By many a deficiency of fat is accepted as a cause. Herter, however, by feeding pigs on skim milk was unable to produce rickets, only obtaining a mucoid degeneration of the fat of the adipose tissue when carbohydrates also were deficient. Apparently rickets cannot be attributed to such factors as potassium phosphate. An intestinal irritation or infection, as shown by a successful experimental case described by Spellman, and experiments on animals indicate that unsuitable food may be capable of producing it. A series of clinical observations made by Freeman indicated that there was less rachitis in bottle-fed children in dirty tenement houses than in clean children fed on modified milk in a light and well-ventilated institution, but the average age was lower in the latter class, so that the two are not strictly comparable. R. W. MARSDEN. THIERY. Contribution to the Study of Tuberculosis. L'Echo Médical du Nord, 1904, p. 267. THE writer refers to the minute structure of the miliary tubercle and then emphasises the following points. Giant cells can be produced by simple irritation and may be found associated with epithelioid cells in granulation tissue. The nucleus as director of the cells' activity is replaced by the tubercle bacillus. The tubercle bacillus acts in two ways, one as a foreign body in the production of giant cells the other by secreting tuberculin, a toxin which has the power of causing a further change, namely, caseation. Caseation is the essential characteristic of the tuberculous lesion. The rapidity of caseation depends on the activity of the bacilli in secreting tuberculin. The giant cells of certain sarcoma and also the myeloplaques differ from the tuberculous giant cells in that the protoplasm remains living and does not undergo necrobiosis. The cancer germ far from destroying the protoplasm seems to increase its activity. JOHN HAY. VEILLARD (J.). Contribution to the Study of "Emitted Rales" through the Upper Air Passages in Pulmonary Tuberculosis and Some Other Bronchial and Pulmonary Affections. Rev. Méd. de la Suisse Romande, 1904. VARIOUS writers have described sounds heard on listening at the open mouth of patients suffering from pulmonary or bronchial troubles. Dr. Veillard describes and classifies these sounds and attempts to give them a prognostic and diagnostic value. He includes all these adventitious sounds under the term "Emitted râles" and classifies them in the following way: (a) Sibilant rhonchi-chiefly expiratory. (b) Fine moist râles-occurring at the end of inspiration and the end of expiration. (c) Large moist râles. He suggests that the site of origin can be inferred from the quality of the sound, for example the large rhonchi are probably produced in the larger air-passages. The sibilant rhonchi may be due to alteration of the vocal cords or to a thickening of the fine bronchioles or prealveolar vestibules; or to a contraction of the muscular ring about the orifice of the alveolus. When these sibilant rhonchi are more audible at the mouth than by auscultation of the chest wall it proves that there is a relative integrity of the pulmonary parenchyma. The fine moist râles are characteristic of a tuberculous lesion of the first or second degree and occur at the end of inspiration and expiration. Their fineness locates their origin in the prealveolar bronchioles or in the alveoli themselves. Differential diagnosis will be difficult in cases of bronchitis with emphysema and bronchiectasis. This method of auscultation is of value in the case of children and can be made use of while the child sleeps provided its mouth is open. The following are the conclusions arrived at by the writer: (1) The râles heard on ordinary auscultation in the interior of the diseased lung can frequently be heard in a more precise manner by direct auscultation-that is by listening at the open or half open mouth. 2. The râles thus emitted are observable and observed as well by the patient who produces them as by the doctor and friends. 3. They form a symptom of diagnostic and prognostic importance in many bronchial and pulmonary affections. 4. Their presence in the case of a patient suspected of a bacillary infection will confirm in an absolute manner the diagnosis of a tuberculous pulmonary affection. 5. However, a focus of pulmonary tuberculosis cured or in the process of advanced cicatrisation can exist without giving rise to the production of any such râles. 6. The quality and calibre of the emitted râles will determine the degree of evolution of the pulmonary tuberculosis. (a) Sibilant rhonchi may be the first appreciable symptom of a bacillary invasion giving rise to a localised catarrh, or the size of a lesion formerly considerable, in the process of regression and cicatrisation the slight concomitant catarrh will be the last phenomenon perceptible from the point of view of emitted rhonchi before the complete silence of the apparent cure. (b) Moist emitted râles of different calibre when they persist are an absolute sign of a tuberculous lesion. JOHN HAY. ROSENTHAL (G.). Respiratory Insufficiency: The Technic. Médicale, May 28th, 1904. RESPIRATORY gymnastics are intended to produce normal breathing, and should be conducted without mechanical appliances. The respiratory movements can be grouped into four classes: 1. Respirations in different regular attitudes. The patient in position of dorsal decubitus, nasal breathing; the inspiration and expiration regulated by the raising or lowering of the hand. If diaphragmatic insufficiency be noted then repeat the exercise with one hand laid on the abdomen while beating time with the other, and see that the patient so breathes that the hand placed on the abdomen is raised during inspiration. Repeat these exercises in positions of lateral decubitus, right or left, with patient seated or vertical; then with arms crosswise in the air or held horizontally in front. 2. Respirations accompanied by passive movements of the trunk arms or legs. There are numerous exercises described under this heading, the essential factor being the pure inspiration and expiration, the movements being only accessory. The following are described amongst many others :-(a) The patient seated, the arms held horizontally out. The patient raises them slowly during inspiration, and lowers them during expiration. (b) The patient seated on a couch with legs extended; lay him down while he is inspiring; or, on the contrary, the patient being extended on the couch, raise him to the sitting posture while he inspires. This last exercise has a remarkable effect on the function of the diaphragm. (c) The patient being laid upon the couch, with legs extended, flex his legs during inspiration and extend them during expiration, and you will notice the energetic action of the diaphragm. 3. Respirations accompanied by active movements of the trunk arms and legs. Still more varied are the active movements. All are good so long as they necessitate only a minimum of effort and are accompanied by nasal respiration sufficient and complete. The author especially emphasises the value of swimming movements as described by Knopfrotation of the arms and springing movements. He insists upon the absolute exclusion from all the respiratory exercises of dumb-bells or weights because exercises requiring force necessitate the closure of the glottis and can only interfere detrimentally with the breathing. 4. Respiration in the different acts of life, such as reading, writing, walking, etc. In the course of the first exercises the doctor must be prepared for three things-the initial coryza, the initial diminution of the perimeter and the fatigue and giddiness of the patient. In the coryza order vaseline 100, boric acid 10, resorcin 1 or menthol 5. The diminution of the perimeter at end of expiration is a good sign, showing that the respiratory excursion is increasing in magnitude. The giddiness is really due to increased oxygenation. This fatigue is inevitable and marks the beginning of useful seances. Little by little the patient becomes accustomed to the increased supply of oxygen. The aim being to establish complete respiration, it is advisable to auscultate the chest and discover those areas of diminished vesicular murmur, then with appropriate exercises to secure a free and agreeable entry of air to those parts of the lung. JOHN HAY. Surgery. RHOADS (T. L.). The Diagnosis of Abscess of the Liver. Surgery, 1904. Vol. xxxix., p. 711. Annals of THE features which characterise a typical case of liver abscess seen early in the course of the disease are:-History of dysentery contracted in the tropics; loss of weight; drawn features; ashy-brown complexion; languor. He is generally an ambulatory case, but feels very much out of sorts, and is willing to try anything to be restored to health. His brain is clear but inactive. The skin is moist; the tongue is coated with greyish fur; the appetite is lost; he is either constipated or has an active chronic dysentery. There is a dragging pain over the liver; the liver dulness is increased; the subcutaneous veins over the hepatic area are dilated, and there is an area of tenderness. The temperature rises in the evening to 100°F. (pure amoebic type) or to 102°F. (mixed infection), the corresponding morning temperatures being 98°F. and 99°F. The pulse in the evening is 95 (pure amoebic type) or 110 (mixed infection), the corresponding morning beats numbering 72 and 85. He feels chilly, but has no rigors. He has a leucocytosis of 12,500, 70 per cent. hæmoglobin, and 3,500,000 red blood corpuscles per cm. The urine shows a trace of albumen, and at times casts. On the other hand, there is no jaundice or splenic enlargement; there are no friction sounds over the hepatic area, nor is there bulging of the chest wall or local oedema; cough is not a symptom; basic pneumonia is absent, and there is no dyspnoea. Stool examinations if positive for amoeba are merely confirmatory, if negative are of no significance. X-rays are of no benefit in the detection of small abscesses in the interior of the organ, but where the abscess has reached large proportions or encroaches on the capsule, the change in the surface contour can sometimes be outlined with the fluoroscope, and this evidence will supplement the information given by percussion, etc. P. R. COOPER. MAGUIRE (G. J.). Acute Contagious Pemphigus in the New-Born. Transactions of the Obstetrical Society of London, 1903. Vol. xlv., p. 429. THE writer gives details of an outbreak of this rare affection which occurred at Richmond, Surrey, in the autumn of 1902. The number of cases was eighteen, the deaths eight. It was proved to have been conveyed from case to case by a certain midwife. A bacteriological examination of serum from two cases showed the presence of staphylococcus pyogenes aureus. The disease was characterised by a bulbous eruption on the skin, variable in extent, the specific micro-organism being found in the contents of the vesicles. In many cases no symptoms other than this eruption were manifested, but a certain number of cases showed grave symptoms of a general infection and invariably ended fatally. The point at which systemic invasion began in these fatal cases was the unhealed umbilical scar. Although the disease occurred chiefly in the new-born and was fatal to these only, it also attacked older children and even adults. Treatment had apparently no effect on the course and duration of the disease. MOSCHCOWITZ (A. V.). A New Osteoplastic Amputation at the Ankle-Joint. Annals of Surgery, 1904. Vol. xxxix., p. 790. THE operation here described is a decided advance on the ordinary Syme's amputation. The writer insists that the good qualities of a stump depend entirely upon the way the bone is covered, i.e., by normal. cartilage or periosteum. To attain this in the case of amputation at the ankle-joint he removes portions of the internal and external malleolus in such way as to leave two osteo-periosteal flaps which can be turned over so as to completely cover the cut surface of bone. The flaps are secured in position with catgut sutures, and the bony stump formed by the lower end of the tibia then forms a level surface covered in part by its own articular cartilage and internally by bone and periosteum. The writer has performed the operation in one case with a perfect result, and has no hesitation in recommending it for regular use in appropriate cases. P. R. Cooper. EDEBOHLS (GEO. M.). Renal Redecapsulation. May 21st, 1904, p. 804. Medical Record, AFTER renal decapsulation, in from three to twelve weeks a new capsule forms, which may be thinner or thicker than the original, but is always more succulent and vascular. Such being the case Edebohls discusses the propriety of a second decapsulation in selected cases in which after a more or less protracted period of improvement the clinical symptoms of Bright's disease return, or become aggravated. He has recently put this into practice in a patient upon whom he had performed renal decapsulation two years previously, and although the case terminated fatally from uræmia which had commenced before the performance of the second operation, yet it showed that the removal of the new capsule presents no greater technical difficulties than that of the original one. RUCKER (S. T.). Treatment of Gonorrhea. ARTHUR H. BURGESS. American Medicine, RUCKER describes the correct technique of his method of treating gonorrhoea, gleet, and stricture by packing the urethra with a medicated |