used in laryngeal cases. Further disinfection of the room is not necessary,

and no case of further infection has occurred. Sometimes mercurial ointment can be freely applied to the skin of the neck and throat with benefit, and occasionally he used borax in the manner recommended by Hood, a small quantity being put in the mouth every half-hour, by day and night, for several days.

MEDICINE.

UNDER THE CHARGE OF

W. PASTEUR, M.D. LOND., F.R.C.P.,

ASSISTANT PHYSICIAN TO THE MIDDLESEX HOSPITAL; PHYSICIAN TO THE NORTHEASTERN HOSPITAL

FOR CHILDREN;

AND

SOLOMON SOLIS-COHEN, A.M., M.D.,

PROFESSOR OF CLINICAL MEDICINE AND APPLIED THERAPEUTICS IN THE PHILADELPHIA POLYCLINIC; PHYSICIAN TO THE PHILADELPHIA HOSPITAL.

SPONTANEOUS PNEUMOTHORAX AND PNEUMO-PERICARDIUM.

MR. R. A. LUNDIE, F.R.C.S., records the following case in the Edinburgh Medical Journal, 1891, No. 1805: A lawyer's clerk, aged twenty, with a tubercular family history, while sitting quietly at home after dinner was seized with sudden severe pain in the left chest. He was forced to take to his bed at once on account of the intense dyspnoea on the slightest exertion. When seen, four days later, there was well-marked left pneumothorax, and he complained of a "feeling of trickling" in the left side. The whole left side was hyper-resonant, and no heart dulness could be made out anywhere. Heart-sounds faint, but otherwise normal, except when he had the "trickling feeling," when the first sound acquired a semi-musical quality. He recovered rapidly from this attack, and returned to his work in less than a month. At this time the heart was normal in position and action.

Not many days after, as he was walking quietly home from work, he was seized with pain in the left side. Next day he complained of discomfort in the left chest with a sensation of "splashing" there. The heart impulse in the fourth and fifth interspaces had a peculiar thrilling feeling, and the heart-sounds were marked by singular, irregular, semi-musical accompaniments. On subsequent more minute examination it was found that there was a tympanitic area which occupied the position of a slightly enlarged pericardium; and the heart fell to the most dependent portion of it with each movement of the patient. The heart-sounds were obscured by irregular, tumultuous, tinkling accompaniments, such that a "peal of bells" was a more apt description of them than the "water-wheel." This was best heard with the patient on his left side. When he lay on his back the musical sounds were at times absent, though the heart-sounds retained a metallic ring. The

diagnosis of pneumo-pericardium was confirmed by Dr. Brackenbridge, who pointed out that when the tympanitic area was rapidly percussed the pitch of the note changed slightly with each cardiac cycle. A fortnight later the præcordial area was still a trifle more resonant than normal. The heartsounds were healthy, except for a faint murmur over the sternum at the level of the third cartilage. The pulse was never in the least irregular.

Ten months later the patient continued quite well, with the exception of occasional painful throbbing below the left nipple, which he never experienced before his illness. It never lasts more than a minute, and recurs at intervals of a week or so. He leads an active life, and is able to play cricket, etc. The most remarkable points of the case are summarized as follows:

1. The presence of a chronic morbid process in the chest, sufficient to lead ultimately to rupture of the pleura and pericardium, with an almost entire absence of symptoms.

2. The occurrence of pneumothorax in conditions of apparent health.

3. Backward displacement of the heart while pneumothorax was present. 4. Recovery from pneumothorax without any signs of inflammation or effusion.

5. The occurrence of pneumo-pericardium after an interval, also in conditions of apparent health.

6. The entire absence of irregularity of the pulse, disturbance of the circulation, or interference with the general health while air was present in the pericardium.

7. Recovery from pneumo-pericardium without any signs of inflammation or effusion, except the small, perhaps normal, amount of fluid in the pericardium indicated by the auscultatory signs.

ALBUMOSURIA.

DRS. LEE DICKINSON and W. K. FYFFE communicated to the Clinical Society of London (November, 1891) a series of twenty cases of pneumonia and allied conditions in which the urine contained albumose. The peptone spoken of in earlier papers on peptonuria would, in the present day, probably be called albumose. In no case was true peptone ever found, but whenever a biuret reaction was obtained this was found to be due to albumose precipitable by ammonium sulphate. After removing from the urine such proteid matter as was coagulable by heat it was treated with nitric acid and the biuret test, and in those cases where a positive result was obtained a pink color appeared at the junction of the fluids on floating the urine on to the caustic soda solution containing copper sulphate. The albumose (proto- and dextro-albumose) was sometimes present in large quantities-more than one per cent.

Judging from the results of experiments on animals, it seemed possible that diarrhoea, from which many of the patients suffered, might be due to albumose in the blood. A high mortality and serious sequelæ, apart from the development of empyema, characterized the cases brought forward.

The origin of the albumose is pus, or at least inflammatory exudation, especially that of pneumonia. Albumosuria also occurs in acute rheumatism. According to the authors its only clinical relation is with diarrhoea, and it has no special relation with organic disease of the kidney.

PULSATIONS AND MURMURS IN THE GREAT VEINS OF THE NECK.

In a thoughtful article under the above title, DRS. SIDNEY RINGER and HARRINGTON SAINSBURY discuss the physiological and clinical significance of pulsation in the internal and external jugular veins. The value of the paper is enhanced by copious references to the works of other observers.

The moving force causing the venous current is a vis a tergo, and the bloodflow into the chest is of a remittent character owing to the effects of the cardiac and pulmonary movements on the stream. As a rule, in health, the obstruction within the chest does not exceed the force urging on the venous blood. In health, under ordinary conditions, however, the remittent action of the venous flow may show itself as a pulsation, the beat of which will be caused by a vis a tergo; whilst in exceptional states in health, and more markedly in disease, such pulsation may be caused by a vis a fronte. Important time-relations mark theoretically the pulsations according as these are direct or regurgitant.

The following pulsations of cardiac rhythm are recognized.

1. Transmission across the capillaries of the intermittent impulses of the left ventricle.

2. Transmission of pulsation from the brain en masse to the veins issuing from the cranial cavity. The authors doubt whether pulsation visible at the root of the neck ever bears this interpretation.

3. Pulsation communicated from an adjacent artery.

(In these three varieties there is no hindrance to the onward flow of the blood, and in the first two the vis a tergo is the obvious efficient cause.)

4. Pulsation in the veins at the root of the neck extending a variable distance up the neck and owning as a cause intra-thoracic changes of pressure. The evidence appears to the authors strongly in favor of a normal jugular pulse in man the result of intra-thoracic changes, and not commonly visible owing to its feebleness and masking by the integuments. Pulsating jugulars, in disease, with overloaded right ventricle, are universally admitted. After discussing the distinguishing characteristics of arterial and venous pulsation the authors state, in regard to that under discussion, that neither the form of the pulsation, nor its site, nor the effects of posture, afford any reliable criteria for determining whether it be of health or disease. On the other hand, "If the veins of the neck, especially the external jugular, of a chlorotic woman be carefully watched in the recumbent posture, with the head slightly raised or not raised at all, it will frequently be determinable with ease that the filling of the vein, its beat, precedes slightly the carotid beat felt on the opposite side of the neck; perhaps it will be found even more readily that the collapse of the vein falls in exactly with the carotid impulse. With each cardiac cycle this sequence is repeated-presystolic filling, systolic collapse. In some forty cases of our own, including pathological cases, though chiefly consisting of anæmias without heart or lung mischief, the systolic collapse was noted in eleven certainly, in two with less certainty. Excluding six or seven cases of actual chest disease, and a few in which no note is recorded about pulsation, the proportion in which systolic venous collapse is observed in marked anæmia without thoracic disease becomes a considerable one, and

probably is little under one-half. The subjects were mostly lying quite flat when this was noted.

"The evidence is fairly complete that the normal venous pulse, when visible, shows its main stroke in the presystole, its main collapse in the commencement of systole; and this accordingly is the point which we must seek to establish in the case of any vein which pulsates-its time-relations-for we shall see that the venous pulse of disease differs very decidedly from the normal pulse in respect of these relations."

This venous pulse of presystolic rise and systolic collapse is spoken of as physiological because it is found experimentally as a constant in healthy animals, and is occasionally seen in healthy men and women. How does the pathological venous pulse-the pulse of obstructed right heart-differ from the above?

This pulse is frequently double, and so far resembles the normal venous pulse. Careful observation of the time of pulsation, however, will show that one impulse, at any rate, falls in with the systole, the other, if well-marked, precedes the systole. There are thus presystolic and systolic impulses, the systolic collapse having been exchanged for a filling out of the vein. Obviously the systolic impulse of the vein is produced by the systole of the ventricle. Whether the tricuspid valve is competent or otherwise is not vital. The distended right auricle conducts back the ventricular pulse, and, as Gottwalt points out, it is the intervention of the flaccid auricle—in health -at the moment of ventricular systole which accounts for the absence of systolic impulse in the veins.-Lancet, 1891, Nos. 3561-62.

MORBID STATES OF THE HEART IN CHRONIC PHTHISIS.

Under this title, DR. W. S. FENWICK (London) publishes the results of an analysis of 1560 post-mortems made at the Brompton Hospital for Consumption, the results obtained being compared with the clinical notes of the

cases.

In about 27 per cent. of the cases there was distinct evidence of hypertrophy of one or both ventricles. The causes of this were three-fold-a compensatory hypertrophy of the right ventricle in fibroid phthisis; left ventricle hypertrophy was mostly due to rheumatic endocarditis. In the remaining cases, about 9 per cent., there were hypertrophy and dilatation of the left ventricle associated with chronic interstitial nephritis. As regards the heart muscle it was "soft and fatty" in 11 per cent. only, being more generally described as pale but healthy." No instance of tuberculous deposit in the heart was met with.

The writer lays some stress on the firm, laminated clots met with at the apex of the ventricle, or in the auricular appendix. In seven of the cases death occurred rapidly in the course of a chronic case. In each instance it was found that a piece of clot had been dislodged from the right heart and had blocked up a large branch of the pulmonary artery. The majority of the patients were females, and on six occasions the embolism lodged in the base of the right lung; once in the left.

No special importance is attached to slight thickening of the mitral and aortic valves met with in 12 per cent. of the cases. True endocarditis was

encountered in 43 cases, in 30 of which the disease was evidently of old standing; in the remaining 13 it is stated to have been recent and acute.

Of the 30 chronic cases, there were 9 of mitral incompetence, 4 of mitral stenosis, 4 each of aortic stenosis and incompetence. In 5 mitral and aortic incompetence coexisted. In 3 mitral and tricuspid disease were associated. In 12 cases the tuberculous disease was "very old ;" in 9 it had undergone recent extension, while in 5 miliary tuberculosis had supervened on old apical mischief.

Of the 13 acute cases, the mitral valve alone was affected in 6, the aortic valve alone in 2, both valves in 3. In 2 the mitral and tricuspid were affected. In 11 of the cases there coexisted a more or less pronounced condition of kidney disease, which, in the writer's opinion, may throw some light on the origin of the endocarditis. In two cases an acute attack of endocarditis occurred in patients in whom acute miliary tuberculosis had complicated the original tuberculous disorder.

In 4 cases congenital malformation of the heart was associated with phthisis. In 3 the foramen ovale was patent; in the fourth the right ventricle was subdivided by an oblique septum. Double phthisis ran a fairly rapid course in each case. Pulmonary tubercle was found in 7 out of 24 cases of thoracic aneurism. In 5 the aneurism involved the ascending arch. In 3 of these the lung disease was obviously recent, in the other 2 latent.

Looking to the clinical side of his tables the writer finds that fatal hæmoptysis occurred nearly twice as frequently in cases where the heart presented an increase in volume as under normal conditions.

With regard to adherent pericardium, which existed in about 7 per cent. of the cases, the symptoms of cardiac failure were usually pronounced during life; in a majority a considerable degree of cyanosis was present before death. The writer adopts the view that cardiac thrombosis is a frequent cause of death, and most likely to occur in cases in which, from laryngeal disease or other causes, the patient has been debarred from taking sufficient nourishment.

The physical signs are with difficulty distinguishable from those of pulmonary embolism, except that the latter are usually ushered in with greater suddenness, are of greater moment, and are apt to lead to the physical signs of consolidation of some portion of the lung.

With reference to the cases of chronic valvular disease a history of previous rheumatic fever existed in 17 of the 20 cases in which the mitral and aortic valves were affected. Of the other 10 cases of stenosis of the various orifices a history of rheumatism was obtained in 2 only. Hæmoptysis was more or less severe in 12 of these cases, and caused death in 4. It appeared to be most frequent in cases of stenosis of the mitral and tricuspid valves.-Practitioner, 1891, No. 281.

MEDICAL TREATMENT OF PERITY PHLITIS.

The view, which appears to be gradually gaining ground, more especially among surgeons, that once inflammation of the appendix cæci has been diagnosticated these cases should be handed over for surgical treatment, has