ing with the previous speakers. For the past ten years he had employed currents of both high and low frequency, and n various forms. For the past two years he had tried the hypostatic current, and during the past year the current of D'Arsonval. He had just returned from a trip abroad, during which he had endeavored to study the work of electrotherapeutists there. He had never found electricity as available as a therapeutic agent as, for example, massage, in the treatment of nervous disease, functional or organic, or of general visceral disease. He did not deny, however, that there was a certain field for electrical treatment. His own experience was entirely opposed to that of Dr. Herdman regarding the eliminative action of electricity. He admitted that, following electrical treatment, there might be increased diuresis or diaphoresis, and an increased output of urea or uric acid, but the same result might follow the taking of a cup of coffee. While making these statements, he wished it understood that he was not trying to depreciate electricity, but rather to justify his belief that electricity was not of signal value in therapeutics. He declared that proof was entirely lacking of the statements made in favor of electrotherapy. He had hoped to hear of new applications of electricity of much promise, but he had been disappointed, and with a fairly extensive knowledge of electricity he felt justified in making these statements.

Dr. Piffard, in closing the discussion, said that he thought the demonstration of the lighting of the lamp should be sufficient to show Dr. Rockwell that a current of much more than two or three milliamperes was employed. The lamp could be brought to full incandescence if specially constructed lamps were used, but because of the peculiar insulation employed in our commercial lamps a spark would occur and break the lamps.

NEW YORK ACADEMY OF MEDICINE.
Stated Meeting, Held October 1, 1903.

CHARLES L. DANA, M.D., VICE-PRESIDENT, IN THE CHAIR.
Predisposition to Tuberculosis.-Dr. JOHN B. HUBER
read this paper.
He said that up to very recently it had
been contended that only a vulnerability to tuberculosis
was transmitted from parents to their offspring. It was a
well-defined law of heredity that functional rather than
anatomical alterations were transmitted. Insanity and
alcoholism were often correlated with tuberculosis. In
tuberculous, as in syphilitic subjects, there were usually
present degenerated states of the tissues which rendered
them an easy prey to bacillary invasion. There was
abundant evidence of primary tuberculosis in the bron-
chial glands, and in almost every part of the body primary
tuberculosis was found. The place of deposit, however,
was not necessarily the point of entrance of the parasite.
The bronchial twigs which supply the apex of the lung
were often defective in their structure, and, moreover,
there were imperfect expansion and aëration of this portion
of the lung, so that it was not surprising that the apex of
the lung should be the point of election for the tuberculous
process. In infants, abdominal tuberculosis was much
more frequent than pulmonary, and at this period of life
gastrointestinal diseases were especially frequent. If
digestion in the stomach were impaired, the tubercle
bacillus might be allowed to pass through the intestine,
and from there they would pass into the thoracic duct and
would eventually reach the pulmonary circulation by the
way of the vena cava. A faulty metabolism played an
enormous part in rendering the tissues vulnerable to the
invasion of tuberculosis. A deficient circulatory system
meant reduced oxidation and tissue starvation, particu-
larly in the lungs. Pulmonary tuberculosis was almost
invariably found in persons dying in the course of chronic
alcoholism. It was difficult to explain the effects of alco-
hol, but the bad effects of alcohol in this disease were
largely connected with the unhealthy conditions asso-

ciated with alcoholism. Poverty, with all that it implied, stood in an important etiological relation to tuberculosis. There seemed to be a subtle relation between insanity and tuberculosis. Many of the inmates of insane hospitals apparently free from tuberculosis on admission to those institutions, developed the disease subsequently, and of those entering with the disease already developed, very few recovered. Altitude, temperature, moisture, season, and soil were probably also etiological factors. Among the diseases predisposing to tuberculosis were bronchitis, pneumonia, influenza, the exanthemata, typhoid fever, and diabetes. The speaker was of the opinion that scrofulosis and tuberculosis were not always the same thing. The scrofulous constitution was one upon which the tubercle bacillus was often, but not always, implanted. The Koch bacillus was by no means the only factor to be dealt with in tuberculosis. The antimicrobic drugs which had been given internally with the idea of destroying the bacilli had been generally worse than useless. Our improvement in the treatment of tuberculosis lay, not in the use of any special bactericide, but in our appreciation of hygienic methods.

Dr. W. FREUDENTHAL emphasized the important part played by the upper respiratory tract in the development of general tuberculosis.

Dr. S. A. KNOPF said that in the main he agreed with the reader of the paper. It had been his frequent and sad experience that the children of tuberculous parents were very apt to contract the same disease, and, hence, he could not understand why some writers still insisted that such parents often conferred an immunity upon their offspring. His own view of the question of heredity in this connection was that there was a transmission of physiological poverty. The majority of tuberculous people coming from large families, according to his experience, were not the first-born, but those born when the parents were comparatively old and feeble. The theory had been advanced that predisposition to tuberculosis was partly dependent upon what might be called a demineralization of the blood. The gentleman who had propounded this theory had also recommended that tuberculous persons be given large quantities of common salt, and, in the speaker's experience, this was a valuable suggestion. Whatever might be the explanation, the fact remained that these persons seemed to thrive upon food containing an abundance of salt.

Dr. A. JACOBI said that alcoholism could only be charged with undermining the constitution, and thereby causing some sort of predisposition to microbic invasion, not necessarily only of the tubercle bacillus. Further than this he would not be willing to admit that alcoholism was a predisposing cause of tuberculosis. We had all been taught that serious heart disease and tuberculosis were not often found associated; indeed, there were some facts pointing rather to the probability of heart disease tending to prevent rather than to cause tuberculosis. Bier had shown that by the artificial production of venous obstruction tuberculous joint disease could sometimes be cured. In heart disease there was venous obstruction in the lungs, and this fact probably explained why tuberculosis and heart disease were very seldom associated. When the conformation of the chest was such as to interfere with the free and natural movement of the lungs, there was more apt to be tuberculous involvement. As far back as 1858 Freund called attention to premature synchondrosis of the sternum and ribs in young subjects as being frequently associated with tuberculosis-a fact which should cause no great surprise, because the effect on the chest would be to make it long and narrow and interfere with the action of the lungs. It was not so much poverty as overcrowding that explained the spread of tuberculosis among the poor. It should not be forgotten that in infancy there was a natural predisposition to tuberculous infection, owing partly to the deficiency in bacterial ferments in the blood of infants as compared with what was

found in older children and in adults, and partly to the anatomical condition of the mucous membrane and the deficiencies of the epithelium there. It had been demonstrated that the tubercle bacillus could pass through normal mucous membrane. Only lately a direct connection had been found between the intestinal tract and the submaxillary gland. Thus, the bacilli might be absorbed in the stomach, be carried to the submaxillary gland without any notable ulceration of the intestine having taken place.

Dr. LOUIS FAUGÈRES BISHOP said that predisposition was not a positive, but a negative thing. Most of us were immune to tuberculosis, otherwise we would contract that The disease, being more or less constantly exposed to it. loss of this natural immunity might result from a variety of causes, as, for example, alcoholism and pleurisy. The object of treatment should be to re-establish this natural immunity. We could hardly expect to eliminate infection entirely, but it could be brought within such bounds that the system could cope with it.

Dr. LOUISE G. ROBINOVITCH said that, according to her experience, extending over a period of many years and including a large number of alcoholic cases in a varied hospital practice, she had been unable to find any direct relation between alcoholism and tuberculosis. She took exception to the statements made in the paper that there was any relation between tuberculosis and insanity, and thought there would be found in the literature high authority in support of her contention.

Dr. MAX EINHORN said that about fifteen years ago he had examined the gastric juice of children, and had found that it differed considerably from that of adults. hydrochloric acid was very rarely found in these young subjects at the period of digestion at which it would be present in abundance in older persons. He mentioned this to suggest that, because of this absence of hydrochloric acid, it might be that the tubercle bacilli were afforded a better opportunity in the infant's stomach for passing through the stomach unharmed.

Dr. Huber closed the discussion. He said that several pathologists had told him that tubercle bacilli were almost never found in the alveoli of the lungs, and that, while particles of dust might be found in the alveoli in cases of anthracosis, this was not common. This fact, therefore, showed the possibility of the tubercle bacilli gaining entrance to the alveoli, even though this was not the usual channel of infection.

Medical Items.

July 1-Sept. 30. .Oct. 11-17..

SMALLPOX-INSULAR.

SMALLPOX-FOREIGN.

Great Britain, Birmingham. Bristol. Glasgow. Leeds.. Liverpool.

Aug. 1-31... .Aug. 30-Sept. 12.

3

New Castle-on-Tyne.Sept. 7-Oct. 3.

Mexico. Mexico.

Merida.

Russia, Odessa.

St. Petersburg. Warsaw Spain, Barcelona. Turkey, Constantinople. Smyrna. Venezuela, Yaritagua.

Texas, Connell.

Castroville. Hondo.

Laredo.

YELLOW FEVER-UNITED STATES.

San Antonio.

Brazil, Rio de Janeiro... Mexico, Mexico..

Merida..

Nuevo Laredo.
Progreso.

Tampico..
Vera Cruz.

3

.Sept. 28-Oct. 4. Sept. 23..

77

Prevalent.

Contagious Diseases- Weekly Statement. - Report of cases and deaths from contagious diseases reported to the Sanitary Bureau, Health Department, New York City, for the week ending October 24, 1903:

Venezuela, Puerto Cabello.

11

I

Great Britain's Mortality Statistics.-The Sixty-second Report of the Registrar-General of the United Kingdom for 1899 gives the death from zymotic diseases at 89,235, or 2,811 per million of population. Tuberculous diseases destroyed 60,659, or 10.4 per cent. of deaths from all Alcoholism caused the death of 2,871, or 112 per million living among males and 70 among females. Cancer and malignant diseases destroyed 26,325 persons, or 829 per million of all ages and both sexes. As to the infant mortality, 163 infants under 1 year of age died in

causes.

India, Calcutta.

Straits Settlements, Singapore... Aug. 29-Sept. 5

PLAGUE-UNITED

STATES.

California, San Francisco....... ...Oct. 7.... ... ... ... ... ... ....

Philippine Islands, Cebu.

PLAGUE-INSULAR.

Manila.

THE surgical opening of a new side-track for the blood of the portal vein has been performed for the relief of atrophic cirrhosis of the liver with ascites exclusively. Ever since Thomas Lens"1 first publication, the fixation of the omentum to the peritoneum has been done to alleviate symptoms resulting from hepatic cirrhosis with vascular obstruction, and the consequent accumulation of the ascitic fluid in the peritoneal cavity.

In the first of the two cases I am about to bring before you, an erroneous diagnosis of adenoma of the liver was the reason for the second laparotomy, and when the true nature was discovered the operation of sewing the omentum, gall-bladder, and liver to the parietal peritoneum was made as an ultima ratio experiment only.

In the second case the diagnosis of hypertrophic biliary cirrhosis-Hanot's disease-was considered prior to the surgical interference and the operation planned deliberately and deemed justifiable by the successful issue of the first one.

CASE I.-Mr. Samuel Magnus, a native of Prussia, thirty-nine years old, a salesman, residing in San Francisco, came under my care September 22, 1902. The father died of some unknown lung and liver trouble; the other family history is negative. He is a moderate smoker, and drinks very little.

He had gonnorrhoea when a young man, but noflues. Suffered from hemorrhoids twelve years ago, from inflammation of the bowels eight years ago, and from muscular rheumatism four years ago. About three years ago the patient suffered from headache, constipation, and tenderness and pain over the liver. His stools were not claycolored, but he passed a little blood with the fæces. He has been more or less jaundiced since that time and did not feel well since. He never had any symptoms of intermittent fever.

The present aggravation of his illness began two months ago, when he suffered from diarrhoea and passed a great deal of slimy mucus with his stool, became more jaundiced again, had poor appetite, and suffered from cramp-like pains over the right hypochondriac and iliac regions. The pain has increased in violence and is particularly severe between the angle of the costal arch and the umbili

cus.

The examination shows his eyes to react normally to light and accommodation and the conjunctivæ of a deep yellow color.

The thoracic organs are normal. There is a pronounced tenderness on pressure below the right costal arch and over the appendix, and a marked bulging in the right hypochondriac region.

On palpation the right rectus is found more re*Read before the California State Medical Society, at the annual meeting at Santa Barbara in April, 1903.

$5.00 Per Annum. Single Copies, 10c.

sistent than the left. A hard swelling in the abdomen can be mapped out, reaching down into the right hypochondrium to near the level of the umbilicus. The upper border of the liver-dulness extends along the superior edge of the sixth rib, its lower border in the mammary line is within one finger's breadth of the umbilicus. The surface of the swelling feels smooth and even. The spleen extends from the seventh to tenth ribs and is easily palpable. Temperature not over 100°, pulse between 70-90.

Diagnosis, chronic appendicitis and enlargement of the liver, probably due to gallstones or some obstruction in the gall-bladder or biliary ducts.

On September 22 the enlarged, inflamed, and adherent appendix was removed by the usual incision parallel to and about 3 cm. to the median line from Poupart's ligament. It had been the intention to extend the incision to the liver and remedy what would be found amiss there, but the patient did so badly during the operation, that it was decided to postpone it. Palpation of the liver at the time of the appendectomy showed it enlarged, especially the right lobe, which could be felt well down below the border of the ribs near the line of the umbilicus. A rather hard large growth, about the size of a large walnut, was found in the lower part of the right lobe. The gall-bladder was found somewhat enlarged, but no stones were palpable. The edge of the spleen could be felt below the margin of the ribs and seemed to be harder than normal. A diagnosis of adenoma of the liver was made.

The pain and tenderness in the right iliac fossa passed off after an uninterrupted recovery from the operation, but the pain and tenderness over the liver still continued, and the patient did not improve much.

On November 4, under chloroform narcosis, an incision was made along the outer edge of the right rectus, commencing at the margin of the ribs and going down 10-12 cm. In incising the peritoneum a small serous pseudocyst is opened and about one teaspoonful of clear watery fluid evacuated.

There were a few light transparent adhesive bands with delicate vessels between parietal and visceral peritoneum over the liver and gall-bladder. The latter was slightly enlarged, about the size of a small plum, rather yellowish-gray in color. Its contents could be easily expressed. There were no stones either in the gall-bladder or in the ducts.

The liver showed a yellowish-red color and a nodular surface, was much enlarged, reaching nearly to the level of the umbilicus, felt much harder than normal and had, in the middle of the right lobe, a little below the edge of the ribs, a hard nodule the size of a large walnut. There were several smaller nodules about the size of a hazelnut toward the left lobe.

The gastroepiploic veins along the large curvature of the stomach and in the omentum were much dilated. The spleen could be felt two or three fingers' breadths below the left costal arch. The omentum was brought into the lower part of the wound and sewed for the extent of 4 or 5 cm

to the parietal peritoneum, so that the latter closed over it.

In the further course of sutures the gall-bladder with its fundus and the liver surface were taken in. In pulling the gall-bladder forward a small superficial tear occurred at its posterior attachment to the liver, and a profuse venous hemorrhage resulted.

An iodoform gauze strip was packed between the gall-bladder and the liver and the wound united around the strip with interrupted layers of chromicized catgut sutures. The skin was united with interrupted silk-worm gut, covered by silver-leaf dressing, and the patient was put to bed. At the end of three days the strip was removed and the remaining opening closed with three interrupted silk-worm gut sutures. The patient went on to an uninterrupted recovery. The stitches were removed on the tenth day. On his leaving the hospital, January 8, the pain and tenderness had entirely disappeared as well as the jaundice, and the liver boundaries were as follows: the upper border coincided in the parasternal line with the upper border of the sixth rib; the lower border was found at the free margin of the ribs in the mammary line. The spleen was still palpable, and no appreciable change in area of dulness was noticeable.

I was fortunate enough to secure his presence here (April 23, 1903), and you can verify by his excellent appearance the continuance of his improvement. He assures us that he never felt better in his life. He has been working steadily for the last three months and has gained about twenty pounds in weight. An examination will show you that the liver does not exceed now the normal boundaries while the spleen is still palpable.

CASE II.-My second patient, Mr. Joseph Biber, a native of Roumania, merchant, thirty-six years old, residing in San Francisco, was admitted to the hospital November 8, 1902. His mother died of pneumonia, sixty-four years old; father is still living at an age of seventy-four years. One sister, when thirty years of age, was operated upon for a tumor of the bowels, no recurrence since the operation, five years ago. He is a moderate drinker of beer and whiskey, but very rarely drank to excess. During childhood he suffered from measles, diphtheria, nasal catarrh and supraorbital headaches, and from his seventh to eleventh years suffered from severe and frequent attacks of diarrhoea. In 1897, after eating pickles, he was taken sick with severe epigastric pain and constant vomiting. The patient was told that he suffered from ptomain poisoning. The attack lasted for two weeks and then passed off, but for the following year the patient suffered from frequent vomiting attacks and loss of appetite and a dull heavy sensation in his right side. About this time the veins of the right leg began to swell. Two years later the patient became slightly jaundiced and his urine very dark; the veins of the right leg also began to dilate. He sought medical aid and felt better periodically, but lost strength. Last year the urine again became dark, the jaundice increased and the patient suffered from a dull heavy pain in the regions of the liver and spleen. There was slight constipation at this time and severe pruritus. At present the patient suffers from loss of appetite, weakness and dull dragging pains in the region of the liver. Respiration, 18; pulse, 68; temperature, 98.2°.

The patient is 5 feet, 4 inches in height, slightly emaciated, having lost 19 pounds since his sickness began, his skin is yellow, and he shows a deep yellow tinge of the conjunctiva. The pupils react normally. The tongue is large and indented at the margin by the teeth. The mucous membranes are pale and

slightly icteric. Thorax is funnel-shaped, bilateral prominence from the third to the fifth costal cartilages, sternum drawn in. Slight excursion of the chest on respiration. Anteriorly there is a slightly higher pitched note on the right side, extending from the apex to the upper border of the fourth rib; vocal fremitus and resonance slightly increased over high pitch area. Heart apex beat not visible, left border of cardiac dulness 5 cm. laterally from the left sternal line; upper border at costal cartilage, right border about middle of sternum not clearly distinguishable. Heart sounds are diminished in strength over all the valves.

Abdomen: Inspection shows epigastric pulsation and distinct bulging in the right hypochondrium. Palpation reveals a tumor in the right hypochondrium, reaching to near the level of the umbilicus, it moves with respiration, and is intimately connected with the liver, painful on pressure, smooth and nonfluctuant. The upper border of the relative liver dulness commences in the parasternal line at the upper border of the fifth rib, the absolute dulness at the lower border of the sixth rib. The lower edge of the liver in the midaxillary line is at the free border of the ribs, 4 cm. below the costal arch in the mammary and right parasternal lines. There is an excursion of 2 cm. on respiration. The edge of the spleen is easily palpable. The area of splenic dulness extends from the upper border of the sixth rib to the costal margin and anteriorly to a point midway between the mammary line and anterior axillary line. Both legs show varicose veins from the feet up to midways on the thighs. They are more pronounced on the right side.

The patient was put on light saline purgatives, full diet, and general roborant treatment, with rest in bed. There was no improvement. Examination on November 23 showed the lower border of the liver at the level of the umbilicus on a point midway between mammary and right sternal line. The other conditions were similar to those on entrance.

. An operation was decided upon and performed on November 24. The incision began at the costal arch, at the outer edge of the right rectus muscle, and followed it in a straight line downward about 12 cm. Division of the fascia and muscle and opening of the peritoneum followed. The liver was much enlarged, extending almost to the umbilicus, distinctly granular, hard to the touch, and of a dark red color with a tinge of yellow. The gall-bladder was about normal in size and of a grayish white, slightly yellowish color. The large bile ducts were free from stones or other obstructions, the bile being easily expressed from the gall-bladder slight adhesions between the gall-bladder and pylorus and duodenum; there was no ascites. The omentum had a light yellowish tinge. The gastroepiploic veins along the greater curvature of the stomach and over the omentum were dilated. The spleen was much enlarged, extending to near the umbilicus, but free from adhesions. The omentum was sewed to the parietal peritoneum in the lower half of the incision with catgut. A very small Mikulicz tampon was introduced, as there was considerable hemorrhage from the easily severed adhesions of the gall-bladder, at its lower posterior surface. The hemorrhage was very profuse, so much so that the intended excision of liver tissue for microscopical examination was abandoned. The upper part of the peritoneal incision was also united with chromicized catgut sutures, which were carried through the gall-bladder and liver tissues. The fascia and muscle were united with interrupted chromicized catgut

sutures, the skin with interrupted silkworm gut. Silver-leaf dressing was applied.

The temperature never rose above 99° F. On the third day the Mikulicz was removed, and wound closed with sutures. Stitches removed on tenth day. Healing by first intention.

At the end of two weeks the patient's appetite improved and the jaundice began gradually to disappear. The liver began to grow smaller. On the date of discharge, January 8, 1903, there was no perceptible icteric tint to the skin, and but a faint yellowish tinge to the conjunctivæ, noticeable only on close examination. The upper line of dulness is the same as before operation. The lower border in mammary line about 2 cm. below the costal margin; from thence it extends outward in a horizontal line to the right sternal border. No appreciable difference was distinguishable in the splenic dulness, though the edge was not so easily palpable. The patient returned on February 15, and examination of the liver and spleen show the same condition as on January 8.

On April 13 he presented himself again at my office and was kindly examined by Dr. Henry Harris, formerly of Johns Hopkins, now assistant professor in clinical diagnosis in Cooper's College, who had also examined him and concurred in the physical and clinical diagnosis previous to the operation. Dr. Harris dictated the following report of a the patients status: (1) Patient of good color, no sign of jaundice of skin or conjunctiva. Nutrition is good, patient complains of no discomfort, feels well, complains of constipation, relieved by laxatives. Pulse 96, regular in force and rhythm, fair tension, small volume, artery walls just felt. Chest funnel-shaped. Lungs clear. Heart negative. Back shows no deformity. (2) Abdomen of

normal contour; flank and inguinal lines symmetri

cal. In the right half 41 cm. from the middle line is a linear scar extending from the costal margin 141 cm. along the outer edge of the rectus muscle. No hernia. The skin of the abdomen is normal in appearance, there is no jaundice, no dilatation of veins, no protrusion of the navel. No caput medusæ. There are three very small cutaneous angiomata, pinhead in size, all of which are on the right side. Respiratory movements are normal and equal, no peristalsis is seen. Litton's sign present.

On palpation the abdomen is soft. Slight pain complained of on pressure over scar at the level of the navel. The areas adjoining the scar are somewhat thickened, more resistent than on the corresponding parts of the left side.

On

Liver. No bulging on inspection. Percussion reveals absolute hepatic flatness to begin in the right mammary line at the middle of the sixth rib, extending 1 cm. below the costal margin. The total vertical extent of hepatic flatness in the right mammary line is 11 cm., being only about 1 to 2 cm. or aboutto of an inch more than normal. In the midaxillary line the vertical extent is 7 cm. deep palpation the edge of the organ is not distinctly felt. There is an impression of a round, descending body at the intersection of the costal margin and the right mammary line. The gall-bladder is not felt. There is considerable thickness in the right rectus adjoining the scar. On auscultatory percussion the lines determined previously by simple percussion are

confirmed.

723

reached on deep inspiration is 9 cm. below the costal margin.

Stomach.-Not dilated. The lymphatic glands are not enlarged. No hemorrhoids. Marked varicose veins on both legs, extending on the left leg to the knee only, on the right to the upper part of thigh. of thigh. Patient presented himself again in July, 1903; improvement continues; spleen appears. smaller.

Hæmoglobin examinations of both patients have unfortunately been lost, only one of Magnus, taken at the time of his departure from the hospital, has been found. With the exception of but 80 per cent. hæmoglobin, this shows normal conditions. Dr. Walsh, our faithful interne, who made the various blood counts, recollects, as I also do, that the first blood counts before the hepatocystopexiæ showed erythrocytes between 3,000,000 and 4,000,000 and hæmoglobin between 50 and 60 per cent., both conditions being markedly improved afterward.

I have also reason to regret that the severe hemorrhage in the second case prevented me from excising. a small specimen of liver tissue for microscopical examination. I must confess that in the first case the idea of excision only occurred to me after the closure of the abdomen, but I doubt now whether I would have risked it at the time, as the hemorrhage. was nearly as bad as in the second case.

A confirmation of the macroscopical diagnosis by the microscope is a circumstance devoutly to be wished for, to satisfy the scientific demands of such observations. However, the history and the long duration of the illness in both cases, previous to the operation, their pathologic-anatomical changes at. that stage, the excessive hypertrophy with induration of the liver, the enlargement of the spleen, the

long standing but variable icterus, the complete

absence of ascites and anasarca, do not well admit of any other diagnosis than chronic biliary hypertrophic cirrhosis of the liver.

In view of the facts communicated to you, the question naturally arises how to explain the curativeeffect of the operation. In atrophic hepatic cirrhosis with accompanying ascites, the portal system being obstructed, the operation is done to open new lines of collateral anastomosis in order to carry off the venous blood from the abdomen. It is a simple physical proposition.

But in this hypertrophic form of liver cirrhosis. Hanot's' (or rather Todd's disease, for Todd described it in 1857, as recorded in an abstract of a clinical lecture, and drew attention to the hypertrophic form without ascites), no such obstruction

exists.

In Hanot's disease, as you know, the hypertrophic growth of connective tissue does not destroy the mass of the liver-cells proper, their quantity remains undiminished, and although the hypertrophic growth of the new connective tissue is not limited to the interlobular spaces, but penetrates at places into the lobuli between the rows of liver cells, these are left unchanged in quantity and quality, and their trabecular structure is well defined. Within these strands of new connective tissue run the interlobular biliary canals, their walls being thickened by highly cellular connective tissue to twice or three times their normal size. These strands also contain small colonies of very tortuous biliary canaliculi, in places dilated and cyst-like.

The blood vessels, hepatic veins, as well as vena porta and arteries, remain wholly unchanged in this disease. The walls of the smallest branches are not thickened, their lumen perfectly permeable, as demonstrated by artificial injections. Only very late