A Metabolism Test for Gout.-Burian and Schur have shown that of the uric acid produced from intaken purin bases, 50 per cent is excreted in the urine. Block found little variation for the same individuals, but that in different patients the rapidity of excretion varies considerably. In normal patients on a purin-free diet, the uric acid output returns to its original endogenous level usually within three, always within five, days after a single dose of purin bases. Hosslin and Kato have used this test to distinguish gout from other forms of arthritis. In all cases they determine the uric acid output on a purin-free diet, and then after giving 1 to 1.5 grams of sodium nucleinate. In two of the three gout cases the uric acid was still high on the seventh day. The third case at first showed no prolongation of the total excretion time, but the maximum excretion was retarded, occurring on the second day after the injection. On retesting this case, a definite prolongation of excretion time was found. In none of the other forms of arthritis was any abnormality in uric acid excretion found. The gout cases tested were not extremely pronounced. In one, the clinical diagnosis was only cleared by a typical joint which developed after the laboratory findings had been made.

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The Leucocytes in Variola.-Kammarer, in Deutsche Archives fur Klinische Med., reports a study of 4 cases in which he finds that a moderate leukocytosis (10,000 to 30,000) occurs at least as soon as the vesicular stage, and subsides very gradually with frequent slight fluctuations lasting well into convalescence. This leukocytosis is due to an absolute increase in the lymphocytes, which occurs as early as the fifth day, and which can still be made out three months after the infection. Polymorphonuclear leukocytes are relatively decreased in number (averaging 42.2 per cent). Their absolute number is on the average normal, though occasionally slightly increased. In severe cases a moderate number of myelocytes and of normoblasts occurs in the first few days. Large mononuclears,

Metallic Tinkling in Hydropneumothorax.From an experimental study of the causation of metallic tinkling in hydropneumothorax, Barach, in Archives of Diagnosis, concludes that this phenomenon is produced most typically, and in all probability most frequently by the escape of a bubble of air from the fistulous opening of a diseased lung below, or at the level of, the liquid. When metallic tinkling is heard as the result of a bubble of air coming up through the effusion, the sound is not produced at the bursting of the bubble on the surface of the effusion but with the separation of the bubble from the fistulous opening of the lung. Metallic tinkling can be produced either by the bursting of a bubble within a bronchial tube, when the latter is connected directly with the air chamber by a fistulous opening of sufficient size, or by a bubble arising from the moist surface of a perforated lung above the level of the liquid, if the bubble is expelled with sufficient force. The characteristic qualities of the tinkling sound are determined by the expulsive force behind the bubble, the proportion of air and liquid in the chamber, the size and directness of the avenue of communication between the resonating chamber and the external atmosphere. The author states that metallic tinkling, as we hear it in the chest, is probably never caused by falling drops, an explanation which to the present has received the widest endorsement.

Early Sign of Intestinal Obstruction.-Wilms and Leuenberger, in Muenchner Med. Wochenschrift, state that if the abdomen is ausculated in conditions of active peristalsis, various rumbling and bubbling noises are heard, due chiefly to the bursting of air bubbles as they rise to the surface of the fluid contents of the bowel. These sounds are, however, usually low-pitched and never have a ringing, metallic character. In ileus, however, even in the earliest stages, ausculation over the abdomen will reveal the presence

of sounds of a clear, metallic, ringing character. Wilms, who is chief of the surgical clinic at Basle and commands an enormous operative material, has found this sound pathognomonic of mechanical obstruction of the bowel. It occurs early in the disease, before fecal vomiting, meteorism or prostration has set in, is never absent in real mechanical obstruction, can be readily heard in the most obese patients in whom the early diagnosis of this affection is usually so difficult and with one exception is never found in any other condition. This exception is postoperative meteorism which can usually be otherwise distinguished from true mechanical ileus. His assistant, Leuenberger, has investigated the phenomenon experimentally and finds it due to the bursting of tiny air bubbles in the bowel under conditions resembling those of intestinal obstruction. This sign is clearly a valuable addition to our diagnostic methods.

Difficulties in Diagnosing Scarlatina.-Schamberg, in Archives of Pediatrics, admonishes that no one symptom of scarlet fever may be relied upon to establish the diagnosis. A proper conclusion as to the nature of the disease can only be arrived at by a consideration of the associated symptoms; the most important of these is the presence of a distinct angina accompanied by a generalized scarlatinoid eruption. In the light of our present knowledge, and in consideration of the public interests involved, the association of these two symptoms compels us to make the diagnosis of scarlet fever.

In treating patients with an acute sore throat, it is inadvisable to administer any drugs which are capable of exciting an eruption of a scarlatinoid character, for, if such a rash appear, Hippocrates himself would be unable to exclude scarlet fever from the diagnosis. The drugs which are most likely to produce an eruption of this character are quinin, the salicylates, veronal, antipyrin, calomel, belladonna, etc.

The author has seen patients suffering from an angina in whom, after the administration of salicylates, a scarlatinoid rash has appeared. rash has appeared. The perplexing problem was here presented of differentiating between scarlet fever and a drug eruption complicating a sore throat. Where a diagnosis of scarlet fever cannot be excluded, our duty to the public demands that the patient be treated as if he were suffering from this disease.

Schlesinger's Sign in Tetany.-Alexander, in Deutsche Med. Wochenscrift, reports positive

findings in the test in two adults, negative in two infants. He believes that it is entirely due to mechanical stimulation of the sciatic nerve by stretching; and is entirely analogous to the Trousseau phenomenon, which Frankl-Hochwart by animal experimentation has shown to be of nervous, not vascular, origin. In both adults, pressure at the sciatic point elicited the typical position of the foot (talipes varus or equinovarus) as well as did Schlesinger's procedureflexion of the thigh with extended knee. The pulse in the foot remained unchanged. Compression of the femoral artery did not lead to the typical foot position. In one case he was also able to bring on the typical position of the hand by hyper-extension of the arm, causing traction. on the brachial plexus. The radial pulse remained unaffected. 慌慌慌

Electrical Treatment of Obesity.-A. Laquerriere, in Journal de Medicine de Paris, details Bergonie's electrical method of treating obesity by exercise of the various muscles, the surface of the body being covered with large electrodes, so that all the large muscular masses are affected. The operator then applies a tetanizing faradic current through the electrodes, in such a manner that there is a rhythmical action, the excitation lasting half a second, and the interval of repose a half second. The current should be strong enough to cause marked muscular contractions. During this treatment the body becomes covered with sweat, but the patient feels no disagreeable sensations, only the contraction of the muscles. The heart and respiration are increased in frequency, in response to the need of increased oxygenation in the contracting muscles. There is no appreciable fatigue when the sittings are properly managed; the appetite is increased and sleep is improved; blood pressure is lowered as it is after simple exercise. One gets general active gymnastics, but involuntary ones, and without the interference of the psychic centers. It is difficult to find any other system of gymnastics that approaches this in the general action of all the muscles. This form of exercise may be used even for persons who are persuaded that exercise is bad for them. Since the movement is involuntary the nervous system does not become fatigued. In the fearful and the neuropath one may get the benefits of exercise without their having any of the inconveniences of it. Bergonie has obtained brilliant results by this method in the obese, but the method may be employed also in all the nutritional troubles. This method is both preventive and curative, since it increases

the musculature of the patient, and he will not again fall into the hygienic faults that have caused his obesity.

Hypothyroidism.-Pittfield, in the New York Medical Journal, points out that hypothyroidism is a disease of many symptoms; its manifestations are so widely divergent, that the attendant has to be familiar with neurological and gynecological practice, and with diseases of the ear. Many of author's patients have seen specialists, some for their dyspnea, some for their hearing, and some for their amenorrhea. All had taken sodium salicylate, some had been treated at Hot Springs. Many obtained relief by massage. Two women, one all but deaf, the other miserable from tinnitus, had their hearing restored so that it was all but perfect merely by taking thyroid extract. From the dermatologist to the heart specialist they had wandered, leaving only the general surgeon alone. It is so often misdiagnosed as rheumatism. Author has seen nine cases with very discrepant symptom-complexes, but all had several things in common. All had given birth to children; all had joint pains that were called rheumatism. The fat ones were all thought to have Bright's disease, the thin ones nervous prostration. Any woman approaching middle life or in the fourth decade, who has had a history of backache, an occipital headache, together with joint pains, dyspnea, asthenia, should be suspected of having hypothyroidism, especially so if she has amenorrhea or had had it during the menstrual life. The symptom most commonly complained of, and that bitterly, is the occipital headache, which is present often, a great deal of the time also giving way of the knees, dyspnea, subnormal temperature.

Test for Gas Bacillus in Diarrhea.-Kendall and Smith, in the Boston Medical and Surgical Journal, describe a method consisting essentially in inoculating sterile tubes of whole milk with a small portion of the suspected stool thoroughly emulsified in it, and immersed in a water bath to above the level of the top of the milk and heated to 80° C. for twenty minutes, incubating at body temperature for eighteen to twentyfour hours. As an alternative procedure the infected milk tube may be gradually brought to the boiling point of water in a water bath, kept there for three minutes, then incubated as above. By so doing, all bacteria not in the spore state are killed and the development of the spores into vegetative cells is unrestricted by the presence of non-spore-forming organism. Those culture containing gas bacilli present at the end

of the period of incubation three prominent features: (1) The casein is largely dissolved (usually at least 80 per cent); (2) the residual casein is slightly pink in color, and filled with holes, the result of the stormy fermentation; (3) the culture smells strongly of rancid butter, due to the formation by the gas bacilli of butyric acid. Gramstained preparations made from such growths show rather thick, short bacilli, with slightly rounded ends. Controls suitably studied culturally have shown that cultures presenting this complex are, in reality, gas bacilli.

The writers have examined the stools from 231 infants presenting a variety of intestinal disturbances, and it was possible to isolate the gas bacillus from 22. It was not possible in any case in which the gas bacillus was recovered from the stools to isolate simultaneously the dysentery bacillus.

The diagnosis of diarrhea due to an infection with the gas bacillus can be made by the means described above within twenty-four hours, at the end of which time it is possible to begin treatment with a definite idea as to the etiology of the condition. The management of all acute diarrheas during this period of twenty-four hours, while the cultures are developing and while the diagnosis is being made, is practically the same, namely, purging and starvation.

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Duodenal Ulcer.-Mendel, in Duetsche Med. Wochenscrift, states that unless we accept the view of Moynihan, according to whom every case of "hunger pain" is one of duodenal ulcer, the differentiation between this disease and ordinary hyperacidity is often difficult. Duodenal ulcer may exist in the absence of tenderness on palpation, vomiting, gastric stagnation, and occult blood in stool or stomach contents. Mendel has discovered another sign which he has found very useful. If we percuss the epigastrium directly, best with a hammer, a small area of tenderness will be found-usually not larger than a fifty cent piece and rigidly circumscribed-over which direct percussion elicits pain. This will be observed in both gastric and duodenal ulcers, even when the palpation reveals no tenderness. The extent of this area and its location will correspond to the size and the site of the ulcer. In duodenal ulcers, the area of tenderness on direct percussion will lie just to the right of the linea alba, a little nearer to the naval than to the costal margin. As the ulcer heals, the area of tenderness can be observed to decrease in extent. In one case of duodenal ulcer, re

cently observed by us, this sign could not be elicited.

Congenital Heart Disease.-Graham showed the Philadelphia Pediatric Society a girl of five years, first child, born without instruments, breast-fed for four months, walked at fourteen months, when she had bronchitis, at which time her heart disease was first noted. At nineteen months she had chicken-pox; measles at two and one-half years; lobar pneumonia, affecting the right lung, seven weeks ago, with crisis after almost three weeks. She is poorly nourished, below normal weight and height. The veins of the upper left anterior portion of the thorax are slightly distended; there is marked precordial bulging; when at rest respiration is 28; pulse is regular, small, 121 per minute. The lips are somewhat blue and pale, hands and feet are cold and fingers and toes are distinctly clubbed. Inspection shows a diffuse impulse in the mammary line in the region of the nipple; palpation shows an apex beat a half inch within, without and above this spot. Relative cardiac dullness extends almost to the right mammary line, to the second costal cartilage and to the left slightly beyond the mammary line. Absolute dullness reaches the lower border of the second rib and almost to the left mammary line. loud systolic murmur is plainly heard over the entire chest, loudest to the left of the sternum at the second rib. It is much less distinct in the auxillary line; also less distinct at the angle. of the scapula than higher up in the back, between the scapula and the spinous processes. The right side of the heart is evidently enlarged, more laterally than vertically. Cyanosis is only present after exertion. The pulmonic second is normal. There is no thrill in the pulmonic region. Dr. Graham believes the most probable diagnosis to be defect of the ventricular septum, patent foramen ovale, with probable obnormal origin of the great vessels. He bases this diagnosis upon the comparatively slight cyanosis, the absence of a thrill, the hypertrophy of the right ventricle being sufficient to overcome the pressure in the left ventricle, the latter being little, if any, enlarged, thus maintaining a fairly good pulmonary circulation.

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Diagnosis Poliomyelitis from Blood and Spinal Fluid. Gay and Lucas, in Archives of Internal Medicine, report having attempted to find a method of diagnosis from the blood or cerebrospinal fluid in cases of anterior poliamyelitis, both in monkeys and human beings. They proceed along two lines of investigation-the exam

ination of the blood or spinal fluid by recognized clinical methods, and testing the fluids by certain biological reactions of immunity. In the acute stage the leukocyte count showed a consistent and early fall. Previous to this, in the incubation and prodromal periods, it was quite stationary. The average of fifty differential counts in the acute stage was: Polymorphonuclears, 40 per cent; large mononuclears, 15 per cent; lymphocytes, 40 per cent; easinophiles, 5 per cent; a slight lypmphocytosis, and slight easinophilia. In the spinal fluid were more characteristic changes. There was a marked increase in the number of cells during the incubation and prodromal stages and the early days of the acute period, being highest in the prodromal stage. These cells were at first mononuclears and were later replaced by polymorphonuclears. A fibrin clot appeared in the early and acute stages, but disappeared later. These findings agreed in both monkeys and human beings. The serum tests corroborated and extended the negative findings of Wollstein. There was no evidence of antibodies in the serum of monkeys taken at intervals during the acute disease or in the serum of unsuccessfully inoculated monkeys. There was, as well, no evidence of antigen in the spinal fluids of monkeys or of human beings at various stages in the disease, or in the blood serum.

Diagnosis of Peptic Ulcer.-Bradshaw, in the Lancet, remarks that, apart from acute symptoms indicating perforation and calling for immediate operation, the signs and symptoms pointing to ulceration of the stomach are notoriously equivocal and uncertain. They practically resolve themselves into three-viz., pain with or without tenderness, vomiting after food, and hematemesis or melena. Where this triad of symptoms is present a provisional diagnosis of peptic ulcer is justified, and the absence of one or other of the three by no means excludes it. In the nervous type of patient, however, pain, unless very severe, is obviously an untrustworthy guide, and no one can fully gauge the extent of another's sufferings. Vomiting also is not uncommon without ulcer, especially in chlorotic girls of nervous temperament. The vomiting of blood or the passage of melena seems to offer more solid ground for a diagnosis. Still even here certainty is not easy to attain. Blood may be vomited, or appear to be vomited, when the source of bleeding is not in the stomach. Young women sometimes have a practice of sucking their gums at night, and especially if carious stumps are present, blood flows, is swallowed, and is subsequently vomited. The author sus

Laryngeal Signs of Tuberculosis.-Minor asserts, in the Journal of the A. M. A., that the symptoms of early laryngeal tuberculosis are limited in number and not as valuable as the signs. The earliest is usually a mere weakening of the voice, which may appear long before hoarseness is noted. Next to this he would note a sense of dryness in the throat followed by a localized tickling or pricking. Pain on swallowing is not usually an early symptom in his experience. The subjective symptoms, however, are relatively unimportant as compared with the objective signs. He has not found pallor of the mucous membrane often as an early sign, and he believes that catarrh with hyperemia is usually the first sign, though it is not diagnostic. It is only when it becomes unilateral and persistent that it becomes really suspicious. An obstinate patchy catarrh confined to one cord is highly suspicious, and in a patient whose lungs are tuberculous may be safely counted as tuberculous itself. Next to this he would note as significant a grayish wrinkling of the posterior commissure, which he thinks is the commonest early finding, but it is not diagnostic. The earliest real diagnostic symptom is a table-like elevation of the mucous membrane in the posterior commissure, and this is pathognomonic. This tends to break down into ulcers and, with their abundant granulations, they may pass for tuberculomata.

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as a site of early changes is the vocal process, the posterior insertion of one cord of the body of the cord itself, where ulcers tend to appear which may be scattered along the edge. He finds some involvement of arytenoid region very early in the disease, localized congestions or thickenings. Thickening of the aryepiglottic folds is a more advanced change, but when present is pathognomonic. Another early change, though a rare one, is the protrusion of a small point of red granulation beneath the anterior commissure, and when seen its diagnostic value is great. In the therapeutics of this stage the author insists first on absolute rest of the voice, not allowing even whispering; next, the avoidance of all irritants, especially smoking, and third, cleanliness; fourth, the use of astringents. He warns untrained physicians against resorting to endolaryngeal applications with the cotton-tipped laryngeal sound in cases of ulceration.

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X-Ray in Gastro-Duodenal Diagnosis.-Adler, in the Journal of the A. M. A., describes his method of diagnosis of this condition by means of the x-ray. He gives a single dose of 1.5 grams of bismuth subcarbonate in half a glass of water and then waits for the stomach to get rid of it, having determined in advance the motility. In cases in which there is no disturbance in motility the picture was taken in from four to six hours after the bismuth, which was given an empty stomach. This would allow time for all the bismuth to disappear from the stomach and duodenum except that lodged in the crater of an ulcer. After the first x-ray examination, one ounce of the bismuth subcarbonate is given in a glass of water and a second picture take immediately. The bismuth rapidly spreads over the entire gastric mucosa, but this can probably be facilitated by having the patient turn from side to side several times. This examination is for the purpose of obtaining a shadow of the entire stomach so as to localize any shadow made on the first plate.

Functional Tests of the Pancreas.-Hirschberg, in Deutsche Med. Wochenscrift, concludes that our diagnostic resources in this direction are extremely divergent, according to the nature of the disease actually present, all depending upon whether its secretion is wholly or partly cut off; and finally upon the physiological presuppositions which have been present in the minds of the investigators and which have led to the formulation of the tests. One cannot tell in general whether a given diagnostic resource is more trustworthy than some other. But if one combines the results of all tests one should have made essential progress in pancreatic diagnosis. In order to recognize acute inflammation of the pancreas, Wohlgemuth's test-the increased presence of diastase in the urine-should be of value. We now make a diagnosis by this means in vivo where formerly we had to await the autopsy. Next in value to this urinary test come the results of fecal investigation as judged by increase of fat and presence of a tryptic and diastasic action of the feces. Results of an oil breakfast for pancreatic action, the presence of undigested nuclei of meat, etc., and many other tests are mentioned, covering the whole of gastrointestinal digestion. Most striking to note is the complete omission of Cammidge's name.