of cases he has found this method of considerable diagnostic value. Thus he was able to make out changes in the peritoneum suggestive of chronic peritonitis, could see distinctly cancerous nodules on the liver, perihepatitis and, in a clinically doubtful case, could make out a gastric cancer. In the pleural cavity, his observations have thus far not led to definite diagnostic conclusions.

Test for Carcinoma.-A test recently advanced by Ascoli depends upon a physio-chemical method, and aims at determining the presence of immune bodies in sera. (This test is applicable not only in suspected gastric carcinoma, but in carcinomata in general; hence it is only superficially touched on here. An exhaustive review of the literature bearing upon the Meiostagmin reaction will be found elsewhere in this issue.) The term meiostagmia (meaning small drop), has been coined by Ascoli, the appropriateness of the term lying in the fact that the surface tension of a given fluid may be measured by the size of the drop the fluid forms when flowing from a small pipette. Investigation was carried on to determine what changes, if any, occurred in the surface tension as the result of the reaction between the immune sera and their respective antigens. The measurements were made by means of Traube's stalagmometer. To a definite amount of serum from a typhoid patient (diluted with sodium chloride solution) was added a certain amount of antigen (extract of typhoid bacilli), and the drops immediately counted. The mixture was then placed into an incubator for two hours, allowed to cool, and then the drops were counted again. A diminution of the surface tension was found to occur under these circum

stances, that is to say, the number of drops formed in a given time was increased. The differences are not great, 1 to 3 drops, but are definite and constant, and the technique according to Ascoli is not difficult nor subject to much error. The reaction takes place even in high dilutions of the antigen. Izar and Ascoli then applied the reaction to carcinoma, at first experiencing some difficulty in obtaining suitable antigen which was finally derived from the transplanted sarcomata of rats. It is noteworthy that this antigen from an animal sarcoma reacts with the human sera of individuals with carcinoma. The reaction, tested by practically the same technique as described above for typhoid, resulted positively in 58 of 62 cases of various malignant tumors, mostly carcinoma, and failed to give a positive reaction in 48 various diseases including two cases of leukemia.

Auscultation of Joints.-Garrod, in the Laucet, reminds us that the production of noises in the joints is a familiar fact, for such sounds are in some instances so loud as to be clearly audible to bystanders, and far more often attract the notice of the persons in whose joints they are produced. The loudest articular sounds are those which have little or no morbid significance, and, speaking generally, the most noisy joints are seldom those which are the seats of the more serious forms of disease. Apart from the more conspicuous reports and crackles above referred to, there are abnormal articular sounds of much

fainter character, which are only audible with the stethoscope, and, from experience gained from systematic examinations extending over some years, the author has become convinced that auscultation affords valuable aid in the diagnosis of the several forms of morbid change to which the joints are liable.

The method of examination is very simple. The stethoscope, and any difficulty which may be exonly apparatus needed is an ordinary binaural perienced in keeping the mouth of the stethoscope accurately applied to the changing surface of a joint in movement is easily overcome by the use of a small chest-piece, or, better still, by affixing to the chest-piece one of the indiarubber ring coverings which are sold by instrument makers. A little practice enables one to dispense with any special chest-piece, and teaches how and where the instrument is best applied to the several articulations. Of all joints the knees are those which best lend themselves to such examination, and no difficulty is met with in keeping the chest-piece applied over the soft parts on either side of the patella. During the examination the joint should be slowly flexed and extended, either by the patient himself or in a passive manner by the examiner. Auscultation of the shoulder-joint is also easy, and the sounds produced during rotatory movements, as well as during elevation and depression of the arm, may be alike studied. Nor is any serious difficulty met with in the application of the method to any of the larger joints, such as the elbow, wrist or ankle. Even small articulations, such as the temporo-maxillary or the carpo-metacarpal joint of the thumb, admit of examination with the stethoscope.

A boy who has to be bribed to be good usually grows up into a man who is good for nothing.

Many receive advice, few profit by it.-Publius Syrus.

Cachectic Form of Meningitis.-Debre, in Presse Medicale, describes a chronic, cachectic form of cerebrospinal meningitis in which, after the first febrile attack has improved, there is a period of lessened symptoms, followed by a fresh attack of fever and severe symptoms, which is again followed by a remission of symptoms. The child gets into a condition of cachexia, with stiffened neck, in which he lies half stupid when not touched, but complains bitterly of pain when touched, his cries being heartrending. The body is much emaciated, the limbs stiffened in flexion, and the neck stiff. There are paresis of all the limbs, incontinence of urine, and bedsores. Reflexes are diminished or absent. After a time this condition may improve gradually and the patient recover without paralysis, but often with deafness or blindness. Autopsy shows thickening of the membranes, dilatation of the ventricles, which are filled with pus, and softening of the cortex. In these cases puncture of the spinal cord does not have the usual effects, the serum not being able to reach the brain or the major portion of the cord on account of the false membranes which have formed around the cord, which do not allow the serum to flow upward. 济

Effect of Child Bearing on Gonorrhea.-Hirst, before the New York Academy of Medicine, stated that pregnancy, parturition, and the puerperium influenced the course of gonorrhea in women and gave peculiar characteristics which might be enumerated as follows: The possible effect of an antecedent infection upon conception; the consequences of coincident infection and impregnation; the virulent character of the inflammation in a pregnant woman; the comparative frequent occurrence of so-called gonorrheal rheumatism; the predisposition to streptococcic autoinfection directly after labor; the tendency to streptococcic necrosis of the pelvic organs in some mixed infections; and the frequent necessity of radical surgical treatment to save the patient. Gonorrhea was a cause of sterility. A salpingitis of specific origin necessarily prevented conception. In hospital practice it was a common experience to see cases of coincident infection and impregnation at the same coitus. Fatal results might follow or, at the

best, a mutilating operation might be demanded. All had noticed the exaggeration of the symptoms of gonorrhea when the infection occurred after pregnancy was well advanced. Out of all the large number of gonorrheal pus tubes he had seen in his gynecological hospital and dispensary service in a period of over twenty years, he said he could not remember a single case in a non-pregnant woman of so-called gonorrheal rheumatism, i. e., subacute arthritis of one of the large joints; but in the University Maternity he had seen a comparatively large number of these cases in pregnant and puerperal women, usually with a clear history of gonorrhea, or with gonococci in the vagina or urethral discharge. If his experience was not exceptional, then the child-bearing process must be a potent predisposing factor in this dis

Radiotherapy in Medullary Affections.-Marinesco, in Annali di Elettricita Medica, presents the results of his study of the treatment of affec-tions of the spinal medulla by means of radiotherapy. He treated in this way three patients suffering from sclerosis in plaques, the rays being used over the cervical region and on the lumbar region, for 7 to 10 minutes. There were no skin effects in any of the patients. He got good results in one case in relation to motor disturbances, tremor, scanning speech, spastic gait, and disturbances of urination. The painful spasmodic contractions experienced at night were lessened. There are many facts with reference to animal experimentation and treatment of human beings that go to show good effects of radiotherapy in nervous diseases. The effect of the rays on young immature cells is remarkable. Some fragile cells in the young when the adult age is reached become indifferent to the rays. In some tissues they produce a proliferative action. The constant influence of the rays on all adult tissues and their karyokinesis is known. In nerve, gland and muscle cells the activity of multiplication is reduced. Most of the inflammatory diseases of the spinal medulla are amenable to radiotherapy. In acute affections in which the nervous parenchyma is already altered radio

Operations on Nervous Women.-Rucker, in the New York Medical Journal, states that the end results from operations on patients suffering from hysteria and psychasthenia are unsatisfactory. In fact, hysteria is the disease most liable to deceive and mislead the surgeon, for two reasons: First, there are few diseases, which flesh is heir to, that hysteria will not simulate so closely that the elect will not sometimes have difficulty in differentiating. The abdomen, especially in the region of the appendix and ovaries, is a favorite seat for pain and suffering. the patient will describe the suffering as being so acute and circumscribed that a mistaken diagnosis can easily be made. Second, hysteria patients are abnormally suggestive. A surgical operation of any kind strongly impresses the subconscious psychic centres, and often their symptoms will completely subside for a short time following an operation, only to break out with renewed intensity later on.

The author concludes:

And

1. Nervous women, as a rule, do not make good subjects for surgical operation.

2. An operation should not be undertaken, unless there is a definite, unmistakable, pathological lesion, and that it is the chief cause of the nervous symptoms.

3. A correct estimate of the end results of surgical procedures cannot be made, unless the surgeon keeps in touch with his patients for months after they return home.

4. In clearing up diagnoses in obscure conditions, every surgeon should seek the aid of a competent internist, neurologist and pathologist.

5. Last, but not least, to no one is the golden rule more applicable than to the surgeon. When a patient presents herself, she seeks relief from suffering. She is not especially anxious "to be cut, but to be cured," and the surgeon should always ask himself the question: If this was I, my wife, my daughter, would I advise an operation?

XXX

Paroxysmal Pulmonary Edema.-Stengel, in the American Journal of the Medical Sciences, says that the prompt effect of a hypodermic injection of morphine in cases of cardiac asthma

led him to use the same remedy in one of the earliest cases of paroxysmal pulmonary edema that was observed by him. The result was so striking that he has used it in a number of cases with satisfactory results, and it was unnecessary to use any other remedy, except as an adjuvant. In a number of cases a single injection, or at most two injections of morphine, with small amounts of atropine, sufficed to break up recurrent seizures. The author, however, regards atropine as of secondary importance. He reviews the value of chloroform, nitroglycerin and venesection. Compared to the simplicity of a hypodermic injection of morphine, venesection. is a procedure of considerable gravity and its effect cannot be more prompt or satisfactory. After the first stage of the attack has been controlled by an injection of morphine and atropine the author deems it advisable to make use of cardiac stimulants to revive the power of the left ventricle and to promote vasodilatation, if this be possible. For these purposes injections of strychnine, digitalin, and nitroglycerin may be employed, and aromatic spirit of ammonia or brandy may be given by the mouth if the patient is able to swallow. In some of the cases under Dr. Stengel's care he has prescribed the immediate administration of aromatic spirit of ammonia, to be followed by an injection of morphine sulphate, one-quarter grain, with atropine sulphate, 1/250 grain, when the first definite symptoms appeared; and the subsequent repetition of morphine and atropine after fifteen minutes and later injections of strychnine and nitroglycerin.

Plaster of Paris as a Primary Dressing for Fractures.-Barksdale, before the Tristate Medical Association, said that in using plaster as a primary dressing a strip of ordinary bandage should be laid lengthwise along the limb, preferably along the front, between the padding and the plaster. As soon as the dressing had been applied, before hardening was complete, the plaster should be cut completely through over its entire length, this being rendered easy of accomplishment by cutting down upon the roller bandage, which was pulled up into the cut plaster, thereby facilitating the manœuvre. After being cut, the roller bandage should be run firmly around the limb so as to keep the plaster snug and prevent splitting. The ends of the fingers and toes should be left exposed so as to permit of frequent inspection, and should the swelling create discomfort or threaten gangrene, the roller was to be taken off and the plaster sprung so as to accommodate the increased bulk. As the swelling subsided the bandage could be drawn

Hernia of the Fallopian Tube.-Parks, in the Journal of the A. M. A., reports a case of femoral hernia of the right side including a pathologic Fallopian tube which could not be safely reduced. The tube therefore extirpated close to the uterus, together with a large cystic ovary plastered up against the femoral ring.

due to tonsillitis that has not been considered as an etiologic possibility. 7. Chronic affections of the kidney may well owe their origin to unrecognized acute attacks of nephritis of tonsillar origin. 8. Much light may be shed on this subject by a study of the urine in a large number of cases of acute tonsillitis."

济济济

ported on account of its rarity, although it is unusual, but as pointing out certain principles of operative surgery. Routine methods are not available here. In this case the abdomen was opened in the median line and the pelvis explored, revealing the conditions. The tube was removed by incising elliptically into the right cornu and the tube lifted out of the sac through the femoral incision. The most plausible cause of the condition is that the hernia was originally a small intestinal or omental hernia; that the abdominal contents were reducible; and that at some time when reduced were replaced by the tube which later became inflamed, adherent and irreducible. The strangulation occurred because of the interference with the tubal return circulation. It should have been a case of ovarian as well as tubal hernia, but, on account of the small ring or the cystic condition of the ovary, this was impossible.

Nephritis Following Tonsillitis.-Loeb, in the Journal of the A. M. A., from a series of cases and the literature which is extensively quoted, he concludes as follows: "1. Acute nephritis

results from acute tonsillitis far more often than

is generally believed. 2. The symptoms ordinarily are not manifested until some time after the inception of the disease. 3. The nephritis is of the hemorrhagic type and differs from that of scarlet fever in that pyrexia, edema, and oliguria are not marked symptoms of the disease. In addition, it follows the angina and is not concomitant as in scarlatina and diphtheria. 4. Judging from the course of the cases reported, there must be many in which a mild nephritis occurs incident to a tonsillitis, which goes on to resolution without patient or physician being conscious of its presence. 5. As each case of lacunar tonsillitis may be a potential source of acute nephritis, it is incumbent on practitioners to observe the urine, not only during the height of the disease, but for some time after as well. 6. Spontaneous or idiopathic nephritis is probably often

borne out by clinical facts, histological studies and animal experimentations. The generally accepted statement that the menopause is established at forty-two to forty-five is incorrect, and forty-six to forty-nine is nearer the actual age in the Eastern United States. In normal women the age at which the menopause appears is influenced by many factors. The menstrual function is influenced by child-bearing, marital relations, good nutrition, and hygiene, city life, and education, while converse conditions tend to an earlier menopause. Climate and race play a definite part in the age at which the menopause occurs, but are probably of a secondary importance in the United States. Hereditary influence is often a potent factor; in some families the menopause commonly occurs early. In the majority of cases, the chief feature of the menopause is not the cessation or diminution of bleeding, but the neuroses. These frequently antedate any change in the menstruation and may continue for six to eighteen months after the final cessation of bleeding. The actual bleeding is, however, the barometer of health. Normally the menopause is established without an increased loss of blood. When menorrhagia occurs an examination is indicated. Metrorrhagia should always be viewed with suspicion. In about 90 per cent of absolutely healthy women the menopause occurs normally, but among average women fully 30 per cent present symptoms which call for a careful physical and gynecological examination. women at the menopause should be under the observation of a physician. Care of the cases at this time will result in the menopause being established with less discomfort to the patient, and many malignant neoplasms of the uterus will be diagnosed earlier than would otherwise have been the case.

All

Let the cogs in your thought-mill be firmly imbedded in the body of the wheel. Then let the thought-wheels whirl as do the worlds in space, until new thought-worlds fly off.

CHRONIC GRASTRIC CATARRH.

Arthur J. Rayson, M. D., B. Sc., M. P. S., Altoona, Mich.-I do not keep tables of percentages, as they are of no use to me; I cannot, therefore, give the percentage of chronic following acute gastritis, but in most of the cases there is this history.

I am unable to give any tabulated statement of these cases in my practice, but they almost all arise from indiscretions in diet or the want of discretion in diet-a too restricted and unsuitable dietary.

There is often some valvular mischief of the heart, a weak action and a struggling against toxæmia. Sometimes there is congestion of the liver, often lithiasis, cholelithiasis, temporal neuralgia, renal inadequacy and back of it all may be malaria; this may not be the order of their frequency though.

The mouth is clammy and dry not nearly so moist as it should be. The breath is foul and a nasty, bitter taste is complained about at the base of the tongue in the morning, which may be slightly furred. The tongue is not always foul and coated; it does not always indicate the condition, nor is anorexia always present. Flatus is the bugbear they come about and the oppression at the heart. Flatus is mostly gastric, inoffensive but abundant; the pain is referred to the ensiform cartilage and epigastrium. Sometimes it is duodenal; there is tenderness over the gall-bladder. Very little vomiting is present. There may be a muddy and itching skin and naso-pharyngeal catarrh. There is some hyperaesthesia. Temperature may be subnormal or slightly raised. Nausea, slight headache, great mental despondency, an irritable temper and consciousness of it, insomnia at the earlier part of the night, horrible dreams, constipation and a general want of effective elimination are all present.

I find the tongue does not have the same appearance in every case; it may be clean, slightly

clean or foul. It was very foul in a case complicated with lobular pneumonia, nor would it clean up altogether.

The urine is generally loaded with lithates; no albumen, but of a dark red-brown color tinged with yellow.

I seldom see a vomit, nor have I any facilities or opportunities to deal with a test meal; this is the work for a hospital, not for a general practitioner.

I do not practice lavage, as I do not believe so much in doing unnatural things. My predecessor told me he lavaged a patient's stomach, but could not get the return flow, so he left it with her. It appears I got her afterwards, for she petulantly said: "Doctor So and So washed out my stomach and had to leave it in." So the lady consumed her own smoke, as it were. Malaria was behind it all. I got her well without lavage; she is well now and rapidly advancing to an octogenarian.

The general principles of treatment are embodied in elimination and assimilation-to get rid of all effete material from the body, unload the portal system and silence any inconvenient and troublesome symptom. An effervescent saline aperient which I can modify and regulate myself I sometimes use. I use other drugs. There is an absence of enzymes. I am in the habit of prescribing what perhaps hardly anyone else knows at all about; it is certainly beneficial. Exceptional opportunities have made me familiar with, and enabled me to do my own treatment with my own formulæ, and I do not propose to disgorge all that I know in this direction; partly because it would not be understood and therefore of no use, for I do not prescribe from the United States Pharmacopoeia nor proprietaries or hardly any tablets, because I do not believe in them, and partly because a general practitioner should not, because he cannot, afford to give away his original methods as can a practitioner holding some public appointment, who looks to his own breth