of some cereal, as wheat or barley, are strung upon a thread, a bead alternating with a grain of the cereal. When the thread so prepared is of sufficient length, its ends are tied and it is laid in the form of a circle at the bottom of a shallow vessel. This is placed under the tap, and the water turned on. Cover-glasses carefully cleansed in a solution of a mineral acid are placed in a circle so that each grain of the cereal rests upon the center of one. The beads hold the thread firmly in place, while the grains of wheat or of barley attract to them the protozoa, which hover about and feed upon the cereal. These grains also prevent the washing away of the glass circles by the current of water.

If too large a number of microscopic forms collect upon the coverglass, it is better to put only beads upon the thread and to place the coverglasses under a bead. Or tiny cups may be used; a cover-glass placed at the bottom of the cup and a fine-meshed cloth tied over the top.

After twenty-four hours a cover-glass is removed for examination under the microscope. Should an animalcule have fixed itself to the surface, it is put back again to await development. It is advisable to have two circles of beads, new forms to be caught under the first, their development to be watched under the second.

If a form is caught that it is advisable to preserve, it is dried at room temperature, stained in the flame and mounted in Canada balsam. It is well to employ some constant differential stain, such as carbol-fuchsin and methyline blue. If no object of interest is found on the cover-glass, it is better to reject it. In the removal of cover-glasses, the circle should always be traversed in the same direction. In this way the forms under observation will more closely resemble those immediately preceding. The interval of time for their removal should also be constant. A new series may be commenced in the first series after a number of cover-glasses have been removed. A single species should be isolated and cultivated to the exclusion of all other forms, but many difficulties are in the way. Three conditions that must be met with are: The organism must be grown in living water; it must have free access to atmospheric air; isolation must be maintained for a long period of time-for months, or even years.

In general, it can be concluded that (a) the protozoa, in rounding out their life cycle, under proper environment, produce their young so as to appear exactly like the pathogenic bacteria in form, size and staining properties, and are demonstrable to the eye; (b) the protozoa have the same action upon laboratory animals that the pathogenic bacteria have upon man; (c) naturally the inference drawn from these facts is that the forms derived from the protozoa and the pathogenic bacteria are identical.

FATAL HEMORRHAGE FROM A DUODENAL ULCER AFTER APPENDECTOMY.-Richard Mühsam, M. D., Berlin, Germany (Deutsche Med. Wochenschrift, 1907, No. 31), gives an account of a most in

teresting case of 'fatal hemorrhage from duodenal ulcer, after an appendicitis operation. He says that as early as 1899, von Eiselsberg called attention to stomach and intestinal hemorrhages after abdominal operations. He detailed seven cases (four of which were fatal) in which hemorrhage occurred after laparotomy, mentioning one case in particular, where erosion of the arteria gastroduodenalis occurred from an ulcus duodeni, eight days after an operation for carcinoma of the right tonsil, the right gum, and right side of the pharynx. In six of these seven cases, there had been resection of the omentum, and division of the mesentery.

Busse collected from Eiselsberg's clinic ninety-six cases of post-operative stomach and duodenal hemorrhage, and quoted the experimental work of numerous writers on this subject, Friedrich, Hoffman, Engelhardt, and Neck. In these cases necrosis of the liver and gastric ulcers followed in the wake of the resection of the omentum. The narcosis did not seem to influence the condition at all.

These changes followed closely upon the retrograde embolism from thrombosis in the omental blood vessel stumps (Engelhardt and Neck). These emboli are found in the venous, as well as arterial vessels, bacteria not being necessary for their production (Engelhardt, Neck and Sthamer).

We now come to the experimental work of Payrs, which was communicated to the last Surgical Congress. He noted, in exposing the omentum to tearing or to high temperature, that clots of blood formed in the small vessels, and that these clots were easily, loosened and floated in the blood stream towards the liver. Following this occurred gastric changes. In the smallest ramifications of the omental blood vessels were seen changes in the corpuscular elements of the blood, with retrograde embolism in the submucous, and præcapillary gastric venous channels, blocking of these vessels, small hemorrhages into the tissue, hemorrhagic infarct formation, erosion and, finally, ulceration.

Among the ninety-six cases detailed by Busse, might be mentioned. twenty-seven abdominal operations, twenty-five operations upon the intestinal canal (seventeen of which were appendectomies), ten operations upon the gall-ducts, and fourteen operations upon the female genitalia. In thirty-four cases, the omental or mesenteric blood vessels were ligated. In forty-three instances it was necessary to deal with purulent conditions. Fatal termination occurred in fifty-five cases. Busse contends that the gastric or duodenal hemorrhages are directly due to thrombotic changes, either in veins or arterioles. In the causation of this condition, one can mention the character of the operation, as well as the factors of local or general circulatory disturbance, poor attention to ligation of vessels during the operation, trauma during the operative procedure, narcosis and nervous influences. The hemorrhage occurs most frequently inside of the first week after operation. The anatomical changes met with are gastric or duodenal hemorrhage, erosion or ulceration. Many times there were no

visible anatomical changes to account for the condition. Prognosis is grave, and treatment symptomatic.

The case which Mühsam reports falls in the group of five cases reported by Dieulafoy and Charlot-fatal hemorrhage from the stomach in cases of children from infancy up to the age of ten years. In Mühsam's case, the autopsy failed to disclose thrombotic changes in the omentum, although it was carefully examined by the obducent, Dr. Westenhoeffer. Microscopically, a round cell infiltration was made out in the connective tissue of the ulcer; beyond this, nothing. It is reasonable to suppose that the ulcus ventriculi was a fresh one, because gastric ulcer, per se, is rare in children. This ulcer showed a tendency to heal, but not in the direction in which lay the artery which was eroded. It is possible that a piece of apple, which was ingested by the child, had something to do with the erosion of the artery, by rubbing against it.

VALUABLE HINTS FOR THE LIFE INSURANCE EXAMINER.-Circular No. 8, issued by the Boston Mutual Life, arranged by their Medical Director, appears in the December, 1907, issue of The Medical Examiner and General Practitioner. It is well worth perusal by all who act as life insurance examiners:

WHEN EXAMINING THE HEART, REMEMBER:

I. To look for the location of the apex beat, and note any deviation from normal on diagrams.

2. To look for signs of interference with the return circulation, such as enlarged veins over the chest, etc.

3. To look for cyanosis, as indicated by the color of the skin and mucous membranes, finger nails, etc.

4. To detect the slightest sign of dyspnoea after exertion.

5. To note the amount of hypertrophy, if any, on the tricuspid areas, indicating location of diagrams.

6. To carefully listen at the mitral, pulmonary, aortic valves, as indicated on the diagrams.

7. To ascertain if a murmur is transmitted to the axilla or carotids. 8. To listen carefully in order to detect intermittency or irregularity in the heart's action, and differences in the length of systole and diastole. 9. To look for pulsations in the epigastrium and other localities.

10. To carefully examine for evidences of arterial sclerosis.

IO.

II. To take the pulse for one minute, and record quality, condition of the radial artery, etc., as well as the number of beats per minute.

12.

To inquire as to bleeding piles and varicose veins. 13. To inquire as to any swelling of the feet and ankles.

14. To bear in mind that plethoric people with thick necks, inclined to obesity, are prone to apoplexy.

REMEMBER, IN THE EXAMINATION OF LUNGS:

I. To examine the chest without clothing, when possible.

2. To look for bulging of the interspaces, flat chest, and chicken breast.

3. To note condition of skin, as to whether it is unduly moist, cold, clammy, etc.

4. To note the rapidity of the respiration.

5. To note if both sides of the chest rise and fall together.

6. To percuss for dullness from the apex to the base, anteriorly, posteriorly, and laterally.

ture.

7. To locate râles, and indicate same on diagram.

8. If pulse is above ninety, for no apparent reason, take the tempera

9. To note if the voice is strong, steady and firm; to look at the mucous membranes, and observe if they are normal in color.

10. That in the early stages of pulmonary tuberculosis, cough may be absent.

II. That a phthisical applicant may have rosy cheeks.

12. To note if clothes fit well. (It often happens that loss of weight is denied, while the fit of the clothing tells a different story.)

13. To ask if he suddenly perspires during the day, and without laying apparent stress upon this incident, ask if he does so at night.

14. To stand in front of the applicant, placing fingers just above each clavicle, and ask him to inspire deeply. If the apices are diseased, applicant will probably show evidence of pain, or soreness, as the inflated lung comes against the fingers.

15. To stand directly in front of the applicant, and place each hand on either side, just below the floating ribs, ask him to inspire deeply, and while he is doing so press firmly. Tenderness will make you suspect pleuritic adhesions.

16. That a prolongation of the expiratory sound is uniform over the chest, and not dependent upon emphysema, should not be recorded.

17. That a few crackles bilateral, at the base, and not associated with dullness, are not necessarily important, but you should give your interpretation.

18. That as we grow older the respiratory sound becomes harsher, and less vesicular, and may be increased in intensity, or diminished. (If these conditions are uniform in an elderly person, and are not due to emphysema, they need not be noted.)

How to Measure the Chest Place the tape at lower angle of the shoulder blades, and when it is brought around it will fall just below the

nipple. The applicant is requested to stand erect, without muscular strain. or rigidity, and told to draw in slowly and steadily a long breath until the chest is thoroughly inflated. Chest circumference at inspiration is thus obtained. The applicant is then asked to count from one onward until the demand for inspiration becomes urgent; chest measurement at expiration is then recorded. (Note if inflation is uniform over entire area.)

THE CLINICAL IMPORTANCE OF THE UNEVEN DISTRIBUTION OF HYDROCHLORIC ACID IN GASTRIC CONTENTS.*-Albert E. Taussig, M. D., and William H. Rush, M. D., of St. Louis, Mo., state that the fundamental assumption that underlies nearly all the work that has been done on the acidity of the gastric contents, is that the latter represent a fairly homogeneous mixture, so that if a portion is obtained by means of the stomach tube its acidity represents fairly well the acidity of the total stomach contents. This is an error. The gastric contents are not homogeneous, and the acidity of the portion obtained for analysis does not always represent the average acidity of the entire contents. If the stomach contents are obtained in two portions, first in the erect, and then in the prone posture, the acidity often varies widely, the difference being greatest with solid or semi-solid test-meals, and least with liquid ones. Moreover, it is impossible, by any means at our disposal, to obtain the entire contents, and the acidity of the unobtainable residue may differ from that of both portions examined.

I. When the stomach contents are expressed and aspirated, in the usual manner, as completely as possible, the patient sitting erect, only at comparatively small portion of the gastric contents can be obtained.

2. After any of the usual test meals, the acidity of the portion so obtained can not be assumed to represent the acidity of the stomach contents as a whole.

3. If, after this portion of the stomach contents has been removed, the patient is made to lie down, it is usually possible by means of aspiration, inflation, and the like, to obtain a further considerable quantity of stomach contents. This second portion often differs considerably in its acidity from the first portion.

4. Even after this second portion has been removed, the stomach still contains considerable unobtainable residue. The amount of this is apparently independent of the total quantity of gastric contents, and probably varies from one to three ounces. Of its degree of acidity we can know nothing; certainly we have no ground for the assumption that it is identical with the acidity of the contents obtained for examination.

5. The quantitative determination of the acidity of the gastric contents is thus seen to be subject to a grave source of error. This will be

*Author's abstract of Monograph read to Section on Internal Medicine, St. Louis Medical Society December 14, 1907, Weekly Bulletin, St, Louis Medical Society.