dominal operations, to his own satisfaction if the sense of touch is hampered with gloves. For operations upon septic cases he believes that gloves ought to be worn, especially if other operations are impending. The degree of certainty with which the skin of the patient can be disinfected depends upon the region. The patient's skin is far more difficult to disinfect than the hands of the surgeon or of his assistants. The writer declares himself as exceedingly dissatisfied with the result of his efforts to disinfect skin. As to sutures, on the whole there is no better material than twisted silk for buried sutures and ligatures. In spite of the efforts of numerous investigators and inventors, catgut still remains an object of suspicion. The writer thinks this is to be deplored because it is an admirable substance for a variety of surgical purposes. He invariably uses catgut for septic wounds. It is invaluable for operations about the rectum and perineum. It is also best to use catgut when there is reason to suppose that the wound is tuberculous. although some specimens may contain no infective organisms, they may contain ptomains which set up and localize suppuration. The writer has not had very gratifying results from the use of silver wire, but he approves of the use of a layer of silver foil for covering wounds. The wound by this means is kept dry, with the entire absence of any trace of redness or oedema. The writer finally treats of the question of sponges. He declares that he is by no means convinced that sponges prepared by the sulphurous acid method are infective. But, he adds, we greatly need a thorough investigation of disinfected sponges by the most rigorous and recent bacteriological methods.

But

Deutsche medizinische Wochenschrift, February 4, 1904. Attempts at a Serum Diagnosis of Carcinoma.-Mertens describes attempts he made to elaborate a precipitin reaction for carcinoma, but like Engel, who recently published similar experiments, his results were unsuccessful. He injected rabbits with extracts from carcinomatous growths, and endeavored to obtain specific precipitations with the blood of carcinoma patients, The results were inconstant, not all the cancer patients reacting positively, while some healthy individuals did give a reaction. The author is not discouraged, however, and discusses the possibilities of the production of a curative

serum.

of

The Value of Rubber Gloves in Manual Extraction of the Placenta.-Baisch enumerates the features which make this one of the most hazardous obstetrical operations, chief being the facts that it must often be performed hurriedly without time for proper hand sterilization, and that during the act of removal all germs present are necessarily actually inoculated into the huge open Wound represented by the interior of the uterus. Under these conditions the use of rubber gloves is of the greatest advantage, and since their use the mortality in these cases has fallen to o per cent. in the Tübingen clinic, while in other large institutions it is in the neighborhood 3 per cent. In Tübingen the number of patients running an absolutely normal course after manual extraction 15 70 per cent. in Berlin and Munich; where gloves are not used it is 51 per cent, and 38 per cent. respectively. In addition to the actual advantage attending the use of gloves is the consolation, in case the patient does badly, that nothing was left undone to ensure her safety. Phthisiogenesis and the Struggle against Tuberculosis.E. v. Behring takes the ground that the tendency to acquire tuberculosis is formed in infancy, and that the socalled predisposition to the disease consists in an infantile invasion of the blood and lymphatics with tubercle bacilli. Pulmonary tuberculosis is to be regarded as the last stage of this early infection, which during childa latent course, but induces an increased susceptibility of the lymphatics and vessel walls to the tubercle toxin. The author's view of the tuberculous disposition is therefore different from that usually accepted, as he considers that it is not acquired through transmission by inheritance, but only through infection in infancy. In order to combat the infections in the radle which may become pulmonary lesions later in life, the author says that until the time arrives when we begin to employ for infants the same protective inoculations he has successfully used in calves, we must prevent the tubercle bacillus from gaining access to the mouths of babies, and must administer tubercle antibodies with their milk. Owing to its mode of formation, freshly secreted milk contains antibodies in abundance, ut many factors, such as heat, cold, long standing, the development of bacteria, etc., quickly destroy them. The author proposes to ensure their preservation by adding formalin in the strength of 1-10,000, to the fresh milk. This does not impair its nutritive value, and the

hood runs

results in the raising of calves have most effectively demonstrated the value of the plan.

Berliner klinische Wochenschrift, February 8, 1904.

A Contribution to the Therapeutics of Neuralgias and Myalgias.-Meyer says that the ordinary coal-tar analgesics, as well as the various systems of hydrotherapy, massage, etc., often fail to subdue obstinate neuralgic conditions. In such cases he has found that hydrochinon does excellent service. He employs it in doses of one to four grams daily, and usually gives it in solution at bed-time. The solution should be fresh, and not be exposed to the light. No unpleasant effects were noted, except in one case in which nausea, tachycardia, and vertigo were produced, but quickly subsided on stopping the drug.

A Case of Congenital Bronchiectasis with Transposition of the Viscera.-Siewert describes the case of a young man of twenty-one who since childhood had had attacks of coughing, accompanied by the sudden expectoration of large amounts of purulent fluid. He was poorly developed mentally and physically, and a physical examination showed complete transposition of the viscera. There were also signs of a cavity in the left upper lobe anteriorly. In the absence of all evidence of tuberculosis, gangrene of the lung, etc., the author diagnoses the condition as a congenital bronchiectasis. This is a very rare condition, as only four cases were found reported in the literature.

Münchener medizinische Wochenschrift, February 9, 1904. A New Symptom in Esophageal Carcinoma.-Steiner describes a case in which the œsophageal bougie was observed to be drawn downward during inspiration and to move upward during expiration. The phenomenon was ascribed to adhesion of a carcinomatous mass to the diaphragm and the autopsy confirmed this view.

Permanent Tubage in Esophageal Stricture.-Schiele treated an oesophageal stricture due to carcinoma at its lower extremity and which threatened to become impermeable, by carrying through it a short drainage tube on a bougie. The tube was perforated in the customary way, and to keep it from slipping into the stomach its upper end was perforated by a thread the ends of which were tied to a suitable tooth. The patient was in this way enabled to swallow fluids and semi-solids while the dilated lower segment of the oesophagus was kept drained. The tube was changed every five days and occasioned no discomfort.

Diagnosis with the Esophagoscope.-Stark calls attention to the value of this instrument, which owes its development largely to the efforts of v. Mikulicz. The author places the patient in the recumbent position on one side and thoroughly cocainizes the pharynx, larynx, and upper part of the oesophagus. It is a mistake to hyperextend the head, as this flattens the oesophagus against the vertebral column and renders the introduction of the instrument more difficult. The technique of the examination is not difficult and the author was successful with every one of his last one hundred cases. Of forty-six patients recently examined, seventeen were carcinomatous, three had cicatricial lesions, two had foreign bodies, two had diverticula (traction), two had diverticula (Zenker's), three had diffuse dilatation, six had neuroses, one inflammation, and in ten complicated conditions existed which did not permit of diagnosis.

Artificial Ischemia.-Müller has performed over seventy major operations on dogs, using suprarenin solution as a hæmostatic and reaches most satisfactory conclusions. The object of the experiments was to determine the value of this agent in controlling the hemorrhage from parenchymatous organs, particularly the liver and kidney during incision and resection. In order to produce satisfactory anæmia in such organs solutions of 1-1000 or 1-2000 are required, but in the skin, fatty tissues, and muscles a strength of 1-5000 or 1-10000 is most suitable. The agent does not appear to be poisonous in quantities ever likely to be used. The vasoconstriction is produced within two minutes and lasts for several hours. Resections of the liver may be performed entirely without parenchymatous bleeding by injecting the solution along the line of proposed incision; and deep dissections of the neck, chest, etc., may be bloodlessly performed in the same way. Slightly pink solutions are safe to use, but a deeper discoloration indicates dangerous decomposition. Capillaries and small vessels are completely occluded, larger vessels are constricted. There is no danger of secondary hemorrhage. When diluted with decinormal salt solution the injection of supra

renin is painless. The author has not yet repeated his observations on man, but is convinced that the agent will be found just as useful in major operations as it has already shown itself in minor surgery.

Book Reviews.

PROGRESSIVE MEDICINE. A Quarterly Digest of Advances, Discoveries, and Improvements in the Medical and Surgical Sciences. Edited by HOBART AMORY HARE, M.D., Professor of Therapeutics and Materia Medica in the Jefferson Medical College of Philadelphia; Physician to the Jefferson Medical College Hospital; one-time Clinical Professor of Diseases of Children in the University of Pennsylvania; Member of the Association of American Physicians, etc. Assisted by H. R. M. LANDIS, M.D., Assistant Physician to the Medical Dispensary of the Jefferson Medical College Hospital; Member of the Staff of the Henry Phipps Institute for the Study, Treatment and Prevention of Tuberculosis. Volume IV, December, 1903. Philadelphia and New York: Lea Brothers & Co., 1903. THIS Volume contains, among other interesting matter, a chapter by J. E. Hemmeter, on diseases of the digestivé tract; one by J. C. Bloodgood, on various surgical conditions, including an excellent review of the literature of tumors, benign and malignant, with some interesting illustrations; William T. Belfield contributes a chapter on genitourinary diseases, and J. R. Bradford one on diseases of the kidney. The practical therapeutics are brought well up to date by H. M. Landis. As a whole, the volume compares very well with those that have already appeared in this series, the editor and publisher both evidently having a fixed determination to make the work all that they have promised for it.

FOURTH ANNUAL REPORT of the WORK OF THE CANCER LABORATORY of the New York State Board of Health, conducted at the Gratwick Research Laboratory, University of Buffalo, for the year 1902-3. Albany: State Department Printers, 1903.

JUST at this time, when the subject of cancer is exciting so much interest the world over, the report from the laboratory established exclusively for the study of this scourge, must challenge our attention. The report before us deals with an investigation of cancer districts; the etiology of cancer, its biology and chemical study; toxic and vital theories regarding its causation; statistics; the physics and therapeutic value of the cathode and ultra-violet rays; closing with an epitome of the history of carcinoma by Roswell Park, M.D. The work, taken as the result of careful investigation in a most important field, will be of decided interest to all those whose labors lie in the same direction.

zu

ÜBER DIE PROGNOSE DER SYPHILIS. Vier Vorlesungen gehalten in den ärztlichen Fortbildungskursen Aachen, 1902-1903. Von Dr. G. MAYER, Geh. Sanitätsrat. Berlin: S. Karger, 1904.

THIS is a brochure of eighty-seven pages only, dealing, however, with the most important subject. It is arranged in the form of four lectures. The first, on the prognosis in syphilis in general specific brain and spinal cord affections and general paralysis. The second, taking in tabes, syphilitic nerve affections, and syphilis of the heart and blood-vessels. The third is upon syphilis of the lung and liver. The fourth, includes syphilis of the kidney, diabetes and gout in their relation to syphilis. The chapters are all written in a pleasing style, and the subject matter is surely worthy of the careful consideration it has received.

A TREATISE ON ORTHOPEDIC SURGERY. By ROYAL WHITMAN, M.D. Second Edition; revised and enlarged. Philadelphia and New York: Lea Bros. & Co., 1903. THE second edition of this excellent treatise should meet with as cordial a reception as the first. Most of the chapters have been revised and extended; new illustrations and x-ray pictures have been added. Congenital hip dislocations, coxa vara, and tendon grafting, which have in recent years actively engaged the attention of the orthopedic world, are extensively discussed by the author. THE PURIN BODIES OF FOODSTUFFS, and the Rôle of Uric, Acid in Health and Disease. By I. WALKER HALL, M.D., Assistant Lecturer and Demonstrator in Pathology, the Owens College, formerly Senior Demonstrator in Physiology at the Owens College, Victoria University of Manchester; Hon. Pathologist to the Salford Royal Hospital. Second Edition (Revised). London and Manchester: Sherratt & Hughes, 1903. THE second edition of this small book deserves greater commendation than the first, if that were possible. A new chapter appears upon the action of drugs on purin excretion. Also some new tables and methods of estimation and preparation are appended. A noteworthy portion of the book is devoted to bibliography. This is exceedingly extensive and forms a veritable library of reference. The construction of the text is condensed and every word is made to count. As a book of reference and instruction upon the subject treated it is by far the most valuable that has yet appeared.

MAMMALIAN ANATOMY, WITH SPECIAL REFERENCE TO THE CAT. BY ALVIN DAVISON, Ph.D., Ex-fellow of Princeton University; Professor of Biology in Lafayette College. Philadelphia: P. Blakiston's Son & Co., 1903. THIS work is intended for the use of the undergraduate student in biology. The major portion is devoted to the gross anatomy of the cat, the various structures being taken up in their logical sequence. The introduction contains a small section on the minute anatomy of the tissues and the preparation and preservation of material for such purposes. There are 108 illustrations, all of which are well executed. The practical questions and sugges tions which are appended to each chapter will be of great service to those compelled to take up the study of this subject without the aid of an instructor. As a work on comparative anatomy it cannot fail to find its place. PATHOLOGIE UND THERAPIE DER RACHITIS. Von Dr. WILHELM STtoelzner. Berlin: S. Karger, 1904. THIS monograph is written with characteristic Teutonic thoroughness, and rachitis is considered from every possible point of view in the most exhaustive manner. Much has been gathered from the European literature that is not generally known in this country, and the chapter on etiology is particularly interesting. The author considers all existing theories untenable, and tentatively submits that the disease may be due to the functional insufficiency of some organ analogous to the thyroid. This view is founded upon the general similarity between rachitis and cretinism, and the author suggests that the adrenals may possibly be the organs at fault. Therapeutically he has found a solution of phosphorus in cod-liver oil the most valuable agent.

Die ersten Zeichen der Nervosität des Kindesalters. Von Prof. H. OPPENHEIM. Berlin: S. Karger, 1904. In this address the author of what is perhaps the best known German textbook of nervous diseases rehearses the various abnormalities of psychical development in children which are often the first aberrations of a mentality tending toward later disaster. While such peculiarities may be, and often are, outgrown, still their timely recognition may be the means of preventing serious difficulties in after years and they deserve the attention of all interested in the problems of childhood.

LES TROUBLES Gastriques DANS LA TUBERCULOSE PULMONAIRE CHRONIQUE. Par Le Docteur E. DU PASQUIER. Paris: G. Steinheil, 1903.

THE author discusses the clinical and prognostic features of the gastric disorders usually accompanying pulmonary tuberculosis, basing his conclusions on a series of eightyfour cases in which analysis of the stomach contents was made. He points out the paramount importance to the tuberculous patient of a good digestive apparatus and emphasizes the necessity of the examination of test-meals in order to carry on the treatment successfully. Every other consideration should be subordinated to the assimilative function and no drugs continued if they react unfavorably on the stomach.

CLINICAL TREATISES ON THE PATHOLOGY AND THERAPY OF DISORDERS OF METABOLISM AND NUTRITION. BY Prof. Dr. CARL VON NOORDEN, Physician in Chief to the City Hospital, Frankfort a. M. Translated under the Direction of Boardman Reed, M.D., Professor of Diseases of the Gastro-intestinal Tract, Hygiene and Climatology, Department of Medicine, Temple College: Physician to the Samaritan Hospital, Philadelphia, etc. Part IV. The Acid Autointoxications, by Prof. Dr. Carl von Noorden and Dr. Mohr. New York: E. B. Treat & Co., 1903.

THIS little compend is a valuable addition to this series. The author presents the results of his investigations into the derangements of metabolism which are concerned with the formation of an excess of acid in the body. This subject is one of great interest to the clinician, for it is true, as said in the preface, that those physicians who successfully treat chronic diseases must carefully observe the digestion, excretion, and assimilation of their patients. TUBERKULOSE-ARBEITEN AUS DEM KAISERLICHEN GESUNDHEITSAMTE. I Heft. Mit 5 Tafeln. Berlin: Julius Springer, 1904.

THIS contribution is divided into two parts, of which the first, by Kossel, Weber, and Heuss, is a comparative study of tubercle bacilli obtained from different species of animals. The results seem to show that in the majority of cases human tubercle bacilli differ in morphology and in cultural and pathogenic characteristics from those found in tuberculous cattle. Occasionally, however, bacilli are found in man which cannot be differentiated from those causing Perlsucht in cattle.

The second part, which is by Weber and Bofinger, discusses fowl tuberculosis and tends to show that the tubercle bacilli of fowls and of mammals possess clearly marked points of difference. The bibliography of both sections is especially valuable.

Society Reports.

NEW YORK ACADEMY OF MEDICINE.
Stated Meeting, Held February 18, 1904.

Dr. ANDREW H. SMITH IN THE CHAIR. The Hospital Car: Its Equipment, Uses, and Importance. -Dr. WM. W. SANFORD read this paper, and said that when the plan of having such a car was suggested to the Erie Railroad officials, a combination baggage car and smoker was selected for the purpose. By removing the double row of seats sufficient room was secured for six ordinary hospital beds supplied with mattress and rubber sheets. In the baggage compartment were operating table, sterilizers, oxygen, drugs, etc. Such a car would prove to be almost invaluable. The doctor showed drawings of a typical hospital car, and this he believed should serve as a type of several cars which should be distributed at certain distances along the roads. He then gave the details of the interior arrangement of such cars, which would be of great value to the companies, as well as to the injured, because of (1) saving of valuable time; (2) bringing to their aid a sufficient number of physicians and nurses; (3) equipment being always at hand. He believed that at present the large number of deaths from railway injuries was due to lack of immediate surgical and medical treatment, the lack of facilities for treating these patients, and the lack of time. The need of such cars seemed to him imperative.

Dr. ANDREW H. SMITH referred to the diminished liabilities of the companies from the results of accidents, and stated that things were different to-day from what they were a few years ago, when the life of a man was considered to be equivalent to $5,000. Then the companies were in pocket if the people were killed outright; if then they were injured and not killed there was scarcely any limit to the amount of damages claimed. To-day life was estimated by the earning capacity of the individual. In case an accident takes place and the company had made no provision for the care of the injured he said the sympathy of the juries would be against the company; but if such cars as suggested were provided sympathy would change in favor of the company.

The Rationale of the Natural Arrest of Consumption; a Study Explaining the Effects of Sea Voyages, with Suggestions as to the Ideal Treatment.-Dr. W. B. McLAUGHLIN of Austin, Tex., read this paper. (See page 367). Dr. GEORGE L. PEABODY said he failed to see how a practical turn could be applied to Dr. McLaughlin's remarks or how any practical deductions could be drawn from this artificial environment. A near approach to such a sterilized atmosphere could be had when people lived in the deserts of Egypt. Years ago a colony of consumptives had lived in a hotel near the pyramids, and they, he thought, breathed sterilized air. The same thing could be accomplished in mid-ocean. But how such could be brought about artificially seemed to him a very difficult problem. He spoke of a semi-charitable, organization society that, a few years ago, was engaged in establishing a home for the treatment of consumptives, and one of the Board of Managers asked him to make some suggestions, that they did not want to feel restrained by ordinary limitations, but they wanted certain compartments where patients could breathe air from the heart of the Adirondacks and other compartments where they could breathe the air of mid-ocean, etc. Of course such a thing was practically impossible. To him it seemed difficult to give a practical hearing to Dr. McLaughlin's extremely good theoretical remarks.

Dr. JOHN B. HUBER said that tuberculosis when due to the tubercle bacilli was not particularly fatal, and only when the mixed infection occurred was the disease rendered serious. Therefore, it was of great importance to attempt to do away with the possibility of mixed infection. Sterilized air was important, too, but there were other things to be considered, such as dry air for

some, moist air for others, sea air for some, and land air for others, etc. Tuberculosis was the resultant of many factors; the tubercle bacill were originally saprophytes, and fed upon dead or decomposing material. An interesting subject referred to the devitalizing tissues of the body, and, he said, tuberculosis depended upon the condition of the bacillus and other microorganisms as well as upon certain predispositions, vicious heredity, alcoholism, poverty, and the like, in the body which made it susceptible to the onset of various bacteria.

Col. W. C. GORGAS said that the main idea of the paper was new to him, but he believed it to be very important as bearing upon municipal sanatoria. He emphasized the importance of a liberal supply of air. Patients taken to such a municipal hospital or sanatorium and treated in the way proposed he believed would get well in three or four months instead of eight or ten months, and so would be a great saving to the city.

In

Dr. S. A. KNOPF advocated better teaching of the masses, that rooms should be better ventilated, that the dark, foul, and filthy rooms should be abolished, and, therefore, much could be done in a prophylactic way. The value of sea air was shown in those children especially who were sent to the sea-side with tuberculous bone and joint disease. In many coughs disappeared. A sojourn at the seaside seemed invigorating and so did good. dealing with the tuberculosis problem, he said we should seek continually after the ideal, but we should also do away with what was impractical. To obtain an aseptic atmosphere was impractical, but it was practical to teach the masses the love of pure air. He said that if the municipalities did their duty they would see that the street cars were better ventilated, and make other changes which would result in making traveling facilities better and less dangerous.

Dr. MCLAUGHLIN believed that if what he proposed could be carried out it would be a great advance in the therapeutics of tuberculosis. So far as sterilizing the air was concerned, he said that a great step toward this end would be in removing the dust.

Stated Meeting, Held January 19, 1904. LEWIS A. CONNER, M.D., CHAIRMAN. Chronic Valvular Disease of the Heart; Pulsating Liver. -Dr. S. S. BURT presented a case of chronic valvular heart disease in connection with the paper which he presented later. The patient was a man, thirty-four years of age, who came first under observation in 1899. He had been an intemperate drinker of beer for twelve years, having taken at times as much as one hundred glasses in twenty-four hours. Shortness of breath on walking began about five years before. At that time he complained of dyspnoea, enlargement of the legs and abdomen, and of prostration. Examination showed oedema of the lower extremities, cyanosis of the lips, marked pulsation of the vessels of the neck, ascites, hypertrophy of both sides of the heart and excessive dilatation. The liver extended from the fourth rib down to the level of the umbilicus on the right side. There was a heaving, expansile pulsation of the liver, due to regurgitation into the hepatic veins themselves. He was treated by paracentesis abdominis and saline laxatives, with strychnine and rest in bed. In a few weeks he was improved in almost every way, and finally the tricuspid thrill disappeared, though the mitral systolic and presystolic murmurs were still present. At

the present time, there was a distinct systolic murmur over the mitral area; there was regurgitation of the blood in the superficial and deep veins of the neck; there was moderate pulsation of the liver; the legs were only very slightly oedematous. Aside from the congested state of the liver, due to the heart disease, it was probable that the man also had hypertrophic cirrhosis of the liver. The speaker said that he had seen very few cases of pulsating liver secondary to a cardiac condition in a very large experience with heart disease. He had occasionally met with tricuspid regurgitation secondary to mitral disease, but none so extensive as this one.

Ascites; Hepatic Cirrhosis; Tuberculous Peritonitis.-Dr. WILLIAM B. NOYES exhibited a small section of the liver taken from an Italian, forty years of age. who had been in the service of Dr. F. C. Keller at the Columbus Hospital. The man had been in the habit of drinking three or four glasses of whiskey a day, and before breakfast. Shortly before admission to the hospital, the abdomen began to swell and become painful. On examination, the liver and spleen and genitals were oedematous. There was no jaundice. Over four quarts of clear and highly albuminous serum were drawn off from the abdomen. The urine was free from albumin. On December 6, six quarts and a half were again drawn off. The liver dulness was increased one hand's breadth below the margin of the ribs. The patient died on December 10. At the autopsy, the peritoneal cavity contained 4,000 c.c. of clear yellowish serum. The peritoneum was studded with minute white tubercles. The omentum was agglutinated to the intestines. The liver was bound down on all sides to the adjacent viscera. It weighed 67 ounces. There was marked perihepatitis. The bile ducts were dilated and filled with masses resembling inspissated bile. There were no tubercles in the liver. There were no stones in the gall-bladder, and the common duct was patent. The intestine was covered with minute tubercles. The duodenum and jejunum were closely adherent to adjacent viscera. The right lung was collapsed and consolidated from the pressure of a large pleural effusion. posed increase in liver dulness was due to a solid mass of omentum, the result of tuberculous peritonitis. How much of the ascites was due to the tuberculous peritonitis, and how much to the condition of the liver, it was impossible to say. The liver was the seat of a hypertrophic cirrhosis. The speaker said that clinicians very commonly classified cirrhosis of the liver under two heads, hypertrophic and atrophic, but, according to the pathological classification of Adami the subject was much more complex. Adami divided cirrhosis into seven varieties, viz.: (1) Portal; (2) biliary; (3) pure cellular cirrhosis; (4) arterial cirrhosis; (5) central lobular cirrhosis; (6) secondary cirrhosis, and (7) sporadic cirrhosis. The liver under consideration appeared to belong to the variety of obstructive biliary cirrhosis, this diagnosis being made chiefly from the obstruction of the bile ducts. The microscopical examination showed a very fatty liver and a very small amount of connective tissue in a very early stage of formation. If the man had not had the tuberculous peritonitis, which caused his death, he would have probably lived a long time despite the hepatic cirrhosis.

The sup

Dr. S. A. KNOPF thought there was no other way of distinguishing ascites due to cirrhosis of the liver and ascites dependent upon tuberculous peritonitis than by withdrawing some of the fluid and injecting it into guineapigs.

Dr. BURT referred to a case of cancer in which the performance of paracentesis abdominis resulted in a fragment of cancerous tissue coming away in the fluid. This led to the diagnosis of colloid cancer, a fact which was very suggestive of what might perhaps be accomplished by this mode of investigation. Fluid removed in this way should be subjected to microscopical examination as a routine measure.

Dr. S. A. BROWN referred to a case of peritonitis with

loculated fluid. About sixteen ounces of fluid were withdrawn for diagnosis. On examining this after sedimentation, small colloid masses were visible and were very characteristic. The diagnosis of colloid cancer was confirmed by the autopsy.

Dr. L. A. CONNER said that the demonstration of tubercle bacilli in the serous fluid removed by aspiration was often very difficult, and the necessary delay of six weeks or more after the inoculation of a guinea-pig was a serious objection to that mode of investigation. But between an inflammatory exudate, such as occurred in tuberculous peritonitis and a stasis exudate, such as occurred in portal obstruction or cardiac disease, there were distinct differences, such as in the specific gravity and the presence of traces of nucleoproteid. The hydræmic transudates gave a very low specific gravity, usually 1008 or less; the stasis transudates of cirrhosis or cardiac disease gave a specific gravity of 1009 to 1012, and the inflammatory exudates usually showed a specific gravity of 1018 to 1025. In tuberculous peritonitis the specific gravity was usually 1015 to 1025. If the albumin were estimated by Esbach's method, or better still, by weighing, some differences would be observed. In the hydræmic transudates there would be hardly more than a trace of albumin, in the stasis transudates the amount of albumin was usually I gm. to the litre, or o.1 per cent., although it was sometimes as much as 1 per cent.; in the inflammatory exudates the quantity of albumin was very large, sometimes as high as 2 or 3 per cent., or 20 to 30 gm. to the litre. The nucleoproteid was much more apt to show in the inflammatory than in the other exudates.

Dr. Burt said that it had been recently demonstrated that nucleoalbumin could be shown very nicely by intravenous inoculation of the material into animals. Within a few minutes the whole venous system became clotted, and the animal died. If the heart were rapidly opened,a long string of blood-clot could be drawn out.

Multiple Serositis and Extreme Myomalacia.-Dr. LEWIS A. CONNER presented pathological specimens taken from a Chinaman who entered the Hudson Street Hospital a few weeks ago in a moribund condition. A diagnosis of pneumonia was all that there was time to make. The autopsy revealed, in addition to the pneumonia, a condition of multiple serositis, a complete synechia of the pericardium, adhesions of the pleural cavities at their bases, extensive perihepatitis and perisplenitis, and more or less chronic peritonitis. The heart was of special interest. The two layers of the pericardium were everywhere adherent, and there was a dense fibrous mass binding down the heart. The organ itself was considerably dilated. There were a few antemortem clots in the dilated ventricle. The most noticeable feature was a lage area of diffuse yellow material in the wall of the left ventricle. It was firm in consistence, and the microscope showed an extreme condition of fatty degeneration of the heart muscle, in some places going on to the point of liquefaction. The coronary vessels were examined with great care, but were found to be practically normal, though the small branch of the coronary artery running to this softened area was very small. However, on examition of the intima and sections very little pathological change was discovered. It was, therefore, very difficult to explain satisfactorily the great diminution of this vessel and the softening of the heart muscle. The great mass of fibrous pericardium lay directly over the thinwalled arteries, and this suggested the possibility that this dense fibrous casing for the heart might, in some way, have caused sufficient constriction to give rise to this very extensive softening.

Dr. C. E. QUIMBY suggested that it would be well for physicians to bear in mind that there were many defects in creation, and that there was no more reason to expect perfection in all of the organs and tissues of the body than to expect every person to have the same size and shape of nose.

Miscellaneous Points on the Palpation of the Chest.Dr. WILLIAM N. BERKELEY read a paper with this title. He said that, as a rule, the books on physical diagnosis were rather lacking in information on palpation for diagnosis. The average physician seemed to think that, in comparison with auscultation, all other methods of physical diagnosis were insignificant.

Vocal Fremitus.-The speaker said that fremitus might be classified as: (1) Rhoncal; (2) tussive; (3) borborygmic; (4) pleuritic; (5) succussive; (6) cardiac and vascular, and (7) vocal. His remarks at this time were limited to the consideration of vocal fremitus. When eogophony was absent, it might be made apparent to the ear by the phonation of the short “oo" as in foot. Vocal fremitus was more reliable when the patient could retain the pitch throughout the test. The vibrations of the voice had a quality as well as a pitch and an intensity. The variation of the fremitus with the varying loudness or intensity of the voice was familiar to all beginners. The lower the pitch, the fewer the vibrations present, and the fewer these vibrations, the more perceptible the individual waves became to the palpating ingers. With women and reasonably intelligent children over six years of age, marked improvement in the fremitus could be obtained if the patient were told to speak in as deep a voice as possible instead of in the usual shrill tone. Palpation of the fremitus should be done with the palmar surface of the forefingers of the hand the observer is most accustomed to use. He did not think the side of the palm was a good surface for the performance of palpation. Two symmetrical areas of the chest should, of course, be compared, but this comparison should be made, not with the two hands, but with the same hand. A highly trained tactile sense was often capable of extraordinarily fine discrimination. It was usually stated that fremitus was conveyed to the chest through the windpipe. This doubtless was true, but it seemed reasonably sure that the elastic walls of the trachea and bronchi also assisted to an appreciable degree. Fremitus was likewise conveyed by the vertebral column and the ribs. Accumulations of fat and muscle on the exterior of the chest were not so destructive of fremitus as was usually supposed. Fremitus was usually universally larger on the right side than on any corresponding portion on the left side. He believed in 60 to 75 per cent. of patients, with the patient in the usual position for examining the back, right vocal fremitus below the angle of the scapula was absolutely larger than over any part of either the right or left chest. The excess on the right side was supposed to be due to the relative anatomy of the right and left bronchus. The excess of right fremitus was physiologically greater in persons between ten and twenty-five years of age than at any other age, a fact to which his attention had been called by Dr. A. A. Smith. This was probably of developmental origin. A numerical comparison of the normal right and left fremitus might seem far-fetched, yet he ventured to affirm that if the right subclavicular fremitus were denominated 3, that of the corresponding portion on the left side would be 2. He had found that a diagnosis of consolidation at the right apex, when the larynx fremitus was to the right fremitus as 4 to 2, or 6 to 3, was usually confirmed by the other signs. The causes of left-sided fremitus excess were: (1) Consolidation of the left side; (2) influences on the right side which dissociated the visceral from the costal pleura; (3) obstruction of the right bronchus, and (4) transposition of the viscera. Plaques of mucus, stenosis, foreign bodies, diphtheritic membrane, and the pressure of aneurysms, glands, and mediastinal tumors were among the obstructions of the bronchus to be thought of. In old women and small, anæmic children the relation might be changed by holding the chin high and rotating the chin to the left, thus artificially compressing the right bronchus. Supposing the loudness and pitch of the voice to be constant, the whole problem in vocal fremitus was

to determine whether it was increased, diminished, or absent.

Dr. BURT said he would like to know why, on listening over a pleuritic effusion, vocal fremitus would be absent on palpation but would be present on auscultation. Vocal fremitus he esteemed very highly, and for that reason he greatly appreciated the paper presented by Dr. Berkeley.

Dr. JOHN HUBER thought the paper was very interesting in connection with the diagnosis of early phthisis, for tuberculosis of the bronchial glands was now generally considered to antedate the affection of the lung parenchyma. Possibly this involvement of the bronchial glands could be detected by vocal fremitus.

Dr. C. E. QUIMBY said that the ear was vastly more sensitive than the fingers, and that this seemed to him to explain the fact that vibrations could be detected by the ear when they were imperceptible to the finger. He would deny that, over fluid, one could sometimes obtain vocal fremitus and at other times could not. He believed that fluid in the chest, which would cut off vocal fremitus in one case, would do it absolutely in all cases in which fluid was present under similar conditions. Years ago he had arranged an apparatus in connection with the Helmholtz resonator by which one could optically demonstrate a valvular murmur by means of a glass flame. He would suggest that the same thing could be done more conveniently by the use of a powder It was also desirable to make use of a resonator that can be tuned to the pitch of the murmur or special vibration.

Dr. S. A. KNOPF said that there was evidently much yet to be learned concerning the science of physical diagnosis. He had been deeply impressed with the remarks made by the reader of the paper as to the sounds which the patient should be made to express. It was his custom to ask his patients to make a humming sound, and then ask them if they felt the vibration of their voice in any special direction. It was interesting to note that when there was beginning consolidation on one side or the other, the patient would often point to this spot as being the place at which the vibration of the voice was conscious to himself. Dr. Knopf said he had used this method as a means of diagnosis for a long time. When asking the patient to make a humming sound he also placed his hands over the chest, and thus readily appreciated the vibration.

ment.

Valvular Disease of the Heart and Its Treatment.-Dr. STEPHEN S. BURT read this paper. He said that without doubt many persons whose valvular defects had been proper compensated for were seriously injured by treatTreatment was not indicated unless the compensatory hypertrophy was followed by secondary dilatation. If there were progressive sclerosis, the duration of the compensation was always uncertain. Mitral stenosis and mitral insufficiency were about equal in their eventualities. Valvular disease in the first half of life, if properly compensated for, was not unusually especially dangerous in connection with pneumonia or with the use of anæsthetics, but the opposite was true in later life. The physician should endeavor in every case of organic disease of the heart to explain to the patient, without exciting his apprehensions, just the significance of the particular affection of the heart from which he was suffering. Plenty of sleep and fresh air, and habitual light eating were important factors in keeping up good health in such persons. Alcoholics should generally be avoided. Very hot baths, including the Russian and Turkish baths, were exceedingly dangerous, as was also swimming. Bathing was largely a matter of personal peculiarity. To condemn a person with heart disease to a life of inactivity was the height of bad management; such persons should have moderate exercise in the fresh air, but no violent muscular exercise should be allowed. The important thing was to insist upon moderation in everything-mental and physical exercise, eating and drinking. When rupture of