Indol, it was pointed out, is produced not only from the proteids of food but also during suppuration in a closed cavity, continued suppuration with a free outlet, and in ulceration or necrosis of tissue, the intensity of reaction increasing with the length of time the suppuration has gone on, the adaptability of the surface for absorption, and the extent of the surface of absorption, suppurative peritonitis, for instance, giving an intense reaction much more quickly than pleural empyema. Indol is not the first product in proteid disintegration, being preceded by tyrosin; but tyrosin does not result directly from proteid disintegration. The source of indol may become clearer by studying the relation of the liver to tissue-metabolism. Urea has been accepted as a product of the liver. This means that its mother-substance was brought to the liver by the blood. Hence, a mother-substance is presupposed, bearing some such relation to urea, leucin, and tyrosin as does indol to indoxyl, or indican to indigo-blue. In consequence it may be said that the liver separates tyrosin from its antecedent, and in the continuation of this process indol is set free. To substantiate this view, the experiments of Nepveau and Villiard were adduced, who were able to demonstrate indol and indican in livers and tumors after death by means of oxidizing agents or by extraction with alcohol. It may be assumed, then, that suppuration, or rapid degeneration of tissue, causes an increased deposit of indol in the liver and increased elimination, and after death it may be possible to extract its oxidation-product, indigoblue, from the liver by oxidation. regard to lardaceous changes, it is difficult to study this process because of the difficulty of determining its existence during life, the cessation of liver-metabolism after death, and the difficulty of studying the substance chemically; but its formation has been limited to two conditions degeneration of tissues and suppuration; and it must be accepted that the deposit of amyloid material is a product of the activity of degenerated cells upon a substance antecedent to the amyloid substance that circulates in the blood. Vaux advances the theory that this antecedent substance is a derivative

In

of indol which retains its power of easy oxidation into indigo-red and indigoblue. He notes the reactions of amyloid material, especially that to iodin, and he states that following his hypothesis these reactions must be considered as indicative of a liberation of indigo-red from the tissues by the oxidizing action of iodin, further oxidation to indigo-blue being produced by sulphuric acid. Other proof is found in the facts that the lardaceous material occurs in chronic suppuration, and a marked elimination of indol is seen in such cases; that the former yields tyrosin, while the derivative of indol is a product of tyrosin; that the former is poor in potassium, while the latter has strong affinity for potassium; that the seat of selection of the former is the liver, while indol is freely deposited in the liver in suppuration; and that the primary factor of the lardaceous material is deposited by the blood, while the derivative of indol circulates in the blood and is there oxidized. In regard to the liver, the experiments cited show that indoxyl or its derivative remains in the liver, hence an excess occurs there in suppuration. The lowered vitality resulting from suppuration prevents proper reduction of indol by the liver, and there remains in the liver a large amount of imperfectly reduced and indigo-forming substance. Nitrogenous waste and products of degenerated cells are added, and lardaceous material finally results. The iodin-potassiumiodid test has been mentioned. It is to be noted further that the power of yielding the iodin-reaction is lost by subjecting lardaceous material to strong potassium hydrate, and that after the action of some reagent a solution of indican refuses to give the indicanreaction, and that hydrochloric acid increases the amyloid reaction and liberates indigo-red in solutions containing indican.

Further confirmation of Vaux's theory is found in the fact that Czerny observed that the leucocytes of animals in whom suppuration had been induced yielded the characteristic amyloid reaction, and in Herter's statement that the chief changes found in chronic indolpoisoning were congestion of the liver

capillaries and pigmentation of the liver-cells. It only remains to be shown that the red and blue colorations of the amyloid reaction are due to indigo-red and indigo-blue.

Some Neglected Signs in Chest-Discases. Dr. Norman Bridge, of Los Angeles, Cal., said that, in the absence of the more pronounced signs of pulmonary tuberculosis, slight evidences, such as weak inspiration, prolonged or harsh expiration, and a variation in the signs on the two sides, must be looked for. He insisted upon making the patient expire profoundly, as rales are often heard then. Deep inspiration and coughing should also be practiced. Cracked-pot resonance is a doubtful sign, but, when it is on one side only and accompanied by rales, it means a lesion. Breath-sounds are very likely to be lessened in the early stages of pulmonary tuberculosis, owing to partial closure of the bronchi from deposit. about them. Greater cough during recumbency on the affected side is a valuable sign, dependent upon the sinking down into lower bronchi of mucus by the action of simple gravity. The comparison of the two sides posteriorly was advised, as in this way one is better able to discover the signs due to the fibrosis that extends around the tuberculous foci and thus to recognize the disease early. Dr. Bridge also insisted that fluid in the pleural cavities is often overlooked in children, as dullness is often absent low down, especially on on the left side, owing to transmitted resonance from the stomach. The intercostal spaces of children do not bulge, though they are firmer and less compressible than those of adults. Local resonance may be distinct, and the only signs that are reliable are the fremitus and the position of the heart. Dr. E. Fletcher Ingalls, of Chicago, said that any localized change is an important early sign, and deep respiration is highly significant. He thought examination anteriorly yielded better results than that of the back of the chest. Rapidity of pulse. is an extremely important early sign. Vocal resonance and sounds resembling bronchial breathing could be heard in nearly all cases, in both adults and

Dr.

children, over a pleural effusion. Ingalls believed more suspected cases were falsely diagnosticated pulmonary tuberculosis than the reverse, thus giving rise to great unhappiness. Dr. James Tyson, of Philadelphia, said that the keynote of the diagnosis of pleural effusion is diminished vocal fremitus; combined with the latter sign, bronchial breathing always means pleural effusion. He asked if Dr. Bridge had found that the fremitus may be, as it is said to be, increased in the pleural empyemata of children. Dr. C. E. Edson, of Denver, said that a rapid pulse that is also "nervous," quick, and irritable, and of small caliber, should always lead to a suspicion of pulmonary tuberculosis, and, if the pulse does not approach normal under treatment, the prognosis is relatively worse. Dr. W. N. Beggs, of Denver, said that the inconstant character of the fremitus in individual cases of pulmonary tuberculosis is an important sign. Vocal resonance may also vary in the same case. The confusion of muscular vibrations with abnormal pulmonary sounds often leads to error. Dr. Beggs also emphasized the fact that in children with pleural effusions the intercostal spaces do not bulge, and stated that in such cases under his observation careful measurements had failed to detect any difference in the expansion of the two sides. Dr. Bridge, in closing, said that his paper was but fragmentary and not intended to include all signs. He, too, had often noted errors due to muscular vibration. He thought examination of the back gave the best results, as early signs are more readily recognized there, and the heart-sounds and the normal differences between the apices do not lead to confusion. If signs of fibrosis extend below the upper lobe, a serious lesion in the apex may be believed to exist. As to empyema in childhood, Dr. Bridge had found the fremitus considerable in cases in which the pleura was much distended but never equal to or greater than normal.

The Medical Treatment of Appendicitis. Dr. Elmer Lee, of New York, opposed bacteria as of serious etiologic. importance in appendicitis, and thought that surgery now played too large a role.

in the treatment, that medicinal treatment should be used in the early stage, and that operation should not be undertaken unless abscess, rupture, or necrosis was diagnosticated. In treatment he used solely free irrigations of the colon with two or three quarts of water, giving large quantities of water internally, using hydrotherapy for fever, and for pain napkins wet with ice-water applied over the appendix. Food is to be limited, and to prevent recurrence the colon should be kept well flushed. Dr. E. J. A. Rogers, of Denver, doubted whether medicinal treatment of appendicitis can be relied. upon, but, if any such is to be used, that proposed is much better than too much interference. The primary cause of the disease is lack of the natural cleansing lavage of peristalsis and the invasion of stagnating contents by bacteria. The various forms of bacterial invasion can never be separated clinically, and, if it be a severe form or if the vitality is low, death will result. One can never tell when a fatality may occur; hence it is wiser to operate in the early stages, and a surgeon of competence and experience should always be called in consultation, in the beginning at any rate, in order that he might have all possible aid in operating when it came to operation. Dr. Henry Sewall, of Denver, said that one must always eliminate functional cases due to an overloaded colon and relieve that organ in such instances, but, if it is suspected that pus is forming or about to form, operation must be undertaken. He thought a middle position the proper one, using one's judgment about the cases to be operated on, but the fear of possible distant sequelæ in cases that would recover leads him to operation in many such cases. Such a case, in which the patient died of hepatic abscess secondary to old subsecal abscess that had never been suspected, he had reported, and he had seen several similar instances. Dr. H. J. Herrick, of Cleveland, thought appendicitis a medical disease to be treated with opium and other measures, and he was opposed to surgery in the early stages. Dr. Wm. Bailey, of Louisville, doubted the success of treatment

by the method of Dr. Lee, and, although many will get well without treatment, he always preferred to have the counsel of an experienced and capable surgeon. from the beginning. Dr. James Tyson, of Philadelphia, believed the diagnosis often difficult, and that many cases that get well under medicinal treatment alone are not appendicitis at all, and he preferred to refer cases at once to a surgeon and sanction operation if he diagnosticated appendicitis. Dr. J. B. Walker, of Philadelphia, mentioned a case in which apparent recovery ensued, but, owing to occupation and distance from a surgeon, operation was undertaken in the interval, and an entirely unsuspected large pus-cavity was evacuated. In another case there was a prolonged illness, during a portion of the time resembling typhoid fever. Upon operation a pus-sac was found, which had probably been present for eleven months. Such cases were leading him to more frequent operation, even when apparently favorable or in process of recovery. Dr. H. A. West, of Galveston, believed that the physician had the greater responsibility, as he usually saw the cases first, and, if he accepted this responsibility without calling in a surgeon, he made himself liable to a charge of responsibility for fatalities. Dr. C. F. Wahrer, of Fort Madison, Iowa, preferred a good physician to a bungling surgeon, but a good surgeon to all others. all others. When good surgical attendance is to be had, operation should be undertaken, but when such aid is not in reach it is safest to first try medicinal measures. Dr. Lee, in closing, said he believed that many cases are caused by dietetic and hygienic errors, and that the correcton of these will lead to cure. Such cases should be treated by the physician.

Some Considerations upon Vremia and its Treatment. Dr. E. W. Mitchell, of Cincinnati, Ohio, agreed with Bouchard that the symptoms of uremia are much like those produced by the poisons that have been extracted from urine, and he thought uremia, often at least, due to auto-intoxication from at destruction of tissue, decomposition of foods in the digestive tract, or resorption of secretions. The quantity of

albumin in the urine is no measure of the danger of the appearance of uremia. In treatment veratrum viride was eulogized. Rest is a most important factor. Drastic diuretics should not be used. Chloroform destroys the bloodcorpuscles if too long used, hence its administration in convulsions should not be prolonged. Morphin may be used once in convulsions in acute cases, but its use in chronic cases or its repeated use in acute cases should be interdicted. Pilocarpin was condemned, as it is likely to drown the patient in his own bronchial secretions. Injections of salt-solution are well used, preceded by venesection if the bloodpressure is high.

When May Women With Heart Disease Marry?

Dr. Kisch (Therapeut. Monats., February, 1898) said the chief points to be considered are: (1) the kind of heart disease; (2) its duration; (3) the presence or absence of compensation; (4) the general health; (5) the social position of the patient.

(a) They may marry if the disease is not of long standing, and compensation is good, and the general health not undermined. They will have during pregnancy, and still more during and for a time after delivery, many troubles due to their heart, but in by far the greater number of cases there will be no danger to life. This applies to wellcompensated mitral regurgitation and stenosis, aortic regurgitation, fairly marked sequela of pericarditis, and to muscular degeneration if not too far advanced. The patients must also be in a position to spare themselves bodily exertion as much as possible during pregnancy, to avoid mental excitement, and to have constant medical supervis

ion.

(b) The prognosis is not so good if the patients are very anemic or nervous, or advanced in years, or if the valvular disease is congenital or acquired in childhood. In these cases the physician should advise against marriage, or at any rate point out that the disease will almost certainly become worse after marriage.

(c) Marriage is to be absolutely for

bidden as dangerous to life when compensation is failing, or when there is advanced muscular degeneration. In all cases where there is dyspnea, palpitation, and quickened pulse on slight exertion, or marked edema not disappearing after rest in bed, when there is tendency to arrhythmia, scanty urine. with albumin, and attacks of irregular small pulse, coldness of the extremities, nausea, dyspnea, syncope, etc., marriage is dangerous, whether the cause of the symptoms be valvular disease, diseased arteries or cardiac muscle. Even those for whom marriage is allowable must follow certain rules strictly:

1. Coitus must not be frequent, and must be continued to the end of the orgasm, otherwise reflex heart troubles and depression result.

2. They must not have more than one or two children, as the strength of a diseased heart diminishes with every pregnancy in geometrical progression. If this rule is followed induction of premature labor will be luckily seldom necessary, since when it is the results are very unfavorable.

IN the London Lancet for May 7, 1898, Wyatt Wingate, M. R. C. S., summarizes as follows, after a comparative. examination of many malt extracts :

I. That Taka-Diastase is the most powerful of the starch or diastatic ferments and the most reliable, since it is more rapid in its action-i. e., "it will convert a larger amount (of starch) in a given time than will any other amylolytic ferment." lytic ferment." 2. That Taka-Diastase seems to be less retarded in its digestive action by the presence of the organic acids (butyric, lactic, acetic), and also by tea, coffee, and alcohol, than are saliva and the malt extracts. This is an important point in pyrosis. 3. That all mineral acids, hydrochloric, etc., quickly stop and permanently destroy all diastatic action if allowed sufficient time and if present in sufficient quantities. 4. That Taka-Diastase and malt diastase have, like ptyalin, no action upon cellulose (uncooked starch). All starch foods should therefore be cooked to permit of the starch ferment assisting nature in this function.

It is a

LAST issue, in a few words, notice was made of the fertile subject of Appendicitis. The discussion of the papers on this subject in the Surgical Section of the American Medical Association, at Denver, was a telling emphasis to the criticism we made. Careful, clearthinking, experienced heads insistingly declared for opposing views, while there was the usual corroboration of both sides by the less weighty and less informed. Not a little of the spirit shown was sharp, probably bitter, and possibly at times even personal. We are all somewhat prone to defend our own views, and seek the bubble, reputation, even with our own mouths. question if the discussion did any good; it is almost a certainty that it did harm. Radicalism fails to convince the courageous conservative; it leads to danger the incompetent and vacillating; it discourages and routs the expectant and hopeful. In questions which involve not. only life and death, but as well the reputation of the surgeon, the consent of the patient, facilities for success, etc., the theoretical must yield to the practical. Even if we accepted the dictum that a tender appendix should always be excised-though a congested liver, a painful kidney, a swollen spleen, an inflamed intestine may be allowed to declare its course-there must arise the reflection that practically such radicalism can never become popularly accepted, hence to urge it is to discourage rather than promote concert

of action. In principle it is true that an offending appendix is better out, not because it is always a source of danger but because no judgment can declare when it is not; but in practice it is equally true that the best interest of the patient can not always be served by radical adhesion to fixed laws.

Here, as elsewhere, the survival of the patient is through the fittest of conditions. These conditions must be controlled by the judgment of the surgeon. To obtain definite data, a point of departure must be agreed upon. It is clear not ten surgeons in this country operate on all cases of appendicitis as soon as the diagnosis is made, however much they may desire to do so. Many of the remainder who follow these ten in theory are far behind in practice. The immense majority are conservative in practice, whatever may be their theory. The general practitioner is utterly unconvinced. Between these two extremes is fixed the great gulf of death from indecision and neglect. An eminent operator said in this discussion:

"There can be no compromise!" But is it true? Do not arbitration, concession, daily and hourly in our lives protect and strengthen both our dignity and our security?

Not only is a compromise advisable, but at present it is unavoidable, and is entered into every day by the very radicals who oppose it.