n l a r g e d g l a n d s is p r o p o r t i o n a l l y increased. H e s u g g e s t e d t h a t t h e edema m a y be due to c i r c u l a t o r y c h a n g e s r e s u l t i n g f r o m t h i s i n c r e a s e d s e c r e t i o n of a d r e n a l i n . V e d d e r (7) s t a t e d t h a t t h e r e is c o n s i d e r able e x p e r i m e n t a l evidence to i n d i c a t e t h a t two v i t a m i n s a r e deficient in t h e d i e t t h a t p r o d u c e s b e r i b e r i and s u g g e s t e d t h e p o s s i b i l i t y t h a t t h e deficiency o f one, t h e a n t i - n e u r i t i c v i t a m i n , p r o d u c e s d e g e n e r a t i o n of t h e n e r v o u s s y s t e m and t h e s y m p t o m s of d r y b e r i beri, while deficiency of t h e second v i t a m i n p r o d u c e s g e n e r a l i z e d e d e m a and t h e s y n d r o m e , w e t b e r i b e r i . S a r g e n t (8) p o i n t e d out t h a t in t h e w e t f o r m of b e r i b e r i an affection of the v a s o m o t o r n e r v e s p r o d u c e s e d e m a while in t h e d r y f o r m p a r a p l e g i c m a n i f e s t a t i o n s a r e p r o d u c e d and p a l s y and a t r o p h y o f muscles occur. The i n s t a n c e cited i l l u s t r a t e s well one of t h e d a n g e r s

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e n c o u n t e r e d in t h e use of " r e d u c i n g d i e t s " w i t h o u t proper medical supervision. SUMMARY A y o u n g m a n e x h i b i t e d g e n e r a l i z e d edema and w e a k ness following a g e n e r a l l y i n a d e q u a t e diet, deficient in v i t a m i n "B." L a b o r a t o r y t e s t s , i n c l u d i n g a s t u d y of t h e p l a s m a p r o t e i n s a n d of t h e i n o r g a n i c c o n s t i t u e n t s of t h e blood w e r e e n t i r e l y n o r m a l . T h e complete disa p p e a r a n c e of t h e e d e m a a n d g e n e r a l s y m p t o m s , a f t e r a course of t r e a t m e n t c o n s i s t i n g of t h e a d m i n i s t r a t i o n of v i t a m i n " B " a n d an a d e q u a t e diet, is p r o o f t h a t t h e 6,~99 avitaminosis c o n d i t i o n w a s a deficiency disease, a or w e t b e r i b e r i . REFERENCES Strauss, M. B. : The etloIogy of "a]cohollc'" Polyneurltis. A m . J. Med. Sci., 189, 378, 1935. 2. McCollum : The N e w e r Knowledge of Nutrition. Macmillan Co., N. Y., 1922. 3. Kobayashl, Y. : Communication on the study of edema in beriberi. Prom in Med., 12, No. 11, 1923. Abs. in Jap. Med. World, 4:13, 1924). 4. Schigeari, A., Okamato, Y., and Taklmoto, S.: The a m o u n t of albumin in the serum of the beriberi patient. Med. News of J a p a n , No. 1011, 1923. (Abs. Jap. Med. World. 3:165, 1923). 5. Nakazama, F.. Sekl, I., and Inawashiro, T. : Colloid-Osmotlc pressure of blood in B. avitaminosis. Tohaku J. Exper. Med., 15:177185, 1930. 6. MeCarrison: The pathogenesis of deficiency disease. Indian J. Med. Res., 6:275, 1919 (Abs. 7, 167). 7. Vedder, E. B.: Beriberi and epidermic edema. Oxford Med., 4: p a r t 1, 274-300. 8. Sargent, W. S.: Beriberi. A n n . of Int. Med., 4:1340-1343, 1931. 1.

ABSTRACTS EXPERIMENTAL PHYSIOLOGY COLP, R .

Billary Duodenal Intubatlon. S. G. 0., ]Zol. 63, No. 2, pp. 157-163, Aug., 1936. In the author's opinion biliary duodenal intubation is a valuable procedure which should be applied in a g r e a t e r variety of conditions. In addition to its use in cases of stricture or division of an extrahepatic bile duct he recommends it in any case in which external billary drainage is undesirable, or one in which internal biliary drainage is imperative. Many persons become markedlv debiliated from prolonged los~ of bile. Another indication for biliary duodenal intubation is in the t r e a t m e n t of choledoehal cysts. I t seems questionable whether this urocedure is preferable in eases of stricture near the porta hepatis in which the distal segment of the duct cannot be found. The author feels t h a t it is perhaps better to transplant a firm fistulous t r a c t into the stomach or duodenum. In selecting the tube to be used the author recommends the best grade ef rubber tubing, which, at the same time, is radiopaque. While a soft and pliable tube is essential it must be sufficiently rigid to maintain its lumen against external pressure in spite of ample fenestration. The tube should be large

enough to fill the choledochus and fit snugly within the narrowed and spastic area of the papilla. It should be introduced from 8 to 10 centimeters down the duodenum and left so or anchored with a silk suture. Five figures and four case reports accompany the article. Nelson M. Percy, Chicago. MOON, V I R G I L H . , AND MORGAN, DAVID

R. Experimental Pulmonary Edema. Arch. Path., 21:5, p. 585, May, 1936. The authors have studied experimentally pulmonary edema in dogs the result of (1) muscle implanted in the peritoneal cavity, (2) burns, (3) intestinal obstruction, (4) the intravenous injection of bile and of sodium glycocholate, (5) sodium phenobarbital, and (6) histamine. The type of edema produced in the lungs by each of the above intoxicants was characterized by a protein content approximating t h a t of the blood plasma and a high specific gravity. This is in contrast to the edema occurring in nephrosis or dietary deficiencies which has a low protein content and a low specific gravity. The above form of pulmonary edema results from increased vascular permeability and is accompanied with hemoconcentration (as much as 30 per

cent increase, in some instances, of red blood cells per cmm. and grams of hemoglobin per 100 c.c. of blood) and with circulatory inefficiency. The mechanism of such edema is integral with t h a t of the shock syndrome. The degree of edema found is less when a f a t a l shock develops rapidly, but when a few days elapse before death occurs it is found to be extensive and a common type of terminal pneumonia is found with it. The acute congestion which precedes this type of edema as an accompaniment of shock resembles in appearance p~ssive congestion. Its differentiation from the latter is to be discussed in a subsequent report. N. W. Jones, Portland, Oregon. GAITHER, ERNEST H.

Recent Advances {n Gastro-entcrology: Chairman's Address. J . A . M. A., Vol. 107, pp. 559-552, Aug., 1936. One of the most stimulating recent publications is the monograph by F a b e r , in which he clearly sets forth his own views and those of other eminent authorities as to proofs of the presence and frequency of both acute and chronic gastritis. He has tried to show the reIationship of acute and chronic g a s t r i t i s to superficial and deep ulcerations; chronic gastritis and its tendency to

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precede ulcer and carcinoma; and the relationship which hyperacidity and anacidity bear to these conditions. Bloomfield and Polland published a monograph termed "Gastric Anacidity" which reports their research work on the secretory function of the stomach. Castle's demonstration of the etiology of pernicious anemia is undoubtedly one of the most brilliant contributions of recent years. Hollander has also done some work concerning the composition of gastric juice. Greengard, Maison and Ivy have isolated a substance known as enterogas-

trone, which inhibits gastric secretion and motility in the dog. Dragstedt has written an article on acute dilatation of the stomach which is valuable to internist as well as surgeon. Rehfuss has written "Medical Treatment of Gall Bladder Disease" while Lyon has done valuable work on gall bladder drainage. The flexible gastroscope has been introduced and is expected to greatly increase the knowledge of gastric pathology in a few years. Clasen and Eusterman have recently published some very excellent work on syphilis of the stomach.

T h e Emulsion of Agar Agar and Mineral Oil s e r v e s a s a n efficient a n d p r o t e c t i v e c a r r i e r f o r t h e p r o d u c t s o f Brewers Yeast i n c l u d i n g t h e Enzymes, invertase and zymase.

The catalytic activity of the Enzymes of Brewers Yeast in the intestinal tract tends to develop a beneficial bacterial field with a definite inhibitory effect on harmful proteolytic bacteria. Normal peristalsis is restored and regular bowel movements re-established, with feces formed soft and bulky. Evacuation results from natural impulse without gripe, strain or irritative stimulation. R i c h in Vitamins B - G o f Brewers Yeast, t h e i r r i c h e s t k n o w n n a t u r a l source. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

T h e m e r i t of Z y m e n o L h a s b e e n a b u n d a n t l y d e m o n s t r a t e d . , ,,

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Gastro-intestinal pain has been ably dealt with as regards localization, genesis, and probable pathways, by such men as Christensen, Boyden, Rigler and Rivers. Rowe, Duke and Vaughan have made splendid progress in allergic manifestations and gastrointestinal disease. The etiology of gastric ulcer is still in the theoretical stage, while Sipoy and Smithies have done much in the treatment of the condition. Sara Jordan has done excellent work in the treatment of peptic ulcer. Miller and Gray have done work on the intubation of the small intestine and have studied the influence of organic and inor~.anic acids on the motility of the small intestine. Crohn presents a splendid piece of work, "Regional Ileitis" claiming the discovery of a new disease entity. Felsen claims that this condition and chronic idiopathic ulcerative colitis are the end results of bacillary dysentery. Bar~.en claims that ulcerative colitis is due to a sgecific organism and reports successful treatment with vaccines and serum. Sullivan has also studied the psychogenic factor related to ulcerative colitis. Ivy has isolated cholecystokinin, a substance which has a specific action on the gall bladder. The function of the liver may be studied by such tests a~ the van den Bergh, coagulation time, sedimentation, galactose tolerance, bronlsuIfalein, rose bengal, TakataAra, and the hippuric acid test. The Enzyme Committee of the American Gastro-enterological Association presented various reliable methods for the study of enzymatic activity. They came to various conclusions, too numerous to enumerate in this brief review. The effect of a diet rich in carbohydrate has been shown by L. R. Brown to bear some relation to the etiology of migraine. Dr. Madge T. Macklin has emphasized and demonstrated the importance of hereditary factors in gastro-intestinal disease. Many advances have been made in radiologic diagnosis of gastro-intestinal disease, among the most important ~f which is Kantor's "Colon Studies" and Schotzki's work on the diagnosis of small ulcerative lesions and the gastritides. Cholecystography has also been greatly improved by the use of an oral dye. Excellent work has also been done in anomalies of the esophagus, especially the congenitally short type. Francis D. Murphy, Milwaukee. BLANKENSTEIN, M. A., AND RICHARDS, C.E. Garlic Breath Odor. J. A. M. A., Vol. 107, pp. 409-410, Aug. 8, 1936. The fetid odor that persists for many hours on the breath of one who has eaten garlic or onions has been thought to be due to substances which pass into the blood stream during digestion.

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Recently work was published which indicated that the odor might arise from particles of onion or garlic retained in the structures of the mouth. Because of the controversy caused by the aforementioned theories, the following experiments were carried out. Garlic in one form or another was fed to three patients, one who had a gastrostomy fistula because of a carcinoma of the esophagus; another who had a tracheotomy fistula because of a cancer of the l ar y n x ; and the third, a boy who

had a tracheal fistula because of a stricture of the larynx. In all of these cases the odor of garlic appeared on the breath, and in none of the cases was it due to the particles left in the mouth. When chloramine was given as a mouth wash, the odor disappeared for only thirty to sixty minutes. F r o m the above results, the conclusion was reached that garlic breath odor is due to substances carried in the blood. Francis D. Murphy, Milwaukee.

REMOVES the D A N G E R in RESTRICTED DIETS Pointing to the fact that one of the causes of vitamin deficiency diseases are restricted diets, and that many cases therefore have specific needs for both vitamin and mineral protection, Charles L. Hartsock, M.D., in his recent paper, "The Role of Deficiency Disease in Diseases of the Gastrointestinal Tract" (Review of Gastroenterology, ~:111, 1936), states: "In practically every disease or functional disturbance of the gastrointestinal tract, some type of restricted diet is prescribed by the physician or voluntarily observed by the patient." Restricted diets indicated in intestinal ulcers, diabetes, obesity, kidney, liver, gastric and many other disturbances, often contribute to the onset of deficiency diseases because of the limited intake of food. Complications develop in these cases which may be more serious than the original ailment. Dr. Casimir Funk (Father of Vitamin Therapy) and Dr. H. E. Dubin, (his collaborator), after years of extensive nutritional research m.ake available to the profession

VI- S Y N E R A L containing the important health-giving factors that are absent in the average restricted diet, viz. all the food Vitamins, A-B1-B2(G)-C-D-E, and the Essential Minerals, Calcium, Phosphorus, Copper, Iron, Iodine, Manganese, Magnesium, Zinc. VI-SYNERAL contains scientifically balanced potencies in safe and sound dosage. It is without bulk, calories, non-irritating, non-allergic. Nutritional deficiencies are multiple and should be treated with multiple vitamin and mineral therapy. ¥I-SYNERAL removes this great danger in restricted diets by supplying the essential elements. Literature, samples and a 100-page book entitled "'Vitamin and Mineral Therapy" By Casimir Funk, Sc.D., Ph.D. and H. E. Dubin, Ph.D. available on request.

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SCHIODT, E. Blood Regeneration in Patients with Hematcmesis or Melana from Peptic Ulcer, Treated with the Usual Ulcer Cure and with the Mentengracht Treatment. Amer. Jour. Med. Sci., p. 163-167, Aug., 1936. In July, 1931, Melengracht altered the treatment of patients with hematemesis or melena in this department. Previously such patients were given the usual "ulcer cure." Instead of waiting about four weeks for the establishment of the "puree diet," he gave it from the first day of admission, which often meant the first day of bleeding. This is a well balanced diet which includes meat, fish and vegetables, fruit, potatoes, in fact all sorts of food, finely minced in the form of force meat, mashed potatoes, pureed vegetables, f r u i t soups, jellies and so on. Lactate of iron and an aperient such as cascara were also given. A careful comparison study was made of 10 patients on the old "ulcer cure" and 10 patients on puree diet and iron. The patients on "ulcer cure" regenerated both red blood cells and hemoglobin much more slowly and less completely than did those on the puree diet and iron. In the latter cases the red blood cells and hemoglobin rose more nearly together, the color index being higher about 1., than in the ulcer cure group. The cases starting with r.b.c. 2.5 million and hgb. 50% on a puree diet with iron showed a rise in 30 days to 4 million red blood cells and 80% of hemoglobin, whereas, those on ulcer cure, with the same start reached only about 3.2 million r.b.c, and hemoglobin 55% in 30 days; a low color index all the way. The patients on the more abundant diet felt subjectively better and t h ei r clinical improvement was obvious to both doctors and nurses. Allen Jones, Buffalo. SYDENSTRICKER, V. P., ARMSTRONG, E. S., DERRICK, C. J., AND KEMP, P. S. On the Existence of an Intrinsic Deficiency in Pellagra. Am. Jour. Med. Sciences, p. 1-9, July, 1936. Method. Five patients were maintained on the original GoldbergerWheeler pellagra-producing diet to which was added 25. gm. of f a t salt pork. Gastric juice was obtained from normal medical students and from patients with no gastro-intestinal disease. To obviate the probability of increased gastric digestion of food, all doses of gastric juice were administered i_- the evening some 4 hours after the evening meal. A f t e r reporting 6 cases in detail the authors suggest t h a t there is an intrinsic factor present in normal gastric juice which makes possible the utilization of minimal amounts of extrinsic factor. (B2). Prolonged remission in two instances indicates t h a t this intrinsic factor may be stored in the body. The hypothesis is advanced that in

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pellagra there is an intrinsic deficiency ROENTGENOLOGY of variable degree. Some retain enough JENKINSON, E. L. to recover on diets grossly deficient in Cholecystography. J. A. M. A., Vol. Vitamin B~; others regenerate it in the 107, pp. 755-757, Sept. 5, 1936. presence of an abundance of the extrinsic factor while some are totally Cholecystography, as brought forth lacking in it but may recover under by Graham, Cole and their co-workers, substitution therapy or die of nervous is quite generally accepted in determor cardiac damage inflicted before ining whether or not the gall bladder is therapy was started. Further, the in- functioning normally. When done under trinsic factor is exhausted or cannot be the proper conditions, namely cooperaregenerated during prolonged depriva- tion and control of the patient, there is tion of extrinsic factor. practically no diagnostic procedure Allen Jones, Buffalo. more accurate.

In Diseases of the Liver and Gall Bladder

The patient should not be allowed to take any f a t t y food from the time of the ingestion of the dye until the films are obtained. The patient should also b~ instructed not to move during the exposure. Slight movement may frequently obliterate a normal gall bladder shadow. Cholecystograms were m a d e on ninety-five patients; forty-nine were females and forty-six were males. The average age was forty-two years, and all had gall bladder symptoms. Seventy of these were normal, twenty-two were pathological and three patients failed to retain the dye. Of the twenty patients with a pathological response, eight or forty per cent showed a normal response after being treated medically with a high f a t diet and dehydrochloric acid; two showed a normal response with stones in the gall bladder, and four showed a poor response with stones in the gall bladder; five showed no response on two or more occasions; one showed a normal response followed by nonfilling; and two showed variable responses. From these results the conclusion was reached that operative intervention is not indicated unless one or more negative responses occur after medical treatment. Francis D. Murphy, Milwaukee. COLLINS, E. M., AND ROOT, J. C.

Ii

I

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V

I C H Y Celestins is invariably prescribed in the important dietetic management of diseases of the liver and gall bladder, in the acute stages as well as when convalescence sets in. For such cases, in particular, its benefits have long been recognized by physicians the world over.

Elimination of Confusing Gas Shadows During Cholccystography. J. A. M. A., Vol. 107, No. 1, pp. 32-33, July 4, 1936. Cholecystographic interpretation is most frequently confused by the presence of gas in the right side of the gastro-intestinal tract. Enemata have been tried as a means of abolishing this condition, but results have been poor. Because of this, pitressin has been tried in doses of one ampoule (10 pressor units) in those cases in which confusing shadows appeared in the right side of the abdomen. Additional eholecystograms are taken forty-five to sixty minutes after the pitressin has been given. Effective results were obtained in 82 per cent of the seventy-three cases; 75 per cent of the patients had one or more stools within 45 minutes of the injection and almost all the patients had mild, crampqike abdominal pains. In some of the cases there was a drop in blood pressure, in some no change and in others a moderate rise. Francis D. Murphy, Milwaukee.

THERAPEUTICS STEIGMANN, FREDERICK, AND SINGER, HARRY A.

Spontaneous Pneumothoraz Simulating Acute Abdominal Affections. Am. Jour. Med. Sciences, July, 1936. Among the abdominal symptoms of thoracic disease, those of lobar pneu-

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monia, acute fibrinous pleuritis, coron- of spontaneous pneumothoracic simuary thrombosis, acute fibrinous peri- lating primary abdominal disease in carditis closely resemble, at times, the tbe medical periodical literature. The "acute surgical abdomen." Disease of authors observed three cases and atthe abdominal structures may be simu- tribute their detection to frequent related by osteomyelitis of the thoracic sort to the Roentgen ray in questionable vertebrae, intercostal neuralgia, etc. abdominal conditions. The cases found Acute cardiac decompensation with sud- in the literature are described and then den hepatic engorgement, ruptured or author's cases. In comment, attention dissecting thoracic aneurism, pulmonary is directed to the difficulty of diagnosis infarct, acute mediastinitis and spon- because intense abdominal pain, nausea taneous r u p t u r e of the oesophagus and vomiting, associated with tendermay mimic p r i m a r y abdominal disease. ness and rigidity which were present in The authors found only four reports the cases recorded, constitute a syn-

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drome which generally demands immediate laparotomy. The error of regarding a sudden pneumothorax as an abdominal lesion can almost invariably be avoided, the authors write, by a careful chest examination of each patient with an atypical picture of abdominal disease. The Roentgen ray is of extreme importance. A small amount of free air is difficult to identify unless fluid is simultaneously present in the chest cavity. Sudden pneumothorax simulates ruptured peptic ulcer so Roentgen r a y serves a double purpose. Many years ago I read a paper at a meeting of the American Medical Association entitled "Abdominal Symptoms of Thoracic Disease" so this valuable contribution by the above authors interests me very much. Allen Jones, Buffalo. BRODY, HENRY, AND SMITH, L. W.

The Visceral Pathology in Scarlet Fever and Related Streptococcus Infections. Am. Jour. of Path., 12:3, p. 373, May, 1936. The authors present a study of the visceral pathology in scarlet fever and related streptococcus infections. I t is based upon the histological examination of material from 44 frank cases and 15 presumptive cases of scarlet fever. They believe the underlying lesion is one of vascular i n j u r y with a concurrent, perivascular round cell infiltration. These lesions were found widespread throughout the visceral organs, particularly constant in the hearts, livers, kidneys, adrenals and spleens of these cases. They believed the lesions were probably due to a circulating toxin, for in no instance were they able to demonstrate microorganisms in stained sections. I n most of the cases hemolytic streptococci were obtained in blood and tissue cultures. The interstitial mononuclear lesion is not considered specific for scarlet fever. It is seen in other infectious diseases when associated with streptococcic infections, notably diphtheria and measles, although less widely disseminated and less frequently found than in scarlet fever. Its frequency in many organs in scarlet fever, however, and the similarity of its appearance in the various organs, suggest the fundamental importance of the lesion in the pathology of this disease. N. W. Jones, Portland, Oregon.

STRAUSS, ALFRED A., STRAUSS, SIEGFRIED F., AND STRAUSS, ~.ERMAN A. A New Method and End-Results ~n the Treatment of Carcinoma of the Stomach and Rectum by Surgical Diathermy (Electrical Coagulation). South. Surg., 5:348-359, October, 1936. Seventy-three cases of carcinoma of the rectum and three of carcinoma of the stomach were treated by surgical diathermy. Twenty-three of the rectal

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AMERICAN JOURNAL OF DIGESTIVE DISEASES AND NUTRITION cases had preliminary colostomy established. All three stomach cases had a jejunostomy done for the purpose of feeding during the course of the treatment. The rectal growths were accessible through a proctoscope. Since the stomach must be kept open for an interval of three to six weeks to allow the proper time interval between the two or three necessary treatments temporary closure is obtained by the use of a zipper or a rubber patch. The progress of the pathological lesion in its response to this type of treatment is described in some detail. There is first excavation, then appearance of edematous jellylike tissue, absorption of this tissue, and connective tissue formation with occasional contraction but usually softening of the tissue. The excellent results reported are attributed by the authors not only to the simple mechanical destruction of the cancerous tissue but also to the liberation of certain substances which are absorbed in the body in general. These substances are believed to stimulate the reticulo-endothelial tissues and macrophages which not only prevent further growth but also help to destroy the growth present. These effects seem applicable to the regional lymph nodes and probably the liver as well. It is interesting to speculate upon the possibilities suggested by this type of treatment and the reaction obtained in malignant cells. J. Duffy Hancock, Louisville.

ABDOMINAL SURGERY

He also INTERNAL

needs EXERCISE

WITH m i l l i o n s of m e n , golf, r i d i n g a n d o t h e r f o r m s of exercise are a d a i l y r i t u a l . I n fact, as doctors k n o w , t h e y m a y o v e r d o it. Yet these same m e n eat m e a l s t h a t fail to give t h e i r systems p r o p e r exercise, m e a l s t h a t m a y l e a d to c o m m o n c o n s t i p a t i o n d u e to insufficient " b u l k . " F r u i t s , vegetables a n d b r a n are t h e best sources of " b u l k . " B u t e x p e r i m e n t s h a v e i n d i c a t e d t h a t , w i t h some i n d i v i d u a l s , t h e " b u l k " i n fruits a n d vegetables is l a r g e l y b r o k e n d o w n i n t h e i n t e s t i n e s . So b r a n is o f t e n m o r e effective. K e l l o g g ' s ALL-BRAN is a n e x c e l l e n t source of gentle " b u l k . " Scientific tests show t h a t it is safe a n d effective. W i t h i n t h e b o d y , this " b u l k " a b s o r b s m o i s t u r e , a n d f o r m s a soft mass. G e n t l y this exercises a n d s t r e n g t h e n s i n t e s t i n a l muscles, a n d cleanses t h e system. ALL-BRAN also s u p p l i e s vitam i n B and contains iron. T h i s n a t u r a l l a x a t i v e food m a y b e served as a cereal w i t h m i l k or c r e a m , or cooked i n t o appetizing muffÉns, b r e a d s , etc. I t is sold b y all grocers. Made b y K e l l o g g i n B a t t l e Creek.

PRIESTLEY, J. T., AND •CCORMACK, C. J'. Generalized Peritonitis Secondary to Rupture of the Appendix. With Special Reference to S e r u m Therapy. S. G. 0., VoL 63, No. 5, pp. 675-680. In the treatment of acute appendicitis the authors prefer the Ochsner type of treatment for those cases with generalized peritonitis. Immediate operation is favored in all cases in which rupture has not occurred, and in certain cases in which rupture has occurred. If r u p t u r e has occurred recently, and peritonitis is not advanced, operation is performed, but extreme care must be taken to prevent spreading the infection. If r u p t u r e occurred remotely, and the process seems to be held in check by the patient's natural defense mechanism, operation may be deferred until localization is completed. Operation may be advisable if a local peritonitis tends to become generalized while under medical management. If operation is performed in the presence of peritonitis, drainage should be instituted, and appendectomy may or may not be performed. If the appendix may be removed without t r a u m a tizing the already inflamed structures it should be done, but if it is not readily accessible it should be left in place and removed at a later date. Routine bacteriologic studies in cases of appendicitis reveal a great variety of organisms. Most commonly aerobic cultures yield Escherichia coli and others, while anaerobic cultures yield Clostridium wetchii and others. The theory has been advanced that the anaerobic organisms create a more favorable environment for the growth of streptococci and other aerobic organisms which are commonly considered to be the lethal organisms in peritonitis. On the basis of those observations Weinberg has prepared three serums to be used as an adjunct to the surgical or medical treatment of acute appendicitis with peritonitis. The first is a polyvalent serum for the anaerobes commonly found in these cases. The second is a colon bacillus serum, while the third is a serum to combat any other organisms present. The authors have used these sera in a number of cases, and are of the opinion that the method offers some hope of reducing the mortality of peritonitis secondary to rupture of the inflamed appendix. Certain of their patients, they believe, have been benefited materially from this serotherapy. They recommend adequate doses given preferably within 24 hours of the onset of peritonitis. It is of value in more

802

AMERICAN JOURNAL OF DIGESTIVE DISEASES AND NUTRITION

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advanced cases also. They use 40 cubic centimeters of the polyvalent anaerobic serum, and 30 cubic centimeters of each of the other two, as an initial dose, and subsequent amounts as indicated. Three tables and a bibliography accompany the article. Nelson M. Percy, Chicago.

STEINBERG, M. E. The Surgical Treatment o/ Deep Seated Non-Resectable Ulcers of the Duodenum. S. G. 0., Vol. 63, No. 5, pp. 625-631, Nov., 1936. The author describes a new method of surgical treatment of deep seated ulcers of the duodenum. Proper and successful application of the method depends upon a thorough understanding of the principles involved and the technic employed. In certain cases in which anatomical anomalies or changes resultant from old inflammatory processes make the application of this method unsafe, the modified Finsterer exclusion operation may be performed. In the author's technic the stomach is divided three finger breadths proximal to the pylorus and the proximal portion reflected to the left out of the way. Through the pylorus the duodenum is palpated, the ulcer located and its size determined. The anterior wall of the duodenum is now incised transversely along a line j u s t proximal to the proximal border of the ulcer and reflected distally. A flap of the anterior duodenal wall sufficiently large to invert and cover the entire ulcer must be obtained; if this is not possible without tension, the duodenum would be closed and the modified Finsterer operation performed. The ulcer is now cauterized with phenol and alcohol, and the mucosa removed from its edges by means of a small currette. The free margin of the anterior duodenal wall is now sutured to the distal margin of the ulcer. Another row of sutures is now placed through the proximal m a r g i n of the ulcer and the serosa of the anterior duodenal wall inverted over the ulcer. The ulcer is thereby covered. The posterior duodenal wall and a portion of the posterior wall of the stomach from which the mucosa has been removed is now reflected over the closed duodenum and sutured in place. Finally the capsule of the pancreas is sutured to the closed end of the duodenum. The author has used this method in three cases and recommends it because it precludes any i n j u r y to the common duct, pancreatic ducts, pancreas, or the blood supply of any of the structures involved. Eight figures and a bibliography accompany the article. Nelson M. Percy, Chicago. BRUNN, H. Acute Pelvic Appendicitis. S. G. 0., Vol. 63, No. 5, pp. 583-592, Nov., 1936. In an attempt to bring forcibly to the minds of the profession a certain form of atypical appendicitis in which the appendix is placed either on the brim of the pelvis, or deep in the pelvis, the author reports in detail several such cases and discusses some of the diseases which are most likely to be mistaken for it. The most constant symptom is pain which, at the onset, does not differ particularly from that of any appendiceal attack. When localization takes place, it is more frequently on the left side than the right side in this type of appendicitis. Vomiting may or may not occur. Diarrhea may accompany the onset. Physical findings are atypical of appendicitis; there may be no tenderness even on deep palpation and no rigidity. The temperature may be normal. Irritation on urination is frequently a symptom which must be brought out on direct questioning. Examination of the urine will frequently show the presence of red blood cells when the appendix lies against the bladder or a ureter. The blood count, which is important, is usually high, 15,000 to 20,000, with a high polymorphonuclear

804

AMERICAN JOURNAL OF DIGESTIVE DISEASES AND NUTRITION

CLINICAL BACKGROUND

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PEPTIC ULCER Creamalin was released to the medical profession because of repeated demands by physicians who were acquainted with the results obtained when the product was in the investigative stage, several years ago. Subsequent usage in thousands of cases by competent clinicians has substantiated the early findings, and still more work is piling up further evidence. On the basis of clinical results, Creamalin merits the clinical consideration of every physician who has occasion to treat gastro-duodenaI ulcers. The producers will be pleased to supply a sufficient quantity of Creamalin for a critical clinical evaluation of this product, either by oral administration, or by the continuous drip method using the new Creamalin Automatic Drip Control. Correspondence is invited.

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count. Rectal examination, properly done and repeated once or twice daily, will reveal tenderness in those cases in which the appendix is low in the pelvis. During the second 24 hours there is a gradual rise i n the temperature, the polymorphonuclear count will rise, and if a Schilling count is made a distinct shift to the left will be seen. If the disease progresses to rupture, the signs typical of an intra-abdominal calamity supervene. The sedimentation rate which is markedly hastened in cases of salpingitis is the best differential point between the two conditions. Bleeding from a ruptured ovarian follicle presents a variable and changing picture. Roentgenograms will aid in differentiating ureteral calculi from pelvic appendicitis. Two tables and some illustrative case reports with individual discussion accompany the article. Nelson M. Percy, Chicago.

CHRISTOPHER,F. Intussusception in Adults. pp. 670-674, Nov., 1936.

S. G. 0., Vol. 63, No. 5,

The author reviews the literature on intussusception in adults and reports two new cases. The etiologic agent most commonly recognized has been a tumor, either benign or malignant. I n adults the symptoms are usually those of acute intestinal obstruction, but they may simulate cholecystitis or peptic ulcer. One case of chronic ileocecal intussusception, and one of high j u j u n a l intussusception due to a papillary adenoma, are reported. Three figures and a bibliography accompany the article. Nelson M. Percy, Chicago. WOLFSON, W. L., AND ROTHENBERG, R. E.

A Simple Method of Amputating Exteriorized Bowel with the Carr Hilar Lobectomy Clamp. S. G. 0., VoL 63, No. $, Oct., 1936. In order to avoid the occasional complications following the secnod stage Mikulicz operation, the authors use and recommend the use of the Carr hilar lobectomy clamp. I t is applied at the bedside about 36 hours after the operation, and usually falls off, or may be cut away, after 4-5 days. A small incision may be made in the distended bowel and a catheter inserted to allow gas and fecal matter to escape when distention becomes marked. I n the author's series of 5 cases no instance of hemorrhage, peritoneal infection, or other complications has developed because of the use of the Call clamp. Three figures illustrating the use of the clamp accompany the article. Nelson M. Percy, Chicago.

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S. G. 0., Vol. 65,

The author reports the appendicitis experience since 1920 of a 42 bed hospital in a small community. A total of 602 cases of acute and purulent appendicitis were treated there during t h a t time. The mortality rate was 2.98 per cent for total cases, 0 per cent for chronic, 3.4 per cent for acute and 15 per cent for purulent. Since 1930 it is still lower, viz., 2.1 per cent for total cases, 2.25 per cent for acute and 13.4 per cent for p u r u l e n t cases. The Battle-Kammerer technique is followed; the stump of the appendix is inverted only in gangrenous cases. Drainage was employed in all pus cases. Ileostomy in the author's opinion should be used only as a secondary procedure but should be done before the small bowel is completely paralyzed. Cecostomy was not used in any case. In the postoperative management the author feels t h a t patients in small hospitals receive better treatment because they are seen by the surgeon rather than an interne. Sufficient fluid to keep the tongue moist, and repeated transfusions in seriously sick patients, are advised. For

806

AMERICAN JOURNAL OF DIGESTIVE DISEASES AND NUTRITION

Authorities agree that choie. retics, whether bile salts or bile acids, are not chola. gogues (they do not stimulate gall bladder evacuation).* The effective and proven chola. gogues are fats and fatty acids.**

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postoperative distention pituitrin or pitressin are employed. If these fail, a duodenal tube is employed and small amounts of hypertonic saline are instilled into the stomach at 3 hour intervals. The author concludes that in the treatment of appendicitis the small hospital is superior to its larger brother in the city in that the patients are attended by staff members and graduate nurses rather than internes and student nurses respectively. Nelson M. Percy, Chicago.

ANNOUNCEMENT B U R E A U OF H U M A N HEREDITY 115, Gower Street, L o n d o n , W . C. I,

England. The object of this Bureau is collection on as wide a scale as possible of material dealing with human Genetics. Later, the tasks of analysis of material and distribution of the information available will be added. The Bureau is directed by a Council representing medical and scientific bodies in Great Britain. It is affiliated to the International Human Heredity Committee, which insures co-operation in all areas where research is proceeding. The Counci] would be grateful to receive all available material from Institutions and individuals, furnishing well-authenticated data on the transmission of human traits whatever these may be. Pedigrees are particularly desired; twin studies and statistical researches are also relevant. As research workers and others who send in material may in some cases wish to retain the sole right of publication (or copyright) those who so desire are asked to accompany their material with a statement t:o that effect. Material should be given with all available details in regard to source, diagnostic symptoms and the name and address of the person or persons who vouch for accuracy. All such details will be regarded as strictly confidential. Reprints of published work would be most acceptable. Further, many authors when publishing material may also have collected a number of pedigrees which they have been unable to reproduce in detail. It is the object of the Council that such records, by being included in the Clearing House, should not be lost. Those wishing for a copy of the Standard International Pedigree Symbols may obtain one from the office. Announcement in regard to the services undertaken by the Bureau will be published from time to time. C h a i r m a n : R. Ruggles Gates. Executive Committee: R. A. Fisher, J. B. S.

Haldane, E. A. Cockayne, J. A. Fraser Roberts, L. E. Halsey (Hon. Treasurer), C. B. S. Hodson (Hon. Gen. Secretary).

808

AMERICAN JOURNAL OF DIGESTIVE DISEASES AND NUTRITION

NEUTRALIZES Without Alkalizing Stomach Contents T R I - C A L S A T E is a buffered neutral antacid that neutralizes HCL without stimulating gastric secretion or alkaliz: ing the stomach contents. For the distressing symptoms of peptic ulcer, heartburn, hyperchlorhydria, etc., TRI-CALCATE provides rapid relief without harmful systemic effects. NOW available in a new economy size. The large size bottle has been increased from 16 to 18 oz. at no increase in price, making in effect a 10% reduction in price to the patient. T R I - C A L S A T E may be obtained on prescription at your pharmacy or direct in 4 oz. and 18 oz. bottles.

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CLUTE, I-I. M. or lower thoracic regions of the epophaThe Problem of Cancer of the Pan- gus. Preliminary gastrostomy or jejcreas. J. A. M. A., Vol. 107, pp. unostomy is done in all cases. In cases of carcinoma of the cervical 91-97, July 11, 1936. Recently the surgical removal of portion of the esophagus with involvesmall tumors from the pancreas and ment of the hypopharynx and the tubtotal pancreatect0my has been re- larynx, complete extirpation of those ported. These procedures were carried structures, with their lymph nodes, is out because of hyperinsulinism and re- the operation of choice. That may be accomplished in a one stage or a two sults have been satisfactory. stage operation. In either case the Cancer of the pancreas is not a rare disease, constituting 4.8 per cent of the esophagus and trachea open externally. The tracheatomy is permanent but the cancer deaths in Massachusetts hoshypopharynx may be reconstructed pitals in 1928 to 1930. On the whole it later. constitutes about 3 per cent of all In cases of carcinoma of the thoracic cancer deaths in the United States. The tumor is most frequently located portion of the esophagus, devised and first performed by Torck, has been folin the head of the pancreas; some are diffuse, and a few are limited to the tail lowed with the greatest operative suc....cess It is a transpleural procedure in of the organ. They are generally adenocarcinomas, but scirrhous forms do oc- which the esophagus is diveded below the tumor and both ends closed, after cur. They metastasize in the usual ways, usually very early. Metastasis is which the tumor is delivered through a separate incision in the neck. If the t~ the regional lymph nodes, liver, lungs and pleura. The tumor as it grow~ may patient survives the operation a rubber produce obstruction of the common bile tube may be used as an esophagus or a subcutaneous esophagus may be reconduct and rarely hyperinsulinism and structed on the anterior chest wall. disturbance of intestinal digestion. In cases of carcinoma of the lower The earliest symptoms of cancer of the pancreas is a dull, boring, epigas- esophagus and cardia resection of the tric pain, digestive distress, epigastric tumor mass and esophagus, gastristomy fullness, abdominal distention, and a m.ay be done through an abdominal insevere loss of weight in a short period cision or through an abdominothoracic of time. Rarely the first symptom is approach as described by Kirchner. Twenty-three figures and a bibliothe onset of jaundice, but usually this, graphy accompany the article. with a palpable tumor in the epigasNelson M. Percy, Chicago. trium, are signs of advanced conditions. The diagnosis depends upon the abPACH, G. T., AND SCHARNAGEL,1. M. sence of lesions in the gastro-intestinal The Technique of Gastric Resectract, and the gall bladder as estabtion f o r Carcinoma. A critical Relished by X-ray, with the presence of view. S. G. 0., Vol. 63, No. 2, pp. the aforementioned symptoms. 189-197, Aug., 1936. Treatment of the condition is most The authors review the history of likely to be successful with surgery, although X-ray and r a d i u m have been gastric resection for carcinoma and foltried with v a r y i n g degrees of success. low the developments in technic from Desjardins and Suave, in 1907 and 1908, the original Billroth I and Billroth I I advocated a biliary intestinal anasto- procedures up to those now widely masis, a resection of the head of the used. The first modifications were made gland and the duodenum, a reuniting of by Schoemaher, Kocher and Habererintestinal continuity, and finally the in- Finney. Each one possessed certain adLater sertion of the pancreas or its duct into vantages and disadvantages. the intestine. Whipple, Parsons and modifications were made by Horsley and Mullins followed this procedure except Mayo. In the author's opinion the Horthat they ligated the pancreatic ducts. sley operation possesses decided advantages over the other operations and Francis D. Murphy, Milwaukee. in the hands of its master originator is suitable f o r the majority of carcinomas "EGG~ERS,C. in the distal third of the stomach. Treatment of Carcinoma of the The Billroth I I procedure, which Esophagus. S. G. 0., Vol. 63, No. made possible the resection of many 1, pp. 54-65, July, 1936. more tumors of the stomach, has been Among the methods of palliative modified in almost every possible way. treatment of carcinoma of the esopha- The modifications proposed by Polya, f us the author mentions general medi- Balfour, Moynihan and Finsterer and cal care, in which the diet is regulated certain combinations of them are most and balanced carefully; then Gastros- widely followed today. Very little, in tomy when swallowing becomes too diffi- modern literature recommends the cult and other methods; namely, dilata- Roux, Kronlein or Mikulicz procedures. tion, intubation, radiation and electro- Sleeve resection of the stomach for coagulation in selected cases with poly- carcinoma is rarely used. I t is better peid types of growth. judgment to excise the portion of the The radical surgical treatment en- stomach distal to the superior line of counters different problems when the excision and make an intestinal anastogrowth is in the cervical, mid-thoracic mosis. Cardiectomy has been performed

810

AMERICAN JOURNAL OF DIGESTIVE DISEASES AND NUTRITION

s~ rarely that no uniform technique has been worked out. Total gastrectomy has been performed in a number of instances. The reported mortality of the procedure is 53.8 per cent. Several recent improvements in technique have been made. Moynihan's suggestion that the esophaRich in citrates, presented in palatable gus be sutured to the j e j u n u m before form. Neutralizes the toxic end pro- the stomach is removed has been widely ducts and takes the load off the kidneys. accepted and used. In rare cases it is Free from tartrates and Sodium Chlo- possible to anastomose the duodenum to ride. Available on prescription in 3 ~ the esophagus. When termino-lateral oz. bottles. Write for trial package and anastomosis between the esophagus and complete literature. j e j u n u m is effected a complementary enteroanastomosis should always be Granular clone between the ascending and deEffervescent scending limbs of the jejunal loop. A bibliography and five figures ac company the article. Nelson M. Percy, Chicago.

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The simulation of acute abdominal disease of a surgical nature by common and uncommon thoracic affections with referred pain and by lesions of the spine and spinal nerves is well known. No reference to pneumothorax simulating the "acute abdomen" was found in the American textbooks or systems of surgery, or in treatises dealing with abdominal or thoracic diagnosis, including continental sources, except by Adams, J. E. "Diagnosis and treatment of the acute abdominal disease," 2nd ed., London, Balliere, Tindall, Cox, 1923. In a careful search, only 5 references from the periodical literature since 1911 were found. Among the six instances reported therein, four spontaneous pneumothoraces were erroneously diagnosed primary abdominal disease. The writers believe that the reported incidence of spontaneous pneumothorax simulating abdominal disease is lower than the actual because of their having seen three such Datients in whom they made a correct diagnosis in a relatively short time. A summary of four previously re~nrted cases and a more detailed account of their own three follows. Authors comments: Sudden pneumothorax furnishes difficulties in differential diagnosis from the acute abdomen, because the clinical picture of sudden rupture of the lung may be chiefly abdominal. Intense abdominal pain, nausea and vomiting, associated with tenderness and rigidity usually involve a decision as to immediate laparotomy. In four of eight reported cases a history of previous gastro-intestinal disturbance complicated the picture. The thoracic manifestations present in pneumothorax may be associated with acute surgical abdominal affections i.e. sudden pain following violent exertion, reference of pain to the shoulder region,

dyspnea, collapse and assumption of the sitting position with the knees drawn upwards. E r r o r in diagnosis may be avoided by 1. Awareness of the symptom complex in pneumothorax. 2. Careful chest examination in atypical abdominal disease pictures. The detection of a pneumothorax requires expert physical examination. 3. Close attention to the abdominal examination, which may disclose the difference between the hyperesthesia of referred pain and the tenderness of abdominal disease. 4. Suspecting pneumothorax if a history of previous chest disease, especially tuberculosis, is obtained. 5. Routine roentgen examination. This is extremely valuable and quickly done. Unrecognizable and atypical pneumothorax, especially if partial, can best be detected by X-ray and on the film better than fluoroscopically, the latter especially when no pleuritic fluid is present. The exposure should be made at the height of forced expiration, when the pneumothorax becomes most apparent. The roentgen ray serves a double purpose, as it distinguishes a pneumoperitoneum, if present, and thereby aids in the diagnosis of ruptured peptic ulcer, which commonly needs to be ruled out because of its similar history and physical findings. Marie Ortmayer, Chicago.

SURGERY OF THE LOWER COLON AND RECTUM MAcGUIRE, D. PHILIP.

"Palliative Colostomy." 63:66-68, July, 1936.

S. G. 0.,

A recently reported mortality of 13.4 per cent in 500 cases of palliative colostomy shows that there is still much room for improvement in the handling of such cases. A new operation is described, which has for its outstanding characteristics a tongue shaped flap of skin and fascia extending medially from the center of the usual left inguinal incision, and a method of s u t u r i n g the lateral peritoneal fold to avoid subsequent herniation and obstruction. An added advantage claimed is that immediate opening of the bowel can be done. Complete details of the preoperative, operative, and post-operative treatment of these cases is to be described in detail in a future publication. Local anesthesia and cyclopropane with the McGill intratracheal catheter are the methods of choice in producing anesthesia in these poor operative risks. J. Duffy Hancock, Louisville.

APOLOGY In the November issue, the address of Dr. Victor C. Meyers was printed at Palo Alto, California, whereas the correct address should have been Cleveland, Ohio.