with a double stream, which much facilitates the washing out of the stomach, but in which the tube whence the liquids issue is, as a matter of necessity, restricted, which is a serious inconvenience. The method of introduction, as described by M. Bucquoy, is as follows. The tube being slightly moistened with water (M. C. Paul recommends that it should be greased with vaseline during the first few days only), the patient takes the free end of the tube, places it in the pharynx, and pushes it slightly, making a swallowing movement. He repeats this swallowing movement a certain number of times, guiding the tube with the hand; this penetrates into the stomach rather rapidly; and the patient stops when he sees near his lips a mark traced at from forty-five to fifty centimetres from the free end then lying along the large curve of the stomach. To charge the siphon, the patient pours alkaline water into the receiver; and, after having filled it, raises it above his head until the liquid has entered almost entirely. At this moment he lowers the receiver below the level of the stomach, and above the bason. The cylinder becomes filled immediately with the contents of the stomach; and it will be seen that there returns a more considerable quantity of liquid than has been introduced, bringing with it the residue of digestion. The operation is repeated a certain number of times, and as often as necessary, until the water returns in an almost limpid state Alkaline water is generaly employed for these operations. M. Constantin Paul has found that the silicated water of Sail, or an antiseptic solution containing thymol or hyposulphite of soda, is useful. To conclude the operation, he pours into the stomach two or three hundred grammes of milk. The first liquids injected are tepid, because they cleanse the parts better; the later ones are cold, because they form a better coating for the mucous membrane, and induce contraction more easily. In certain serious cases, the operation is renewed twice daily; in ordinary cases, once only at the beginning, then less frequently afterwards. Whatever may be the nature of the gastric affection thus treated, according to M. Paul, good results are almost immediately obtained; in the first place, cessation of the pain; then the appearance, at the end of some days, of spontaneous action (in the case of dilatation); finally, a reappearance of the appetite, and a much more rapid augmentation of weight than would be believed. At the present time, washing out of the stomach is no longer limited to dilatation, as it was at first. It is applied to various affections. M. Paul quotes cases of gastralgia, of hysterical vomiting, of gastric ulcer, which have been thus completely cured. He has thus been able to greatly relieve the sufferings of a woman who had fæcal vomiting, and who suffered from an umbilical hernia; finally, in cancer of the stomach, the symptoms are very much relieved, and it is possible even to bring on a notable temporary improvement. MM. Bucquoy and Ferrand have also observed cases of cure of simple ulcer. M. Debove likewise has reported, in the Progrès Médical, an extremely remarkable case of cure of a patient suffering from a simple ulcer, probably very old in origin, with absolute intolerance of the stomach, and a state of extreme cachexia. The favourable results obtained were almost immediate; and, at the end of six weeks, the patient, who had increased from one hundred to one hundred and twenty-five grammes daily, was on the road to complete recovery. Professor Germain Sée, in his treatise on gastro-intestinal dyspepsia, relates a certain number of cases which well demonstrate the utility of this method in gastric affections of very different kinds. He speaks of the case of a young girl suffering from serious anorexia, with invincible refusal of all nourishment, who had reached the last stage of marasmus, and who was treated for six months with this mechanical treatment. Dr. Sée has also seen obstinate vomiting thus stopped; cancer is greatly relieved, and dyspepsia of the cachectic form, which seemed of the nature of cancer, has been completely cured. In the last case, as well as being a means of treatment, it forms a true method of diagnosis. This brief enumeration shows the great importance of this new mode of treatment, which unites perfect harmlessness to very great facility of employment, since, up to the present time, not a single accident has been known to occur from the operation.-British Medical Journal. NOTH NAGEL ON THE CLINICAL AS- tant point is the reaction of bile-pigment,which may be frequently met with. Crystals of triple phosphate may be found in any stool, To determine whether conclusions can be and they are not met with in typhus dejections drawn from the condition of the fæces as to the in greater quantity than normal. Salts of lime nature of the pathological process in the (including oxalates) occur also in the fæces, but bowels, and as to the seat of the disease, they appear to be of no diagnostic value. whether in the rectum, colon, or small intes- Cholesterine is a component of normal fæces, tine, is the object of an extremely able article and does not possess any significance. "Charby Professor Nothnagel (Zeitsch für Klin. Med., cot's crystals" are also to be found. Of the vol. iii, p. 241, 1881.) He concerns himself various articles of diet that appear in the fæces, almost exclusively with the macroscopic and Nothnagel only touches upon such as are of microscopic examination of the fæces, since this particular diagnostic importance. Starch. In method of investigation is of much greater the normal condition, with an ordinary mixed practical importance to the physician, and diet, starch-granules do not appear in the much more readily carried out, than chemical stools, but small, irregular particles, which analysis. This article embodies the results of colour blue with iodine, occasionally do occur. the examination of more than 800 fæces. In Any deviation from this is pathological. many cases the examination was conducted Muscular fibre is to be found in small quantity daily until death, and most people will agree in normal fæces with mixed diet, but occurs to with Nothnagel, when he remarks that such a great extent when much animal food is investigations are not amongst the most de- taken (diabetes); and it is particularly interlightful. In regard to consistence, he divides esting to observe that in many intestinal disfæces into three classes-the firm, the pap-like eases muscular fibre is to be found in large (breiig.) and fluid, the first of which are gener- quantity in the stools, even in cases where erally normal, the others pathological. The starch does not appear, showing how much most important clinically is the variety of more readily the latter undergoes digestion than pap-like consistency, which is occasioned by a the former. Fat occurs in normal fæces, both very intimate mixture of mucus. Often the in drops and in needles. Sometimes Nothnagel naked eye detects nothing resembling mucus, has found it in large quantity without any but microscopically its presence is readily made pancreatic disease. Milk, in the form of out. Such consistency may be occasioned by coagulated flakes, showing countless enclosed admixture of fat, water, parenchymatous tissue oil-globules, is often seen in normal fæces. of vegetables, and fruit, etc. Fluid fæces can Such are the more important articles of food never, according to Nothnagel, be occasioned which occur in the stools. Regarding mucus, by the consumption of large quantities of many important diagnostic indications may be water. In five cases of diabetes insipidus which derived from its presence in the fæces, in what he had recently watched, there was nothing of form it appears, whether it is coloured or this kind. Hard fæces in small balls, like the colourless, and in what way it is mixed up with fæces of sheep, are not, according to Nothnagel, the fæcal matter. In the adult, no mucus is to at all a certain indication of obstruction. With be found either macroscopically or microscopicregard to reaction, there is considerable variety, ally in normal fæces. Its occurrence is always fæces being acid, neutral, or alkaline at differ- pathological, and it may appear either (a) as a ent times. In typhoid fever they are as a rule thin layer over well-formed fæces, or (b) intialkaline (though, exceptionally, Nothnagel has mately mixed up with the fæcal matter, or (c) found a strong acid reaction); and in a doubt the fæces may consist entirely of mucus, (d) as ful case, if the reaction were not alkaline, it mucus cylinders in the so-called tubular would go against the diagnosis of typhoid. The diarrhoea, (e) in balls resembling boiled sagocolour of the fæces may be affected by various grains. The latter form Virchow has considarticles of diet and medicine; the only impor-ered as of vegetable origin. And, finally, Nothnagel describes a new appearance (1) in which the mucus takes the form of round yellow balls, quite unlike sago. The epithelium which frequently occurs in the sputum undergoes certain changes in shape, which Nothnagel describes with great minuteness, and for which the original article must be consulted. The 'round cells' which occur in the fæces have some diagnostic significance. They vary in size from that of small, white blood-corpuscles up to that of the largest giant-cell. In simple catarrh of the intestine, mucus, containing round cells, does not occur. Its presence in the fæces indicates an ulcerative process. Nothnagel states nothing new regarding the presence of blood in the fæces; and to the presence of animal parasites, their eggs, etc., in the fæces, we need not here allude. Nothnagel proposes, in a continuation of this article, to consider the clinical bearing of the appearances here touched upon. - London Medical Record. EXAMINATION OF SPUTA. IN suspected cases of phthisis where it is very desirable to know the progress made by the disease, great aid may be procured many times by an examination of the sputa of the patient. It is now a recognized fact that phthisis has been diagnosed, and is diagnosed in this way, weeks, months before other signs are manifest. As expected ingredients in the sputa, one finds remains of food, starch granules, epithelium, air bubbles, mucous cells, pus cells, blood corpuscles, large granular cells, and, perhaps, pigment cells. If now besides these are found fragments of lung tissue, as yellow elastic fibres, it shows that there must be a disintegration of the pulmonary tissue, a condition which must denote serious trouble. If these fibres are not found it does not by any means prove that serious trouble may not exist, but their presence is very significant. Some special directions should be given to the patient whose sputa we are about to collect. First, the mouth should be carefully and thoroughly rinsed and the teeth brushed after each meal. Second, the vessel in which the sputa is collected should be scrupulously clean. Third, if the patient is in the habit of using tobacco, it should be denied during the collection of the sputa, as the fibres of the leaf might mislead and cause a wrong diagnosis. If the amount of sputa is small, then all raised during the twenty-four hours should be saved. If large, that first raised in the morning should be preferred. Any little grayish masses should be chosen and placed at once under a microscope. Acetic acid will clear up the mucus, etc., and render more distinct the yellow fibres if they are present. If this examination reveals nothing, the following method should be adopted: Make a solution of sodic hydrate, 20 grains to the ounce of water. Mix the sputa with an equal bulk of this solution and boil. Then add to this mixture 4 or 5 times its bulk of cold water. If possible, pour into a conical-shaped glass and set aside. Soon the yellow fibres, if present, will fall to the bottom; from where they can be drawn up with a pipette and examined. Several glass slides should be examined at a single sitting, and the examination should be repeated every few days until the presence or absence of these fibers is satisfactorily demonstrated.-Cincinnati Medical News. APHONIA THE RESULT OF DIVISION OF THE RIGHT RECURRENT Nerve by a STAB WOUND.— Dr. Lefferts reports, in July number of The American Journal of Medical Science, the following remarkable case. A healthy woman at. 47, while lying in bed on her left side, was stabbed in the right side of the neck by her drunken husband with a long narrow-bladed pair of shears. Complete aphonia followed and remained persistent, although the wounds (two) healed normally. The patient is able to speak only in a whisper, and suffers from slight dyspnoea, especially on exertion. A laryngoscopic examination shows absolute paralysis of all the muscles of the right vocal cord. left vocal cord moves freely and compensates for the defective action of its fellow, by passing the median line on adduction, its arytenoid cartilage passing in front of that of the paralysed cord, and thus fairly approximating the edges of the cords. The CASEOUS ACCUMULATIONS IN THE MIDDLE EAR REGARDED AS A PROBABLE CASE OF MILIARY TUBERCLE. BY THOMAS BARR, M.D., GLASGOW. In this paper, attention was first drawn to what was said on the subject by such writers as von Tröltsch. An account was given of recent views on the pathology of miliary tuberculosis, as expressed by Buhl and Cohnheim, as well as by eminent British pathologists. There was a general agreement that acute tuberculosis depended on a virus, and that this virus often consists of caseated products of inflammation accumulated in some part of the body. An anatomical description of the cavities of the middle ear was given, the frequency of exudative diseases in these parts was pointed out, and the character of the exudations was noted. The peculiar structure of the middle ear was dwelt upon, because it favoured the retention, drying, and ultimate caseation, of the catarrhal products formed therein. Reference was next made to the facilities for the absorption of the caseated matter afforded by the blood-vessels of the middle ear, and by the lymphatics; absorption by the former leading to general tuberculosis, and absorption of the latter leading to local tuberculosis, and especially to tubercular meningitis. There was special danger of tubercular self-infection when such caseous collections existed in persons of scrofulous tendencies or at the tubercular age. There was a stage in the purulent process when there was greater danger of pyæmic phenomena; but there was also a stage when the tendency to tubercular self-infection was greatest, and that was after the discharge from the ear had spontaneously ceased or had been cured by treatment. fortunately, there was a paucity of material derived from observation, on account of the middle ear being usually ignored in post-mortem inspections and in clinical examinations. Un WICKHAM LEGG ON BILE. "To what purpose, then, serves the bile?" asks the author in p. 155, and his reply is worth quoting. "It cannot be looked upon solely as an excrement, for it has been seen what deep changes in nutrition follow its diversion from the body. There is no evidence that it is necessary for the completion of the process of digestion in the stomach or intestines; indeed it may be said by some physiologists that it does harm to the process in either viscus. The view that it acts as a sort of natural purge has little against it; but at the same time, there is but little in its favour. to the power of the bile in arresting putrefaction, it would seem that it must be small, if, as soon as it arrives in the intestine, it begins itself to undergo putrefactive changes. The view that the bile neutralises the acid of the chyme must fall with the establishment of the fact that the bile is not alkaline, but neutral in reaction. The only office which remains to it is that of emulsifying fats, a property known to the Greeks 2,200 years ago, and of changing As starch into sugar. Euonymin and iridin are shown to be (as most practitioners now know,) active cholagogues. Dr. Legg points out that the want of colour of fæces is not necessarily due to a decrease in the secretion of bile, as it may be due to the absorption of bile after it has passed into the intestine. Chemical analysis is, in his opinion, the only trustworthy guide in judging of the presence or absence of bile in the fæces. -Birmingham Med. Review. PEPSINE AS A SOLVENT IN ALBUMINOUS OBSTRUCTION OF THE BLADDER.-Dr. Hollmann (Nederl. Weekbl., 18, p. 272) reports the case of an old man, aged 80, suffering from retention of urine, in whom the introduction of a By catheter failed to procure the desired result. It was found that the bladder contained coagulated albuminoid masses, mixed with blood. A few hours after the injection of about sixteen grains of pepsine dissolved in water, a large amonnt of a dark, viscid, fetid fluid readily escaped by the catheter.-London Medical Record, Medical News and Abstract. a simple and expeditious plan, the middle ear in the cadaver might be examined by the pathologist. It was urged, in conclusion, that in the case of tubercular disease, and especially of meningitis, attention should be given to the condition of the middle ear.-The British Medical Journal, THE ACTION AND USES OF ANTI PYRETIC MEDICINES. BY PROFESSOR FOKKER, GRONINGEN. While there is no great difficulty in understanding the mode of action of simple refrigeration in the treament of pyrexia, that of antipyretic remedies, administered internally, is still obscure. We must assume, either that they lower the temperature of the body by interfering with the circulation, or that they exert a destructive action, in virtue of their antiseptic properties, on the low organisms to which the pyrexial phenomena are presumably due. The second of these hypotheses is the more likely one. It may, of course, be objected that such remedies can never be administered in sufficient quantities to insure their presence in the blood in such proportions as to render it aseptic, or, at any rate, to exercise an antiseptic influence. It must not be forgotten that any hostile factor, though unable of itself to check the multiplication of the organisms, may succeed in doing so when combined with others equally hostile to bacterial life. It is quite possible, moreover, that antipyretic medicines may accumulate in particular organs, which may then exert a disinfectant influence upon the blood. Antipyretic remedies may legitimately be given in febrile maladies, when the heat of the body is such as to threaten the patient's life, or even the integrity of his tissues. Under such circumstances, those aromatic remedies which are, at the same time, bacterial poisons, should be preferred to physical methods of refrigeration. But when the temperature of the body does not rise to a dangerous height, the employment of such remedies in antipyretic doses is undesirable; since a degree of heat only a little above the normal temperature of the body is injurious to the vitality or the virulence of the pathogenic organisms. It is quite possible, indeed, that the febrile heat may be one way in which the system reacts against the organisms, and tends towards recovery. In all cases, therefore, when the temperature does not rise so high as to be of itself a source of danger, physical refrigeration should be avoided, and the antipyretic remedies should only be prescribed in relatively small doses.-The British Medical Journal. THE CLINICAL VALUE OF THE EXAMINATION OF THE URINE IN BRIGHT'S DISEASE. BY T. GRAINGER STEWART, M.D., EDINBURGH. The subject was discussed under the following head: (a) Quantity: Diminished: 1, in inflammation (early stage and during exacerbations). Normal: 1, in middle stage of inflammation; 2, in earlier stages of cirrhosis. Increased: 1, in waxy throughout (unless interfered with) and preceding even the albuminuria; in cirrhosis-later stage; 3, sometimes in advanced inflammation and during absorption of dropsies. Suppressed: In inflammation acute and advanced cirrhosis: (b) Specific gravity and solids. Influenced: 1, by amount of water; 2, by amount of urea; 3, by amount of other solids; urea in different forms. (c) Albumen, serum-albumen, the only very important form; quantity in different forms; explanations. (d) Blood. [1, Early inflammation and acute exacerbation; 2, very rarely in waxy kidney; 3, occasionally in late cirrhosis with other hæmorrhages. (e) Tubecasts; varieties; different views as to the origin; abundant and varied in inflammation; few in waxy kidney; few in cirrhotic kidney. ON DIFFERENT FORMS OF BRIGHT'S DISEASE. BY DR ROSENSTEIN, LEYDEN. The following is a summary of the paper :1. the anatomical basis of the disease described by Bright is the diffuse inflammation of the kidneys. 2. Consequently those demonstrable renal changes, which are not of an inflammatory character-e.g., "the kidney of pregnancy," the "cyanotic induration" observed in conditions of venous obstruction of the system, and the "pure amyloid degeneration," do not repre sent, though associated with anasarca and albuminuria, forms of Bright's disease, but are independent affections, strictly to be differentiated from this disease. 3. Different forms of Bright's disease are to be distinguished anatomically as well as clinically, according to the "acute" or "chronic" course of the inflamma tory process. 4. The acute form is characterized by the emigration of colourless blood |