mediastium is very loose. The vertebrae, sternum and ribs offer considerable resistance, especially in older people, and this must be considered in tapping the pericardial sac, particularly if deformities of the spinal column exist, for they alter the shape and position of pericardial exudates. The position which the heart assumes in the pericardial fluid depends upon its physiologic position and attachments. Below, its fixation to the diaphragm through the vena cava inferior and above through the aorta and vena cava superior to the thorax give it an excentric hold, giving the left side more room for displacement than the right. (See cut.) Besides this the right half of the heart is prevented from displacement forward or backward by the sternum and vertebrae, while the apex and a part of the left side have no such support. As the exudate increases it spreads

to both sides and backward on either side of the spinal column, particularly to the left. Later it spreads downward between the left half of heart and diaphragm and up along the large blood vessels. Anteriorly and posteriorly the parietal and visceral pericard usually remain in contact, practically separating the fluid in two parts and at times producing friction sounds. The author heard friction sounds in a case from whom he later removed 1500 ccm. liquid. Very large pericardial exudates simulate left side pleural exudates, but can be differentiated by careful physical examination and tapping. The exudate extends upwards in the pericardial sac along the large vessels, assuming the form of a chimney. The outlines of the exudate upon percussion usually vary from that of a triangle to a quadrangle, but much depends upon adhesions or other pathologic conditions of the surrounding organs. The lungs retract as the exudate grows and the parietal and visceral pleurae come in contact, often forming adhesions. In performing paracentesis with a small trocar under aseptic precaution there is little danger of infecting the pleural cavity or of producing pneumothorax. The surgical procedure resorted to depends on the nature of the liquid. In purulent exudates it is best to make a free incision into the pericardial sac either by removing a few ribs or by cutting between the ribs. In serous, sero-fibrinous and hemorrhagic exudates it is not always necessary to operate, and if it should become necessary a simple paracentesis will suffice. The author believes the majority of the latter exudates disappear spontaneously, depending on their cause. If the exudate interferes with the cardiac and respiratory functions producing dyspnea, cyanosis and abnormalities of the pulse the fluid should be removed. Also

exudates which remain stationary (tubercular) should be removed by paracentesis.

[TO BE CONTINUED.]

About Collargol (Crede). - (Wiesmann, After a number of years experimenting Therapentische Monatshefte, August, 1905.) with silver preparations, Credé, in 1895 produced itrol (silver citrate) which is a powerful bactericide, non-poisonous and non-irritative, but as it coaguates the albumins of the blood it is useless for intravenous injection. In 1897 Credé introduced collargol (pure metalilc silver) which does not coagulate serum albumin. The therapeutic effect of collargol is due to several factors, the chief factor being bactericide, electrolytic, and producing leucocytosis. Collargol is administered intravenous, subcutaneous in ointment, by injections are painful, and at times case inmouth and rectal injections. Subcutaneous flammation and necrosis. In alimentary and nervous disease collargol is preferable to silver nitrate as the former does not produce argyrie. It is best given in pills dose 0.01 gram (3-20 gr.) For rectal injections 50 c.c. of a 1% solution should be used morning and evening. Good results have been obtained in chronic diarrhea, tubercular enteritis and typhoid fever, also in epilepsy, neur algia, neurasthenia and chorea. Ung. Credé is one of the best methods in which to ad minister collargol, but where the skin is dry and relaxed, or if a rapid effect is necessary, collargol shoud be used intravenous. For intravenous injections Credé used 5-15 ccm. of a 2% solution or 3-9 ccm. of a 5%, solution solution, i. e., 0.1 to 4.5 gram (1.5 to 6.75 gr.) to be repeated in 12-24 hours, if necesadapted for injection. Collargol is indicated sary. The veins in the elbow region are best in most septic infections and often does good as a prophylactic. The writer concludes that collargol is almost a specific against sepsis, and should be used in traumatic cases to prevent sepsis Also in infectious diseases if there is danger of sepsis. It is a very reliable prophylactic. The method of adminis results are necessary it must be used intratration is very important, since if immediate venous, for less serious cases the ointment is preferable, and in crhonic cases it should be given by mouth or rectal injections. leaves the body sooner after intravenous injection than after other methods of adminis tration, and consequently must be repeated oftener.

It

The Therapeutic Use of Alcohol Locally.— (Walko, Prag. Med. Woch., No. 5, 1905.)The writer applies alcohol for deep-seated and superficial inflammations, using concentrated 96% in the former and about 50% in

the latter cases.

The skin should be washed

with soap and benzine to remove the fat as this will produce a more decided cutaneous reaction (hyperemia). Thirty-eight cases of erysipelas were treated with aclohol compresses and the writer believes the disease was checked and the fever quickly subsided. Ten cases of tubercular peritonitis improved or were cured by the use of alcohol com-. presses over which he placed flaxseed poultices, to accelerate the action of the aclohol. In perityphilitis he uses alcohol compresses and covers them with an ice bag, also with favorable results. This will not prevent recurrences or lessen surgical interference.

Pathogenesis and Treatment of Articular Rheumatism. Parhorn and Papinian, (La Presse med., 1905) report a case, male, age 47 years, who suffered for twenty years from articular rheumatism affecting the knee and ankle joints, so that he could hardly walk. At the time the patient consulted them his knee, ankle, wrist and finger joints were swollen and crepitation was elicited. Besides this he had albuminuria and eczema of the face and head, chilly sensations, dry skin and dry, brittle hair. From this they concluded that his thyroid glands were abnormal. The patient was treated with thyroid of sheep with a decided improvement of his rheumatism and eczema. A nephritic patient with edema oligurie, etc., received thyroid glands with decidedly beneficial results, proving that albuminuria is no contraindication to thyroid medication, and showing probably that in some cases albuminuria may be due to an abnormal secretion of the thyroid glands. The writers believe that some forms of rbeu. matism may be due to diseases of the ovaries and in these ovarian extract is indicated.

OTOLOGY.

ALBERT F. KOETTER, M. D.

The Nature of the Otosclerosis in the Light of the Laws of Heredity.- Koerner (Zeitschrift fuer Ohrenheilkunde) proceeds from the biological law that only such peculiarities or their material substrata can be inherited whose disposition is present in the germ plasma of the parental sexual cells and not only do these determinants originate from the plasma of the parents, but from the entire ancestral plasma. As such determinants disposition to disease can be inherited. According to Siebenmann's perception we deal in the otosclerosis with an abnormal embryon al process of growth, the last phase of which is the spongiosis of the bone. This abnormal process of growth is the determin

ant present in the ancestral plasma, and as such inherited. To this disposition to disease is added an exogenous course such as puberty, childbed or disease of the tympanic mucous membrane in the labyrinthian wall and this brings out the disease. According to this explanation every case of otosclerosis is inherited. That this transmission cannot be proven in every case is due to the fact that the determinants in one or the other generation may remain dormant to appear suddenly, latent transmission. In this way those apparently spontaneous cases of otosclerosis may be explained, where lack of sufficient knowledge of ancestors makes it difficult to trace the determinants. Is this ful control of otosclerosis is gone, and we hypothesis correct, every hope for a successagree with Koerner in forbidding marriage to every individual deaf from otosclerosis. In female progeny of otosclerotics, celibacy should be insisted upon, as each pregnancy may cause the latent determinants to become active.

A Peculiar Burning of the Drum Membrane.

(Haug, Munich.)-Man of 48, at the moment in which a Swedish match was scratched, felt a sharp sticking pain in the ear turned toward the individual who lighted the match. On examination membrane appeared greatly congested in the middle of posterior half a gravish black prominent point, the size of a pin-head surrounded by a narrow grayish white zone was noticed. Felt with a probe like a tough mass, which fell off on further probing, showing a sharply rounded loss of substance of the membrane. The loosened particle was proven to be a part of the match. Hearing distance on injured ear twenty-two feet. Temporary thin serous secretion, after six days, loss of substance was replaced by epithelium. The injury in this case was favored by the wide. and nearly straight canal of the patient.

Treatment of Otitis Media Acuta in Children.-(Percy Fridenberg, American Jour. of Surgery). As a prophylactic measure author recommends the systematic cleansing of the nose and nasopharnyx with alkaline and antiseptic solutions used in a spray and not in syringes; in infants instillation of a drop or two of sterile oil in each nostril, in older children oil spray to prevent a rapid drying of the nasal mucous membrane. Rest in bed, regulation of diet and bowels, with bulging membrane, early paracentesis, which author performs after thorough disinfection of canal under ethyl chloride or chloroform narcosis, He uses Graefe's cataract knife, paracentesis, needle being too narrow to allow a free incision. The incision is made from below up

2

wards pushing in the knife until it almost touches the inner wall of tympanic cavity. Afterwards frequent syringing of the ear without using force, with lysol, creolin or sublimate solutions at 108 deg. F., then drying canal. The removal of secretion is promoted by means of suction. All these measures are sufficient for the main indication, viz., the removal of secretion; the second indication, prevention of a reinfection; careful antiseptic treatment of nose and nasopharynx and the external canal is sufficient; third indication, good drainage by means of a broad incison of membrane, laying of the head on the diseased side. Author cautions against the use of powder on account of danger of retention of pus, also the use of H, O2 as its combination with pus causes deposits easily bring about closure of the perforation. So-called dry treatment is deleterious, as .only the fluid part of the secretion is allowed to pass through the tampon and the corpuscular elements. Pus and bacteria, as in a filter are held in the depth of the external canal at the inner end of the tampon. Catheterization of the Eustachian tube presents two difficulties: first, the introduction of a new source of infection from the nasopharynx; and second, the carrying of infec tious material from the tympanic cavity to distant parts of the temporal bone. Abortive measures, as leeches and the ice bag are only to be recommended in the beginning of the disease, and then only for one or two days, narcotics only to be used when pain is severe. When definite involvement of mastoid process is present, opening of process should not be delayed.

On the After-treatment of the Radical Operation of the Middle Ear with Picric Acid. -(Bandy, Monatschrift fuer Ohrenheilkunde.) In the polyclinic of Urbantschitsch on cases of radical operation of the middle ear, when the process of epidermization was hindered or prevented, and no local disturbance was present. Author attempted the usa of picric acid. He used a ten per cent ethereal solution, which he painted on the thoroughly dried wound surface every second or third day. A tampon was omitted on account of the danger in withdrawing the same, of damaging the newly formed epidermis, dusting only an antiseptic powder on the same. It was demonstrated that the secretion immediately diminished, the granulations disappeared and the epidermis was pushed rapidly from the margins and covered the wound surface. In a small number of cases the treatment was without result. In fourteen cases healing was achieved, in one case in six days. In suppuration from the

tubes the treatment was successful in only a small number of cases, but brilliant results were obtained in attic suppuration where epidermization failed without any known

cause.

INTERNAL MEDICINE.

O. E. LADEMANN, M. D.

The Effect of Mixed Narcosis on the Internal Organs.-Müller (Archiv f. klin. Chirurgie, Bd 77, Heft 2, 1905) contributes an additional study of the effects of oxygen-chloroform, oxygen-ether and the combined chloroform ether oxygen narcosis on the organism of both man and animal. With reference to the oxygen-chloroform narcosis, the author observed the following: (1) The lowering of blood pressure during the anesthesia was not as marked as with chloroform alone; (2) it bas a beneficial effect on respiration; and (3) the organic changes (fatty degeneration) are not as widely manifest, and the metamorphosis to a less degree. The favorable action of the oxygen depends on the small amount of chloroform required for a comparative narcosis, and the beneficial effect of the oxygen on cellular activity, and in avoiding a systemic intoxication of carbon-oxide. Oxygen-ether possesses similar advantages over simple ether narcosis, namely: (1) The blood pressure during the entire anesthesia is constantly above normal; (2) respiration is quiet, deep and regular devoid of any cyanosis and stertorous breathing; and (3) the fatty metamorphic organic changes are decidedly less. Chloroform or ether in combination with oxygen does not entirely eliminate the deleterious effects of either of these anesthetics. The oxygen narcosis does not, however, produce as profound an anesthesia as the simple anesthetics, particularly ether. In neurasthenics and alcoholics it not infrequently occurs that an oxygen narcosis is insufficient to effect an adequate anesthesia. The combined ether chloroform oxygen narcosis reduces the dangers and disadvantages of the simple anesthetics, or those respectively in combination with oxygen to a minimum. According to Müller this combination is pre-eminently the it has its contra-indications and not absosafest and best anesthetic in general, although lutely devoid of danger.

A New Reaction for the Detection of Acetone in the Urine, together with Remarks on Acetonuria. Frommer (Berliner klinische Wochenschrift, No. 32, 1905) recommends the following as an efficient and reliable test for acetone. Render 10 c. c. of urine alkaline with 1 gm. of potassium hydrate, to which

add 8 to 10 drops of a 10 per cent alcoholic solution of salicylic aldehyde (salicylous acid 1 gm., absolute alcohol 10 gms.,) and heat to a temperature of about 70 deg. C. The appearance of a purple-red ring indicates a positive reaction. Contrary to the assertion of some writers, regarding the frequency of acetonuria in pregnancy where the fetus died, the author found it present in only two out of five instances. During pregnancy acetonuria is a seldom occurrence. On the other hand, it is quite constantly present during the first two days of puerperium.

The Value of the Various Forms of Hemoglobinometer. -Fussell and Marcellus (J. A. M.A., Sept. 9, 1905) have undertaken this study because the general practitioner, as a rule, looks on hemoglobin instruments in general as a sort of a medical toy, to be used largely by the consultant, and because they

believe that the use of these instruments is practical and requiring but little time. The authors made a comparative hemoglobin estimation in fifty cases using the methods of Fleischel, Dare, Tallquist and Gowers. The average individual difference between the Fleischel and Dare method was 3.3 per cent, with Fleischel and Tallquist 3.2 per cent, with Dare and Tallquist 3.3 per cent, Dare and Gower 3.4 per cent. Their conclusions are as follows: 1. Any one of the instruments studied by us is sufficiently accurate for practical purposes. 2. No practitioner practitioner should neglect to use one of these instruments. The Tallquist scale is cheap and convenient. 3. The Tallquist scale can be used for routine observations and either of the other instruments for detailed and more accurate work. 4. The Dare instrument is just as accurate as the Fleischel, and takes much less time to manipulate. 5. For the general practitioner, the value of these instruments may be fairly arranged as Tallquist, Dare and Fleischel.

Experiments to Determine the Action of Stomachics on the Gastric Secretion.-Hoppe's (Berliner klinische Wochenschrift, No. 33, 1905) experiments, which consisted in effecting a gastric fistula according to the method of Pawlow in a number of dogs, are of practical interest. He observed that the administration of the tannate of orexin stimulated the output of both the gastric secretion and hydrochloric acid in dogs with a chronic gas. tritis, whereas the orexin had absolutely no effect on the secretion in dogs with a healthy stomach. The bitter tonics (quinine, condurango, etc.) only stimulated the secretion after the ingestion of food. Of the different stomachics, condurago possessed the most decided effect, producing a rapid transitory

increase in the secretion, but without any increase in the hydrochloric acid.

On the Use and Abuse of the Stomach Tube. Palier (New York Med. Jour., Aug. 19, 1905) believes that gastric lavage is practiced too frequently in this country when there is not only an indication, but sometimes when contraindicated, and the stomach tube is not used often enough as a means of diagnosis. In obtaining the gastric contents, the writer uses three vessels wherever possible. In the first vessel he collects the first few centimeters, in the second enough for making an examination, and the remainder in the third. The second vessel usually contains the fluid of highest acidity. He holds that a chronic gastric trouble cannot be scientifically treated without an examination of the gastric contents as the symptoms are unreliable and the physical signs never sufficient to corroborate a diagnosis. To this end he cites several cases, illustrating the utter impossibility of correctly diagnosticating and treating gastric diseases without the aid of the stomach tube. The contraindications of introducing the tube are really very few, providing it is carefully done, with a soft rubber tube. Among them he gives hematemesis, aneurism of the aorta and advanced pregnancy. diac affections differ so widely in numerous respects that each case must be judged on its individual merits. He gives as indications for its use, when the stomach cannot empty itself, when there is alimentary stasis, when, so to say, drainage is necessary and where there is much mucus in the stomach.

Car

Acute Swelling of the Thyroid Gland following the Administration of Potassium Iodide.-Csillage (Wiener med. Wocheshrift No. 33, 1905) reports an instance of this kind in a man with secondary syphilis. Even small amounts of potasisum iodide caused a considerable swelling of the thyroid gland with each successive dose. Remarkable about the case was the abeyance of all other symptoms of iodism.

A Test for Lactic Acid.-Croner and Cronheim (Berliner klin Wochenschrift, No. 34, 1905) suggest a modification of Vournaso's reaction. The reagent is prepared as follows: Potassiuim iodide 2 gms, mercuric iodide 1 gm. are dissolved in 5 cc. of distilled water, filtered and water added to make the total quantity 50 cc. To this 5 cc. of anilin are added and the reagent to be kept in a dark place. Before using the reagent is to be thoroughly shaken. The filtered stomach contents to be tested for lactic acid is rendered alkaline with a 10 per cent potassium hydrate solution, boiled and the above re

agent added. The presence of lactic acid is signified by the formation of isonitril, characterized by its peculiar odor.

Functional Heart-Diagnostic.-Selig (Prager med. Wochenschrift, No. 30 and 31, 1905) describes in detail a functional heart test consisting in climbing stairs of graduated height. In individuals with an intact heart the organ, in nearly all instances, is capable of adapting itself to such bodily exertion. On the contrary, should cardiac disturbances evidence themselves, pointing to a slight muscular weakness or slight dilation, it is strongly suggestive of beginning or existing

diseases of the cardiac musculature.

GENITO-URINARY.

T. A. HOPKINS, M. D.

Urinary Diagnosis.-M. L. Harris, Chicago (Jour. A.M.A.), describes and discusses the merits of the various methods devised of late years for ascertaining the conditions of the different portions of the urinary tract. He points out the advantages and disadvantages of ureteral catheterization and those of the segregating apparatus, more especially his own, with which he has had most experience. The cost of the catheterizing instruments and the great skill required, necessitating long practice, limit the use of these devices, valuable as they are, to the hands of a very few operators. The use of the segregator calls for less practice and skill, but it is available only in selected cases where the anatomic and pathologic conditions are favorable. Thus thickening of the base of the bladder, intravesical growths, enlarged prostate, etc., may any of them interfere with its usefulness, as also do some of them with that of the ureteral catheter.

Its most satisfactory use in determining whether kidney disease is unilateral or not, whether certain pathologic products come from the kidney or the bladder, and the amount of work done by each organ. Segregation is not, however, a simple procedure; the failures that have been reported, Harris is convinced, were due to bad selection of cases, in attention to details or to expecting too much of the instrument. The value of the cystoscope is emphasized; its use should precede both catheterization and segregation. Having collected the separate urines, the next thing is to ascertain the functional activity, combined and separated, of the kidneys. Here the elimination of solids is the index, and for this we have recourse to cryoscopy, since the freezing point indicates the number of molecules in solution. If there is a marked

lessening of the solids from one kidney as compared with the other. it means an abnormality. All the factors, the time and the considered. To see whether elimination of body weight of the patient, however, must be excrementitious matters is complete by the urine, blood cryoscopy is available, but there may factors intervene. For reliable deductions from combined blood and urine cryoscopy we must know the amount of the former secreted in a given time, together with the body weight and general diet, and in regard to the latter the amount of hemoglobin and other factors that may influence the freezing point. After mentioning the phloridzin test, Harris summarizes the newer aids to diagnosis in diseases of the urinary tract in the order of their value as follows: 1, The cystoscope; 2, ureteral catheterization or segregation with comparative analyses of the separate urines; 3, the X-ray; 4, the phloridzin test; 5, comparative cryoscopy of the separate urines; 6, cryoscopy of the blood with the necessary

corrections made.

The Individual Treatment of Diabetes Mel

litus. Henry S. Stark (Med. Record) advises the treatment of the individual patient in diabetes mellitus, rather than the arbitrary treatment of the disease by stereotyped methods. The severity of the pathologic process cannot be measured by the amount of sugar in the urine. We should study the power of the patient to assimilate carbohydrates; his general state, whether anemic, plethoric, obese, or emaciated; his mental attitude, his digestion, his ability to maintain nitrogenous equilibrium, the complications, and the preferences of the patient as to diet. We cannot put our patients on a diet that starves them of carbohydrates, but only lessen the amount taken. Under prophylactic treatment the author advocates a modified diet for the children of diabetics, with a systematic examination of the urine. occurrence of an excess of uric acid may be a forerunner of diabetes. Treatment must be systematic. The patient should be restrained from gratifying his appetites for food and drink. If emaciated and weak, a diet of increased fats is valuable. For glycosuria and polyuria codeia should be given only in very moderate doses. For the skin lesions about the genitals the author uses & soothing lotion and protective application. In bad case catheterization for a time works well. We should prevent diabetic coma, as when it is established very little can be done. For this he uses alkali-therapy, purgation by croton oil, blood-letting if necessary.

The

Exstrophy of the Bladder.-H. M. Sherman, San Francisco (Jour. A.M.A.), reports