CASE IV. Margaret K., aged 32 years, married; suffering from pain along the course of the saphena vein, following an abdominal operation. The pain, which was constant and dull, sometimes extended over the entire limb. I prescribed salophen, 10 grains, four times daily, after employing codeine and phenacetine. At the end of a week and a half the patient felt much relieved and was walking about, having only slight pains at times.

ALBUMEN IN THE URINE.-Exactly what value should be placed on the appearance of albumen in the urine is difficult to determine, because it is frequently found in urine of apparently healthy persons, and because it may and does result from temporary slowing of real circulation, and from local or general influence of drugs administered as medicine. One thing certain, it is not a normal constituent of the secretion, and whatever the cause, albuminaria is a certain sign of derangement more or less serious. Three things should be remembered, namely: That it may result from a simple retardation of circulation in kidney; that it may result from lesions of its filtering structure; that it may be a sequence to more or less grave blood changes. It may, therefore, be inferred that albuminaria is not a trustworthy symptom, as is affords only imperfect notions of cause, extent and value of diseased conditions present. Not quantity of albumen, but condition of kidney function as it relates to quantity, specific gravity, presence or absence of definite castes, blood, mucus, etc., must form the framework of our prognostications. Usually wherever albuminaria is, there is also some disturbing factor which threatens the vital forces, and these are either vascular or nutritive in character. So numerous are the states in which symptom manifests itself that it would exceed the limits of a brief notice to enumerate them all by name. After the continued use of certain medicines in many cases of poisoning, in acute stages of fevers, in various forms of nephritis, as Bright's disease, in diabetes, in pregnancy, etc., albumen in the urine is often met by the observant physician. Its appearance in convalescence after toxic agents that have caused disease, presumably have been eliminated, foretells the approach of Bright's disease. Albuminaria may assume an intermittent form, showing itself in the secretion during the day and vanishing during the night. During the day's activities, toxics reach the maximum of elimination. In many cases there is a latent lesion of the kidneys, possibly overlooked, coupled with which is a condition of auto-infection engendered by bad food, bad air, bad hygiene, by indigestion and constipation, or other potential cause. Another point to be considered is the possibility of inherited weak kidneys unable to assume function of secretion and elimination. It is a matter of observation that children born of women in eclampsia, seem to be predisposed more than others to nephritis and its consequences. A curious feature of some cases of diabetes where albumen is present, is, as the quantity of albumen increases, that of grape-sugar decreases, and vice versa. From the foregoing we may conclude that albuminaria is referable to two classes of causes. If potential destruction of renal organs, uremic intoxication soon follow; if less intense, no disorganization may result, and time being given for removal of cause, albuminaria will be made to disappear.- Medical Summary.

The Reviewer's Table.

Books, pamphlets, instruments, etc., for this department, should be sent to the Managing Editor, Saint Louis.

THIS book is one of the most original works that we have recently seen, the subject matter impresses us most favorably. Autoscopy of the larynx

AUTOSCOPY OF THE LARYNX AND THE TRACHEA. (Direct Examination without Mirror.) By ALFRED KIRSTEIN, M.D., Berlin. Authorized translation (Altered. Enlarged and Revised by the Author) by MAX THORNER, A. M., M.D., Cincinnati, O., Professor of Clinical Laryngology and Otology, Cincinnati College of Medicine and Surgery; Laryngologist and Aurist, Cincinnati Hospital, etc. With Twelve Illustrations. One Volume, Crown Octavo, pages xi-68. Extra cloth, 75 cents, net. The F. A. Davis Co., Publishers, 1914 and 1916 Cherry Street, Philadelphia; 17 W. Forty-Second Street, New York; 9 Lakeside Building, Chicago.

must possess many advantages over the methods now commonly employed, bringing the larynx, as it does, into the field of direct vision. The author makes the technique of this method of examination appear very simple, enters into all its details and emphasizes the text with excellent illustrations of the various

steps. After reading the book we feel that is only a matter of time when autoscopy will be generally practiced by American laryngologists.

THIS manual is an abstract of Dr. Thorington's previous writings and lectures on Retinoscopy, delivered during the winter course on Ophthalmology

at the Philadelphia Polyclinic. The author first points out the wonderful advantage of retinoscopy over other methods, i. e., the examiner is able to estimate, in a remarkably short time, the exact refraction of an eye without questioning the patient. This is a point of especial value when we have to deal with young children, illiterates and the feeble-minded, or in cases of amblyopia, nystagmus and aphakia.

RETINOSCOPY (or shadow test) in the determination of refraction at one meter distance, with the plane mirror, by JAMES THORINGTON, M. D, Adjunct Professor of Diseases of the Eye in the Philadelphia Polyclinic and College for Graduates in Medicine. Twenty-four illustrations. Price $1.00. Philadelphia: P. Blakiston, Son & Co.

Under the head of suggestions to the beginner, the author rightly says, that careful attention to details must be given, and not a little patience possessed, as it is not a method acquired in a day, and it is only after weeks of constant application that accuracy is acquired. Then follows a description. of the necessary instuments (among which are the author's mirror and asbestos chimney), the arrangement of light, position of surgeon and patient, and the behavior of the light and shadow in the various forms of ametropia. The text is profusely illustrated, and every detail of the method described in plain language and with as few technicalities as possible. This manual should be in the hands of every student and ophthalmologist, as with it any one may acquire a working knowledge of the method, by study and practice in his own office. J. E. J.

PHYSICIANS Who contemplate a trip to Philadelphia this year, should reserve their quarters at Hotel Hanover, if they desire first-class accommodations at a reasonable rate. $2.00 per day, American plan, is the special price named by this house to members and their families, and reservations should be made early to secure pleasant rooms.

COMPRISING THE REGULAR CONTRIBUTIONS OF THE FORTNIGHTLY DEPARTMENT STAFF.

Difficulties of Climatotherapy.

(Am. Jour. Med. Sciences, January, 1897.-Walker.)

Lack of General Information as to the Elements of the Climate Affecting Health, and the Consequent Lack of Ability Wisely to Use the Agent. -The question paramount in most minds about to employ climate in a given case is, "What is the best climate for phthisical patients?" The question should ever be, "What is the best climate for this phthisical patient?" There is no antibacillary climate habitable. Climate is or may be a factor to aid in resisting disease by recuperating energies, or by lessening causes of aggravation. It is a complex factor, variously compounded. It should be prescribed, as any other remedy is prescribed, with knowledge of its constituent elements, and with forethought as to the effects of the especial combination and the especial case at hand. The four elements of climate chiefly affecting health are: temperature; humidity, including sunshine; air-movement or wind, and atmospheric pressure, including altitude. As nearly as possible in a given case, one should choose that place whose possession of these constituents are due to: 1. Distance from the equator. 2. Height above sea-level. 3. Distance from the sea. 4. Prevailing winds. 5. Character of the soil.

It must be apparent that, in our vast extent of continent, bathed on its eastern and western borders by the principal oceans of the earth, extending through the breadth of the temperate zone, and possessed of mountains and plateaus, so located as to insure to our patients altitude with such combination of desirable qualities as are unequalled even in the best of Alpine sta

tions; I repeat, with such factors for modifying climate we should be, and are, able to find within our own borders, and on the islands adjacent, all varieties from which to make selection. Our high-altitude stations are considered by most authorities as superior to those of the Engandine in many respects, one of which is the absence of wet soil from the melting of snow, it seeming to dry away, owing to the amount of sunshine, and the character of the soil. The Engandine at the time of snow-melting, in the spring, is unfitted for consumptives, though they may return later with benefit. objectionable feature in our Colorado climate is the dust, which makes it less desirable for irritative mucous membranes than is the Engandine, which, during the winter, is snow covered. Apart from this feature, however, Colorado and New Mexico, running into Texas, present the climate par excellence for all cases of phthisis in which altitude is not contraindicated.

Dr. Holland, the English-speaking physician at San Moritz, agrees in the main with C. Theodore Williams and most of our own authorities as to the advantages and contraindications of altitude. The latter writer has formulated the following as his experience of the influence of altitude in phthisical cases:

"I. Enlargement of the thorax, unless opposed by fibrosis or by extensive adhesions.

"2. Males and females seem to do equally well, and profit most between the ages of twenty and thirty; males over thirty and females under twenty being benefited least.

"3. The climate is especially beneficial in hemorrhage cases. (Holland considers that hæmoptysis is not a barrier to high-altitude treatment, so that the formerly supposed contraindication is losing supporters abroad as well as with us.) In hereditary cases it seems to exercise a distinctly counteracting influence on the development of phthisis.

"4. It is most effective in cases of recent date, though of utility in those of long standing. To insure benefit, at least six months, and preferably, two years' stay, is desirable.

"5. It produces undoubted improvement in 75 per cent of phthisis generally, and arrests the tuberculous process completely in 45 per cent.'

He considers that its influence is best shown in consolidation, in which improvement may be looked for in 87 per cent and arrest in 57 per cent.

In excavations great improvement occurs in 55 per cent and arrest in 16 per cent, so far as his cases may be taken as a measure. The general improvement of which he speaks consists in improved digestion and assimilation, gain in weight, and return of normal functions, and of color, and of muscular, respiratory and circulatory power, at the same time that the evidences of disease cease to manifest themselves.

This list of contraindications will serve as a basis for decision, and probably applies with equal force to all high-altitude climates.

"2. Fibroid phthisis and all other conditions in which the healthy pulmonary area hardly suffices for respiratory purposes at sea-level.

"3. Catarrhal and laryngeal phthisis. (Holland would include cases with so-called gastrointestinal catarrh.')

"4. Acute phthisis of all kinds, especially when associated with nervous irritability.

"5. Phthisis with pyrexia.

"6. Emphysema.

"7. Chronic bronchitis and bronchiectasis.

8.

Organic disease of the heart and great vessels. (Holland considers obstructive disease to be an absolute contraindication; but, from his experience, if the pulmonary condition warrants the prescription of high altitude for its treatment, regurgitant lesion of the heart is no barrier.) "9. Diseases of the liver and kidneys, including all forms of albuminuria.

❝IO. "II.

Disease of the brain and spinal cord.

Anæmia. (Holland, on the other hand, has found that anæmic cases, as a rule, do well, especially in summer; whereas, the scrofulous do better in winter. This applies especially to children, who should arrive early in the season, before November. Solly's experience supports that of Holland as to the benefit of high altitudes in anæmia.)

"12. Patients too feeble to take exercise.

Patients who have degenerated organs from long residence in

tropical countries.

In considering the effects of altitude, Williams does not forget a most important adjunct to altitude, to which his patients were subjected, viz., the careful medical supervision, as practiced in the Alpine stations, where most of his cases were sent, and where supervision is both easier and more complete than in the Riviera and most of the southern resorts. His admission on this score corresponds with the repeated and unanimous advice of those familiar with our own high-altitude stations-that patients sent to such places should not be left to their own devices in using so potent a remedy, but should be referred to some competent physician, whose familiarity with the effects of altitude may help the patient to avoid deteriorating agencies, and to obtain the best results possible by a careful supervision of his life and habits.

Dr. Solly, in a paper read before the American Public Health Association in Denver, 1895, deals with the hæmatogenetic results from altitude ina thoroughly scientific manner. He quotes from a paper by Dr. Egger, before the Congress at Wiesbaden, 1893, to show the resulting increase in red corpuscles and in the total amount of hæmoglobin in the blood. In other words, the blood, as an oxygen-bearer, is decidedly magnified. Solly concludes, from these studies, which have been verified by studies by Koeppe and Wolf, that we have good reason to believe that there is developed in life at high altitudes a greater power of resistance to the attempted lodgment of germs within the body by means of the increased germicidal character of the more highly oxygenated blood and through the more perfect working of the heart and lungs.

It must be remembered that our resorts at high altitude furnish us not only with the especial stimuli to the respiratory and circulatory functions