January 12th.-Patient very much prostrated; lower lip excoriated; pulse frequently becomes irregular; breathing difficult and labored, but cyanosis is slight.

January 13th.-Color has become waxen; breath very foul; cyanosis more marked; abdomen is distended; some delirium and restlessness;; carphologia and subsultus tendinum, varying with a semi-comatose condition; pulse weak and very irregular; inhalations of oxygen were used for three minutes every half hour, and have improved condition somewhat. Patient has been lying on

left side for last twenty-four hours, and complained very much when disturbed. Examination of heart shows a dilatation of right side, dulness extending only a finger's breadth from the right sternal margin.

January 14th.-Patient's condition worse, symptoms of intoxication being more marked. Patient had a series of chills; temperature went up to 105.2 deg.; sponging proved ineffectual; patient gradually became weaker and died at 10 a.m.

Autopsy-Six hours after death; body well developed and nourished; rigor mortis and post-mortem staining slight. On

section-Thorax: No pleural adhesions; both pleural cavities contained a considerable quantity of sero-purulent fluid: right side, six ozs.; left side, twelve ozs. Right lung: Filled cavity fairly well, was soft and flabby, pitting on pressure, crepitates and floats; on section, smooth, darker than normal, showing hyperemia throughout, and edema of lower lobe; small sections taken from different areas readily float; no consolidated areas visible; bronchi normal. Left lung: Considerably collapsed, and pressed upwards and backwards; crepitates throughout, though less than right; responds to hydrostatic test; bronchi normal. Heart: Pericardium non-adherent; cavity contains about four ozs. of sero-sanguino-purulent fluid; both surfaces markedly roughened, dull and dark in appearance; heart weighs four and a half ozs., is oversized for child of eight years, but is firm. On section, right side muscle appears paler, but not thicker than normal; endocardium shows no signs of inflammation, no dilatation of cavities; pulmonary and tricuspid valves competent and natural in appearance; left side, wall of ventricle hypertrophied, three-quarters of an inch thick; endocardium healthy; wall of left auricle slightly thickened; posterior and outer parts completely covered with extensive verrucose excrescences, greyish-white in color, quite firm in organization. Mitral valve admits three fingers; cusps show large vegetations completely covering them, and extending down the tendinous cords for a short distance; no ulcerative process visible microscopically; the valve is thickened, but no tearing nor perforation. Aortic valve looks healthy and competent. Coronary and other vessels look normal. Liver: Somewhat enlarged, pale, firm. Gall-bladder full and duct patent. Spleen: Enlarged, seven inches by three and a half inches, looks hyperemic and softened; mesenteric glands not enlarged. Kidneys: right shows stellate hemorrhages in cortex; capsule non-adherent; cortex not thickened. Left-in lower quarter is a fibrous scar, sclerotic and white, extending through cortex and medulla, probably an old infarction. No. metastatic abscesses nor emboli found. Other organs and structures appear healthy.

Microscopic Examination.-Section of vegetation from left auricular wall shows inflamed connective tissue, round cell infiltration and granulation tissue, some organized fibrin.

Bacteriologic Examination.-Cultures from the pericardial fluid show the diplococcus pulmoniæ. Heart blood does not show anything.

Features of interest in this case are: (a) The extensive mural distribution of the vegetations, which alone mark it as malignant; (b) the mural excrescences being limited to the left auricle; (c) the pure pneumococcic infection; (d) the enlarged spleen; (e) the severe pericarditis and pleuritis, with sero-purulent effusion as complications; (f) the absence of any apparent preceding or accompanying pneumonitis; (g) the absence of emboli.

Regarding the distribution of the vegetations, we all agree, I think, that the presence of extensive vegetations on the cavity endometrium always means malignancy. Both Osler and Holt mention the greater frequency of the involvement of the left ventricle over any other surface in mural endocarditis.

Of thirty-three cases of malignant endocarditis reported by Weichelbaum, seven showed a pure pneumococcic infection. Twenty-five per cent. of Osler's cases were from that source.

Traube says endocarditis from pneumococcic infection is short in duration, less fatal, temperature continuous, and embolisms rare.

Viewed from a pathological standpoint, a severe verrucose endocarditis, due to pneumococcic infection, may be just as malignant as a severe ulcerative process.

Henry L. Elsner, Professor of Medicine, Syracuse University Medical College, reports a case of extensive mural endocarditis, of pneumococcic infection, in which there were no symptoms nor signs of pneumonia, and makes this statement, that endocarditis following or accompanying pneumonia is rather rare.

Of 254 cases of pneumonia seen in the Tübingen clinic (Henke Virchow's Archiv., Bd. clxiii., No. i.) but one was observed to have endocarditis.

We know that the endocarditis of pneumonia has special anatomic peculiarities, viz., the right side of the heart is attacked with an unusual degree of frequency, and the aortic more frequently than the mitral valve.

Sandford Blum, Professor of Diseases of Children, University of California, reviews the subject of the etiology of endocarditis, with especial reference to bacterial agencies, and sums up his thesis thus: 1. Bacterial agencies are active in the cause. 2. The presence of bacteria in the circulation is not sufficient cause alone; a locus minoris resistentiae must exist (experiments of inoculation, in which the endocarditis is not wounded, give negative results, but when you wound the endocardium, as by puncturing the aortic valves, through the left carotid artery, plus inoculation, you can produce an infective endocarditis). 3. Not all bacteria cause endocarditis, but in general those which are pathogenic for the individual. 4. Congenital and infantile, due to defective. development. 5. Endocarditis due to mechanical or chemical

insults.

Dr. Glynn, in his Lumlein lectures at the Royal College of Physicians, London, 1903, speaks of the great frequency of enlarged spleens in his cases of endocarditis and looks on this as a very valuable aid in diagnosis.

Osler says the diagnosis of the condition rests on physical signs that are notoriously uncertain.

The examination of the blood is important, and should be made in all cases where infection is suspected.

COUGHS AND COLDS.

BY WILLIAM F. WAUGH, M.D., CHICAGO, ILL.

THE digestive system is taking a well-earned rest, after its painful experiences of the past summer. Many a little grave is filled by the patients of the men who "do not believe in intestinal antiseptics," and who "do not know that the sulphocarbolates are used internally." Those who rely upon chalk mixture, rhubarb, calomel, bismuth, tannin mixtures, Hope's paregoric, and those who "are going to try Haller's acid next summer, have made their usual average, saving all but the bad cases, and winning just enough success to encourage them in persisting in the old way. The men who do not know it all, but are willing to try a new idea, have tested the sulphocarbolates and the alkaloids, and have scored heavily in the race for life and for success. They have renewed their faith in their art, and once more believe that the doctor's profession is a God-sent one, and that they can do something else besides mutilate their patients.

Now we have the respiratory mucosa to deal with. Who was it said the doctor goes forth to visit his suffering mucous membranes? He was right, for a very large percentage of our work is with these tissues.

Is there any malady that has more remedies than a common cold, or is more universally mistreated? Nearly everyone recommends treatment involving the swallowing of much water, and this fills the blood-vessels to repletion, and they discharge their 'surplus into the channels offering the least resistance, and these are the partially paralyzed vessels of the inflaming respiratory

tract.

They must be partially paralyzed, for the vasomotors lose their tonicity and permit more blood to enter than is normal. Why not squeeze out this surplus by giving strychnine up to its full effect, till the vasomotors are restored to normal tone? But if there is too much blood here, there must be too little somewhere else, as there is nothing to indicate that there is more blood in the body than the normal quantity. But this means that some other vessels are partly empty, are contracted—that is, their vasomotor contractors are spastic. Hence we may reach the difficulty in another way, by relaxing these spastic vessels and permitting the surplus blood to flow out of the distended pituitary tissues. Here is where our hot foot-baths, hot drinks. and, depressing remedies come in. We may combine these two principles, by adding to our strychnine either aconitine or veratrine, selecting

the latter if the elimination is faulty. Burggraeve said that both these processses could be stimulated at the same time, the spastic cells or fibres taking up the aconitine and the patetic fibres absorbing the strychnine, just as bone cells absorb lime and nerve cells phosphorus, both presented to them by the blood. Is there any more difficulty in conceding to the cells the power of taking up such drugs as they require to restore physiologic balance, any more than the power of taking up such food as they require for the same purpose? Just what is the difference between foods and drugs, if either is needed to restore the equilibrium we term health? Try it, anyhow; giving strychnine arsenate, gr. 1-134, and amorphous aconitine, same dose, and repeating every fifteen minutes till the effects of one or the other are manifest, in slowing pulse or increased arterial tension. If the patient is below par, add digitalin Germanic (really digitalein), gr. 1-67, to reinforce the strychnine; or if the pulse is full and fast, the emunctories closed, add veratrine, gr. 1-134, till the occurrence of slight nausea or gastric burning indicates that enough has been taken. By this time the "cold" will be a thing of the past, and the doctor will have learned, if he did not know it before, what truth is in Burggraeve's theory as to the simultaneous action of apparently antagonistic remedies.

More than once we have spoken of faulty elimination in connection with colds. Were we to desire a cold, we would eat a Thanksgiving dinner, and shut up the eliminative doors. Don't try it; but the next case you get, stop all food, and especially all drink, and eliminate, sweep out the alimentary tract, open up the skin with pilocarpine, or the kidneys with bryonin or apocynin, or both by veratrine; and the phenomenon of a disease" jugulated" will be demonstrated. The old woman-it must have been. one who advised to "feed a cold," must have considered the cold's interests, but not the patient's. The absolute stoppage of all food and drink-we mean water, too-gives the best results when trying to abort an attack.

The greatest of remedies for a tight dry cough is to be found. in ipecacuanha-not the crude drug, which contains the acrid emetic principle, cepheline, but the milder emetine, which is also an eliminant and acts on the liver more effectually even than does calomel. Give gr. 3-67 to an adult every half hour till the secretion becomes thin and free, and the hyperemia of the bronchi and larynx has subsided. If nausea supervenes, lessen the dose, but continue the remedy. It has no known equal. By leaving out the cepheline you get the maximum effect on the respiratory mucosa with the minimum of nausea. In the rare cases, when there is an idiosyncrasy against all forms of ipecac, even in minute doses, we may fall back on apomorphine. This is not