ABSTRACTS

ical study and observation, especially of those patients who present abdominal symptoms following the administration of cinchophen. It is urged that a roentgenologic search for peptic ulcers be made in this group of patients. That such a study may prove to be of more than academic concern and indeed of therapeutic value, is indicated by the fact that a massive hemorrhage from an ulcer may be either the direct or the contributory cause of death, as attested by the two cases under discussion. Finally, the ubiquitous usage of cinchopben or its derivatives for the relief of various algesias suggests the need of an enquiry into the history of all peptic ulcer patients relative to these therapeutic agents.

.-e,O AB3TI II

II

"'Amebiasis in Northern New Jersey." 409-413, Sept., 1933.

A m : d. Med. Sc., 186:

The authors state that in examination of stools they have been able to demonstrate cysts only in patients suffering from dysentery and have seen no healthy carriers. The symptoms of amebic dysentery are diarrhea and weakness. There is not much pain although there may be occasional colic. The stools are usually liquid, fecal in character and contain blood, The blood may be occult. The specimen should be examined as fresh as possible within a few hours after passage, preferably in a warm chamber in order to find living forms. If kept warm for some hours it may be overgrown by colon bacilli. In the cases of chronic diarrhea in which the living amebae commonly are riot found in the stool, a diagnosis is most difficult and several examinations must be made at intervals. Once the diagnosis is made, the majority of patients are promptly cured by 9 or more intramuscular injections of emetin hydrochlorid (1~ to 1 grain). In the long-standing cases with atrophic changes in the bowel wall and stool showing much pus and other evidence of secondary infection, emetin hydrochlorid is not so effective. Manson-Bahr recommends emetin bismuth iodid in these cases in doses of 3 grains per day for 10 or 12 consecutive days. In association with emetin bismuth iodid, he gives each morning an enema of 2.5 per cent Yatren (iodin-oxyquinolin-sulphonic acid) in warm water (250 cc.) The authors have used this method in one case with disappearance of cysts from the stool. It was not so successful in another instance. A high-caloric, low-residue diet as devised by Bargen and Victor in the treatment of chronic colitis was prescribed, in the behef that placing the large bowel at rest aids in the healing of the lesions. In the treatment of carriers, Craig mentions the use of emetin bismuth iodid and yatren. These drugs require that the patient be kept in bed. He found acetarson (Stovarsol) in tablets of 0.25 gm. 3 times a day for 1 week and repeated for a second week after a week's rest was effective in banishing the cysts. Five cases in New Jersey are reported in people " w h o did not go to the tropics, the tropics came to them" by way of imported fresh vegetables. "Many cases of amebic dysentery in the temperate zone result from eating uncooked contaminated vegetables." O. K. T. ROGERS, SIR LEONARD.

"'Tropical liver, hepatitis 117-123 (August) 1933.

and

abscess."

Practitioner,

SUMMARY

An instance of cinchophen poisoning associated with gastric ulcers is reported and another case is collected from the literature. The probability of cinchophen acting as the etiologic agent is suggested and discussed. Attention is directed to the need of further clinical and roentgenologic studies of the stomach and duodenum of patients who exhibit cinchophen poisoning. It is suggested that a careful anamr~esis in all peptic ulcer patients from the standpoint of cincbophen therapy might yield interesting data.

•

ASHER, MAURICE AND KRAEMER, MANFRED.

13I :

Emetine hydrochloride is most satisfactory in amebic hepatitis and is given subcutaneously or intramuscularly in 1 grain doses in adults once daily, up to a total of 12 to 15 grains only in one course, for fear of its cumulative action producing muscular paralysis of a troublesome nature. In order to lessen the danger of a relapse it is, however, advisable to follow the course of emetine injections by the oral administration of 20 to 30 grains ipecacuanha, with 10 grains of tannic acid to counteract its nauseating effect, last thing at night, three hours after a light meal, for a week with a view of eliminating the causative E. histolytica from tbe lumen of the bowel; some prefer the more drastic emetine bismuth iodide in I grain doses three times a day for a week for the same purpose. Stovarsol in 4 grain doses once daily for a week is also of value. Alcohol sbould be strictly avoided by

3[

II

ACT$

~

Oo

I

all subjects of amebic disease as it strongly predisposes to amebic hepatitis and liver abscess. The diagnosis and treatment of amebic abscess of the liver is discussed and it is noted that amebic abscess of the spleen may also occur.

O. K. T . MAGATH, T. B.

"Amebiasis.'" Proc. Staff Meetings Mayo Clinic, 8:703-705, November 22, t933. In order to diagnose approximately 100 per cent of infestation, one must examine at least six formed stools. T h e same effect will he obtained by examining three liquid stools. An excellent demonstration may be made by obtaining a smear from the base of an ulcer, through the proctoscope, for then one sees thousands of organisms in a small space, Magath has not found the culture method as satisfactory as direct examination of stools'. Magatb points out that the cysts, which transmit the infection are relatively resistant. They may exist for as long as six months in water and may pass through the gastro-intestinal tract of the common house fly without injury. Chlorine, which is so generally used for the purification of water supplies is relatively ineffectual; it takes a hundred times as much chlorine to kill the cyst of the ameba as is used in water supplies. While the ameba in the motile stage is quite readily killed, it is possible to transmit the disease by means of these forms, but the passage must be direct. Both the cysts and the motile forms are readily killed by drying and by a temperature as high as 68 degrees C. for five minutes. A. G. N. BROWN, P. W.

"'A Clinical Note on Amebiasis.'" Proc. Staff Meetings Mayo Clinic, 8:706-708, Nov. 22, 1933. Brown believes it wise to concentrate the dose of emetine hydrochloride, especially if the patient is acutely ill, by giving 3 grains (0.2 gin.) in divided doses the first day, 2 grains (0.12 gin.) in divided doses the next, and 1 or 2 grains in divided doses the third day, Emetine may be given intravenously, but results are so prompt and satisfactory with subcutaneous injection that a more hazardous method does not seem to be needed. Arsphenamine while efficient is expensive and takes several weeks for a course. Of the arsenicals, stovarsol and acetarsone have been discontinued because cases of peripheral neuritis developed. Treparsol has been used and with proper caution no serious difficulties have arisen. Carbarsoue does not seem to be superior, if as effective, as treparsol. This later drug is prescribed in tablets of 0.25 gin. with each of the three meals, for four days, and repeated for two more such courses, allowing a ten day period of rest between courses. Administration of treparsol and of emetine is started at the same time. In resistant cases in which one hesitates to continue these drugs for extended treatment, an iodine containing drug is fairly efficient. Yatren (known also as anayodin, chiniofon, and quinoxyl) is given orally, 3 gm. in divided doses, daily for a week; this treatment is repeated after an interval of a week. Vioform is given orally, 0.75 gin. in divided doses daily for ten days. Both drugs may cause diarrhea and it may be necessary to decrease the daily dose. Failure to persist in adequate and properly spaced treatment is responsible for failures. After a course of treatment stools are examined on three successive days. If negative, this test is repeated a month later and again after two or three months.

:}~

.AMERICAN J O [ ' R N A L OF I)IGESTIVE DISEASES AND . ~ t ' T R I T I O N

CHOPRA, R. N. "'Treatment of Chronic Intestinal Amebiasis with Carbarsone.'" Indian Med. Gaz., 68:315-319, June, 1933. Carbarsone ( 4 - c a r b a m e n o - p h e n y l - a r s i n i c acid) was prescribed in 31 patients suffering f r o m chronic intestinal amebiasis and 23 were cured. T h e drug was given in doses of 0.25 gm. twice daily for 10 consecutive days in gelatine capsules by m o u t h . T h e patients were kept on ordinary diet and, except a saline p u r g a t i v e whenever required to relieve constipation, no other drug was given. Five or more negative e x a m i n a t i o n s of the stools on different days after cessation of all treatment was the criterion of cure. F o u r additional patients left the hospital i m p r o v e d b u t before these tests could be made. T h r e e of the f o u r failures had the cystic form. Auto-vaccine given either preceding or along w i t h carbarsone treatment b r o u g h t about a cure in cases in w h i c h bacillary dysentery was associated w i t h the amebic infection. In one case carbarsone failed, b u t e x t r a c t u m kurchi l i q u i d u m w i t h liver extract was effective. In another, cure was effected by a course of emetine b i s m u t h o u s iodide 2 grains daily for 10 days. No u n t o w a r d s y m p t o m s occurred in the series and continuation of the drug beyond the 10 day period is being tried in patients w h o have s h o w n i m p r o v e m e n t b u t not cure in this length of time. M. E. S. DOUGHERTY, MARK S., JR., AND LEGUIN, FRANCES. "'Amebiasis." Am. d. Nursing, 3 3 : l O 1 9 - 1 0 2 4 , November, 1933. T h e n u r s i n g care, in general parallels that followed in n u r s i n g t y p h o i d fever. A t times the patient m a y have fifteen or t w e n t y stools a day and the proper care of the skin on the buttocks, back, and perineal area m u s t be given special attention. T h i s is particularly true in the severe case of amebic dysentery. T h e skin sbould be kept clean and dry a n d bland o i n t m e n t s m a y be used to lessen irritation. Accurate records of the n u m b e r a n d character of stools should be kept and it is particularly i m p o r t a n t to note a n y u n u s u a l a m o u n t of blood in the stools. T h e diet plays an i m p o r t a n t role in the treatment and consists essentially in a nutritious, low-residue, wellbalanced diet. A t first the patient m a y have a p o o r appetite a n d m a y have a moderate or severe anemia. T h e tray should be attractive a n d tbe nurse sbould see that a proper a m o u n t , of food is eaten. T h e disposal of the excreta is one of the greatest responsibilities of the nurse. T h e technic used routinely in disposing of t y p h o i d stools m a y be followed. P r o b a b l y the surest and m o s t effective way to dispose of the stools f r o m patients w i t h amebiasis is to see that these stools are burned. T h e thermal death p o i n t of the cysts is generally considered to be a b o u t 68 degrees C. Also the preparation of the stool for laboratory e x a m i n a t i o n is of importance. As the endamebae stop m o v i n g quickly on chilling, the stool s h o u l d be collected in a w a r m container and placed in the h a n d s of the laboratory technician for e x a m i n a t i o n at once. The interval of time between the passing of the stool and the e x a m i n a t i o n in the laboratory should n o t be more t h a n f r o m fifteen to thirty m i n utes. T h e convalescent care is concerned mainly w i t h adequate feeding and m a i n t a i n i n g the patient's morale. M. E, S. POINDEXTER, HELDRUS. "'The Puerto Rican Strain of Endameba Histol!ltica. Comparison of the Diagnostic Value of Direct Smear Examination and Cultivation with Pathogeniciuj Test." The Puerto Rico Journal of Pub. Health and Trop. Med., 9:31-36, Sept. 1933. One complete stool e x a m i n a t i o n of 5 6 4 individuals s h o w e d 12.4 per cent positive for E. histolytica and 46 per cent positive for E. coll. It is believed that the percentage of positives w o u l d have been increased by repeated e x a m i n a t i o n s of stools f r o m these same individuals at short intervals. W h i l e the percentage of positives for E. histolytica by direct smear e x a m i n a t i o n s alone and by cultivation were essentially tbe same, the combined m e t h o d s gave a slightly higher percentage. W h e n only the cysts are present in the stool, it is easier for the less expert laboratorian to make a differential diagnosis of E. histolytica f r o m a culture (after excystation) t h a n f r o m the direct smear e x a m i n a t i o n alone. C u l t u r a l m e t h o d s s h o u l d be more generally used, n o t as substitutes for the direct m e t h o d , b u t as a useful supplement. T h e h i g h carrier incidence in the island and a relatively l o w percentage of clinical cases of amebiasis, Poindexter explains partly on the basis of acquired i m m u n i t y . He also believes that the dietary habits of m o s t of tbe people of the Island w h i c h consist of h i g h carbohydrate diet tend to decrease the activity of the endamebae w i t h o u t retarding their rate of development or interfering w i t h the life cycle. E x p e r i m e n t a l w o r k on kittens fed on a h i g h carbohydrate diet tended to confirm this interpretation of his observations. S. S. Mc. REFD, ALFRED C. "'Amebiasis A Clinical Summary.'" 40:6-11 (Januartt) 1934.

Calif.. and Western Med.,

T h e incidence of amebiasis in California is reported as a p p r o x i mately 10 per cent of the p o p u l a t i o n . A h i g h rate noted a m o n g

house wives seems i m p o r t a n t because of the p r i m a r y m e t h o d of transmission by food handlers. In treatment clinical and laboratory evidence of hepatitis is carefully noted, and the use of arsenicals is closely guarded accordingly. Patients s h o w i n g cysts, w i t h little or no diarrhea or dysentery, are given a routine course of carbarsone orally. In the presence of motile forms, carbarsone is given rectally in addition. In cases where amebas persist, or as a p r i m a r y treatment, v i o f o r m orally is given in 0.5 g r a m dosage twice daily for ten days. T h e s e courses are alternated or repeated, w i t h intercurrent free periods of ten days for full d r u g excretion, according to persistence or reappearance of amebas in the stools. Resistant cases m a y receive, in addition, emetin h y p o d e r m k a l l y , in appropriate dosage. T h e a u t h o r is d o u b t f u l as to the actual added benefit f r o m this procedure, a l t h o u g h emetin is the drug of choice in f r a n k amebic hepatitis. T a n n i n preparations and b i s m u t h subcarbonate are used in persistent diarrheas and dysenteries" s y m p t o m a tically, combined w i t h belladonna where pain is excessive. Dietary principles in severe resistant cases include h i g h protein, s m o o t h diets, with a m i n i m u m of starch. Calcium and v i t a m i n contents are kept h i g h by use of tribasic calcium phosphate, dicalcium phosphate, and v i t a m i n concentrates, especially American wheat kernels and extract of brewer's yeast. Resistant cases, and those w i t h incurable infiltrations and cbronic ulcerative colitis, m a y require surgical treatment, consisting of appendectomy, ileostomy, pararectal a n d other procedures. Autogenous stool vaccines are of vaIue in some cases where secondary infection prevents cure. Protein shock is occasionally of use. C o l o n irrigations w i t h bactericidal solutions such as acriflavine, are helpful f o r bacterial complications, We have f o u n d a few ounces of one per cent tannic acid of s y m p t o m a t i c help where rectal bleeding is p r o m i nent. K. A. B. BOECK, WILIAAM C. "'Amebic Invasion of L~jmphoid Tissue and its Probable Clinical Significance." Ann. Int. Med., 6:1564-1547 (June) lO33. F r o m the results of cultivation of E n d a m e b a bistolytica in kittens ( 1 9 2 4 and 1 9 2 5 ) Boeck finds that there are t w o f u n d a m e n t a l kinds of amebic lesions: first, erosion-ulcers of the epithelium which m a y become deep and u n d e r m i n i n g in character, often secondarily invaded by bacteria; second, a localized abscess in l y m p h follicles, liver, lung, brain and spleen. (Pathological pictures are presented to illustrate these types.) His path61ogical observations, applied clinically, indicate that all patients in p o o r health and underweight, those w i t h nervous and physical exhaustion, and those w h o m a y be subject to recurrent attacks of arthritis and other diseases c o m m o n l y associated with focal infection, s h o u l d be t h o r o u g h l y examined for this parasite. [n the so-called carrier cases of chronic amebiasis, slight erosion-lesions of the intestinal mucosa or invasion of solitary l y m p h follicles m a y represent portals of entry for the absorption of toxins f r o m the colon. T h e bacterial toxins m a y be the more i m p o r t a n t etiologic factor in the p r o d u c t i o n of ill-health and chronic disease in such cases o f parasitic invasion. F u r t h e r investigations c n patients w i t h H o d g k i n s disease have failed to s h o w any amcbae present in the enlarged l y m p h nodes. R.M.

Amebic d!/senterg, a review. 18, 1933.

J.A.M.A.,

101:1639-1641. Nov.

A review of the literature on the subject of amebic dysentery, covering s y m p t o m s , diagnosis, complications, prognosis and treatment, is presented as a s u m m a r y of current knowledge regarding this disease. J. T . S. LUpO, MASSIMO. "'Un segno radiologico della cotite da ameba istolitica ( A radiologic sign of colitis due to Ameba histotgtica)." RadioI. Med., 20:709-715, June, 1933. T h e a u t h o r presents radiograms in f o u r cases of ameba histolitica illustrating a b u t t o n - l i k e niche, characteristic, be believes, of cases of ameba histolytica and one w h i c h he has never seen in any case of non-arnebic colitis. T h e b a r i u m o u t l i n i n g tbe deep ulcer underm i n i n g the mucosa of the intestines is the base of the collar b u t t o n and this is connected w i t h the bowel l u m e n by a short and small canal (the stem) and the ulcerated mucosa is the bead of the collar b u t t o n . T h e margins appear regular and plain, b u t observed w i t h tbe lens are fringed and anfractuous. W . H. R. FITZGERALD, G. H. "'Gaoano, a new specific for Amebic Dtlsenterg." Gaz., 68:458-459 (August) 1933.

Indian Med.

T o w h a t extent Gavano, a new synthetic preparation by Bayer, is capable of p e r m a n e n t l y eliminating the E n t a m e b a histolytica, the a u t h o r cannot say as yet; b u t in no case in his experience has it failed to relieve the s y m p t o m s of amebic dysentery, and this w i t h o u t causing the patient any of the discomforts associated w i t h any of the recognized f o r m s of emetine treatment. Nausea is u n k n o w n .

A I " N'I'R A( "I.'S

T h r o u g h its action on the medullary centers it causes a lowering of blood pressure and diminishes CO,,, elimination: this increases vagal activity and resnlts in increased peristalsis of the large intestine. B. S. H. BARROW, JOHN V. "Amebic @senterq." (January) 10~4.

Calif.

and

Western

Med,,

40:6061

Emetin, as well as arsenic, should not be used beyond their physiologic activity. E m e t i n hydrochloride given intravenously, o n e - t h i r d grain, daily the first week. repeated on alternate days thereafter for five doses, will accomplish as m u c h as the large dosage and practically insure against injury by the drug. "The same dosage twice weekly may be continued for m o n t h s , with no cumulative action. T h e liver is t h u s protected and there is less danger of relapse. Meanwhile the treatm e n t with carbarsone should start co-incidentally w i t h the emetin and be continued with one capsule each m o r n i n g and evening, for ten days only. One should be constantly on guard against arsenical saturation, which is usually first manifested by redness or itching of the skin. T h e arsenical treatment m a y be repeated in full or in part. after a ten-day interval. One repetition usually suffices to rid the patient of tropozoites and cysts. W a t c h f u l search for organisms in the stools during the next year. at intervals of t w o or three m o n t h s , is the safest procedure in guarding the patient against damage f r o m the organism and f r o m the drug. T h e a u t h o r has never f o u n d a case of damaged heart in patients so treated. J. R. B. SUMERLIN, El. S. "Amebiasis incidence in prtu'ate pracm-e." 3, 1034, 102: 363-364.

dour. A,M.A. Feb.

T h e incidence of E n d a m o e b a histolytica varies f r o m 0 2 to 15 58 per cent. depending, no doubt, u p o n the class of patients and the geographic location. S u m m e r l i n reports an incidence of 2.3 per cent in 1.~39 adults and 0.4 per cent in 513 children examined in the ReesStealy clinic. San Diego, in the past four years. R o u t i n e examinations were made, n o t limited to patients w i t h gastrointestinal complaints. Experience in this clinic s h o w s that a single fecal e x a m i n a tion will reveal the protozoa actually present in over 00 per cent of the cases, if a liquid specimen is collected following a sahne cathartic and examined while w a r m . For the detection and identification of protozoa, a c o m b i n a t i o n of the cover-glass preparation in physiologic solution of s o d i u m chloride and a modification of D o n a l d s o n ' s iodine-costa m i x t u r e ~ was employed. W i t h the iodine-eosin m i x t u r e properly adjusted, the cysts appear as bright yellow circles in a red field: the flagellates and motile amebas stain red. T h e oil i m m e r s i o n objective was used to s t u d y the internal structure. In almost every case the cysts of E n d a m o e b a histolytica can be identified in the cover-glass saline solution p r e p a r a t m n bv their large highly refractile chromatoida[ rods. T h e identification of motile f o r m s is frequently difficult. Good illumination is absoluteb' essential. It was f o u n d unnecessary and undesirable to use p e r m a n e n t preparations stained w i t h H a i d e n h a i n ' s i r o n - h e m a t o x y l i n solution of s o d i u m chloride saturated with iodine, l part: physiologic solution of s o d i u m chloride, 2 parts. These solutions are kept in separate d r o p p i n g bottles and mixed fresh daily. J, H. A. 1. Saturated solution of eosin in phyd,~loglc ~olutlon of sodmm chloride, 1 part; per cent potassium iodide in physiologic solution of sodium chloride saturated with mdine, 1 part; physiologic solution of sodium chloride. 2 parts, These solutions are kept in separate dropping bottles and mixed fresh daily.

"Amebic dvsenter9 and food handlers." Lancet, dan. 6, I9~4. pp. 46-47. In the public health section of the Lancet. the Chicago epidemic is discussed and it is said: "So far as public health control in E n g l a n d is concerned there is perhaps less likelihood of an outbreak here: b u t s h o u l d one arise the means of checking it w o u l d be less effective than in Chicago. No distinction is made in o u r notification scheme between amebic and bacillary dysentery, nor are there powers available for the routine e x a m i n a t i o n of f o o d - h a n d l e r s . " \V. E . V . ROCK. ROBERT E. "Management of amebic &tsenteru.'" Dec.. 1033.

Minn. Med., I6:748 740.

Emetine is sometimes recommended in doses of 0 . 1 0 gm. (yr. 1 1 i ) daily for ten or more days. Rock warns that this invites depression and paralysis of the heart (shortness of breath and marked cardiac a r r y t h m i a ) gastrointestinal irritation and acidosis. He recommends complete bed rest. Emetine hydrochloride should be given subcutaneously in daily dosage of 0 . 0 4 gin. (gr..2::) for seven days. Intramuscular injection of emetine is exceedingly beneficial: i n t r a v e n o u s administration ( 0 . 0 3 gin. or yr. 1'~), used rarely in acute f u l m i n a t i n g type, is inadvisable. B i s m u t h subnitrate or subcarbonate is very effective in large, heaping teaspoonful doses every f o u r h o u r s foe 7 to 10 days, F o r the first few days the p o w d e r is given suspended

o,>

in w a r m water, later in h o t milk, T h e subnitrate is considered better treatment than the b i s m u t h emetine iodide. Liquid diet. consisting of well-cooked vegetable soups, tea sweetened to the limit, etc.. is recommended during the first 4 days of the acute stage. Ipecac in salol-coated pills is begun at the entrance to the convalescent stage w i t h cyst-laden stools. T e n pills of 5 grains each, a n d w i t h the salol covering inferred by a needle, are given at bedtime each n i g h t for one to t w o weeks. Rock also mentions yatren. It m a y be given by m o u t h (gr. VI t.i.d.) and concurrently by rectum ( 2 0 0 ee. 2.5 per cent retained for 2 hours} if indications p o i n t to lesions in the lower bowel. A cleansing enema of 2 per cent s o d i u m bicarbonate precedes the yatren retention. For clearing up the histolytica carriers, nearsphenamine is given intravenously (0.3 gin.) every third day until ten injections are reached Stovarsol or treparsol is given by m o u t h in doses of 0.25 gm. t.i.d., for a week: t h e n , o n c e daily for 2 weeks. C o m p l i c a t i o n s will be lessened by a careful note of any fever rise or leukocvtosis: thus a p r e - s u p p u r a t i v e hepatitis is f o u n d early. After becoming cyst-free, the patient should report every three m o n t h s d u r i n g the first year for stool examination. D. F. SAUNDERS, EDWARD WATTS, HOLSINGER. HUBERT B.. AND COOPER, ~/IARY k . , B. S. "'The role of infection in gastric and duodenal ulcer." Am. J. Med. So., 187:246-248, Feb. 1934. A stJ:eptococcus was isolated f r o m 30 resected ulcers of the s t o m a c h and d u o d e n u m by p l a n t i n g bits of the ulcer tissue in 0.5 per cent h o r m o n e agar immediately u p o n resection. All these strains were proved identical by agglutination, cross a g g l u t i n a t i o n and a g g l u t i n i n absorption and also identical with three strains isolated f r o m c o w ' s milk. In previous w o r k its n o n - r e l a t i o n s h i p to all other focus streptococci was proved, its f u r t h e r relationship to ulcer has been previously s h o w n by the high titer agglutination of patient's sera suffering f r o m gastric ulcer against an antigen of this organism, and the n o n - a g g l u tination of control sera. It has been demonstrated to be present in great n u m b e r s in immediately prepared Levaditi sections of h u m a n ulcers. Experimental w o r k was next undertaken to determine the role played by this o r g a n i s m in the p r o d u c t i o n of ulcers. F o l l o w i n g surgical duodenal drainage in dogs, 14 typical ulcers were f o u n d in 5 of the g r o u p of 10 fed cultures of the organism, and only 2 erosions in 2 of the control group of ct not fed the organisms. C. G. O. T . SAUNDF_RS, EDWARD WATTS, HOLSINGER, HUBFRT B., AND COOPER. MARY A., B. S. "Anaph~llactic-like reaction produced b~l the streptococcus of clastric ulcer," Am. d. Med. Sc.. 187:249-25~, Feb. 1934. F u r t h e r s t u d y to determine the tissue reaction of animals to t h e streptococcus isolated f r o m gastric ulcer d e m o n s t r a t e d that there is a definite animal reaction towards the o r g a n i s m (streptococcus a n d that this reaction can be made more severe by previously inoculating the animal w i t h the organism, and that an i m m u n i t y can be developed in the animal by frequent injections at daily intervals. T h i s type of sensitivity which the animal develops m a y well explain the periodicity of s y m p t o m s presented by ulcer patients. It w o u l d also explain the local reaction w h i c h occurs w h e n vaccine therapy is instituted. C. G. O, T . FONTAINE, RENE AND MARCEL BERARD. "'La section des nerfs erecteurs d'Eckard a-t-rite an effect durable sur la motdite de la c,essie et du colon? (Does section of the erector nert'e of F_chard hat'e a lasting effect
34

AMERICAN JOURNAL OF DIGESTIVE DISEASES AND ~'UTRITION

FELDMAN, MAURICE.

"'The redundant duodenum." Am. d. Med. Sc. 186:198-202, August, 1933. From a study of ten cases of redundant duodenum, it appears that the superior portion is the more frequent site and that ulceration is not an unusual finding in these cases. The clinical significance of the redundant duodenum has not been fully established. It is apparently more common than is ordinarily recognized. The Roentgenologic method of examination offers the best possible means of establishing the diagnosis. PALMER, WALTER LINCOLN.

"'Fundamental Difficulties in the Treatment of Peptic Ulcer." d. A. M. A., 101:1604-1607, Nov. 18, 1933. Evidence is summarized, showing that ulcer formation depends on the presence of acid gastric juice. Treatment to be successful must protect the lesion or the cells of the mucosa from the destructive effect of the acid. The antacid regimen of Sippy or one of its modifications is, on tbe whole, the most satisfactory form of medical therapy now in use. Mucin or some such substance may form a coating over the surface of the ulcer and thereby protect it from the attack of the acid, but satisfactory proof of this has not yet been produced. Mucin does not accomplish complete neutralization of the gastric free acidity. Atropine, in physiologic doses, decreases gastric secretion, but the attendant atropine effects seriously limit its usefulness. Gastro-enterostomy may or may not lower the acidity but rarely produces complete neutralization. Subtotal gastrectomy usually resuits in complete and permanent anacidity. The objections to its general adoption are the relatively high mortality rate and the gravity of the lesions when they do recur. COMROE, BERNARD I. "'Association of pituitary tumor and peptic ulcer." Am. d. Med.

Se., 186:568-573, Oct., 1935. T w o cases are reported of primary pituitary tumor associated with peptic ulcer in which (for the first time, the author believes) the diagnosis was made before death. Cushing has recently called attention to the relationship between lesions of the interbrain "and peptic ulcer. Inasmuch as lesions of the pituitary gland are always associated with disorders of the suprarenal cortex, and since recent experiments have shown that damage to the suprarenats will repeatedly produce intestinal ulcers (in animals), it is suggested that these two cases might supply the missing link in the chain of evidence supporting the alleged etiologic relationship between peptic ulcer and the endocrines. Treatment of early cases of peptic ulcer by means of pituitrin subcutaneously seems worthy of trial. VANZANT, FRANCES R., ALVAREZ, WALTER C., BERKSON, JOSEPH, AND EUSTERMAN, GEORGE B.

"'Changes in Gastric Acidity in Peptic Ulcer, Cbolecystitis and Other Diseases.'" Arch. Int. Med., 52:616-631, October, 1933. An increase in free acidity occurs in the case of duodenal ulcer (expressed as approximately 12 units), an increase which varied with the size of the ulcer, with the number found at operation and with the severity of the symptoms produced. Less than one per cent of the patients with duodenal ulcer failed to show free acid after an Ewald test meal. No difference was found in gastric acidity to indicate those cases in which, after gastroenterostomy there would be recurrence and those which would remain symptom free. In 174 men with gastro-jejunal ulcer, the mean free acidity was lower than normal by about 4 units. The incidence of true achlorhydria was 71 per cent of normal. In the case of gastric ulcer the mean free acidity was lower than normal by about six units. This lowering was more marked in the cases of ulcers situated in the proximal two-thirds of the stomach. The incidence of achlorhydria was half of that observed in normal persons. Practically no change from normal was found in the mean free acidity of patients with cholecystitis and cholelithiasis. No change from normal could be found in the gastric acidity of patients who had submitted to cholecystectomy. In the case of patients who suffered with a combination of disease of the gallbladder and ulcer of the duodenum, the acidity was slightly higher than in the case of patients with uncomplicated duodenal ulcer. Normal standards had previously been established based on the records of 3,746 persons (Arch. Int. Med. 49:345, March, 1932). The author's technic is given in the previous article. KING, E. S. J. AND P. MACCALLUM.

"'Pancreatic Tissue in the Wall of the Stomach." Archly. Surgery, 28:125-138, January, 1934. Nodules of tissue indistinguishable microscopically from pancreas have been observed in the wall of the stomach by many investigators. From a study of four cases of pancreatic tissue in the wall of the stomach and a review of the literature it is concluded that pancreatic tissue arises from the epithelium of the stomach under the action of

abnormal stimuli and does not arise as a "cell rest" from the displacement of a pancreatic anlage during embryonic life. COLLINS, A. N. AND G. L. BERDEZ.

"'Chyle Cysts of the Mesentery." Arch. Surg. 28:335-344, February, I934. A freely movable tumor in the lower part of the abdomen which fluctuates and has a midline attachment should suggest mesenteric cyst. The discovery of chylous ascites by exploratory puncture may assist in establishing a differential diagnosis. Marsupialization has resulted in the largest number ot~ recoveries. Chyle cysts of the mesentery are relatively rare but have been encountered from early childhood to old age. T w o cases are here reported. FINE, JACOB, AND LEVENSON, WALTER S.

"'Effect of Foods on Postoperative Distention." Am. d. Surg,, 2I: 184-203, August, 1933. It appears that in the treatment of distention, the baneful influence of certain foods must be considered along with the probably equally vital role of swallowed air. Liquid carbohydrates are a particularly important source of distending gases. The higher the glucose content of these carbohydrates the more gas is likely to form, although certain ones containing not more than five per cent glucose may also produce severe grades of distention. Of the latter, orange juice and ginger ale deserve special mention. Other foods capable of causing significant degrees of gaseous distention are milk, whether pure or in mixed form, and foods rich in cellulose, such as bean puree. The general condition of the animal subjected to the experiment, the amount of food, and the state of motor, secretory and absorptive activity in the intestine may vary the amount of distention even in the same type of operation and similar preoperative and postoperative management. The necessity of administering liquids and carbohydrates in the immediate postoperative period can be met by the parenteral administration of glucose solutions, while the desirability of re-establishing normal peristalsis, which is better initiated by the resort to solid or semisolid foods, would be more safely and effectively accomplished by the use of such foods as toast, gruel or other cooked cereals, egg albumen and other non-gas producers within a reasonable time after nausea and vomiting have subsided. RANKIN, FRED. W.

"'The Present-Day Treatment of Colonic Cancer.'" Am. d. Surg., 23:36-42, January, 1934. Almost a year has elapsed before the average patient with cancer of the colon or rectum has an accurate diagnosis made, although diagnosis in the hands of efficient roentgenologists is so accurate as to leave little to be desired. There are no pathognomonic symptoms which bring individuals suffering with organic lesions of the large bowel to seek advice at an early period. Acute intestinal obstruction is rarely produced by colonic cancer so that preliminary preoperative preparation and careful selection of operative procedure is possible. Adequate decompression of the colon by means of irrigations and mild purgatives is first attempted. If such measures fail, surgical decompression is essential as a means to restore the normal healing power of the issues prior to anastomoses to prevent postoperative leakage. Feeding barium by mouth is deprecated because of obstruction produced and difficulty of r e m o v a l . Rehabilitation of the patient is attempted in preoperative care. A diet high in calories and low in residue is utilized. For a number of years the author has used a mixed vaccine of streptococci and colon bacilli administered three days preoperatively. Theoretically this is a correct procedure and practically it has proved useful. Discussing operative technic, the author believes that the graded operation is best in the majority of cases. The most essential general principle in the postoperative care is the prevention of peristaltic activity as nearly as possible; first, by adequate administration of morphine; second, by refusal to give fluids by mouth until after a postoperative period of forty-eight to sixty hours has past. Other important factors in the author's treatment of these cases are discussed together with an analysis of end-resuhs. An average of the five-year cures of cancer of the right bowel, with and without nodal involvement, showed 57.6 per cent, while the growths of the left half of the colon showed a total of 51.3 per cent of five-year cures.

BENEDICT, EDWARD B. AND ALLEN, ARTHUR W.

"'Adenomatous Polypi.of the Stomach, with Special Reference to Malignant Degeneration." Surg. Gynec. Obst., 58:79-84, January, 1934. In a series of 17 cases of gastric polypi giving fairly severe symptoms, there was microscopic evidence of potential malignancy in seven cases, or an incidence of 41.2 per cent. In view of this high incidence of malignancy and the tendency to moderate or even very severe hemorrhage, radical surgery must be seriously considered in all gastric polyps.