or three hours. The astringent selected can be given with or alternating with the sulphocarbolates. Pain will yield readily to atropine as a rule, especially if strychnine is given with it. If intractable, however, capsicin and cannabis will stop the trouble. A dose or two of chlorodyne may prove of use in the beginning of the trouble, but if opiates can be avoided it is best to do so. If the bowel is fully emptied and nothing put in it. with the exception of the things named above, and if at the same time the intestinal antiseptic and some one of the astringents are exhibited, the summer diarrhea of the adult will end quickly enough to suit even the patient. If the form of the disease is nervous, proper attention must be given to the system generally. The nervous tone is below par, and here is the field for strychnine, iron and nuclein. The triple arsenate granule of alkalometry should be given, one several times a day after nutriment has been taken. Passiflora will calm the nerve storm, as will also scutellarin, while dermatol and strychnine will act as a tonic generally and soothe the irritation of the bowel at the same time. This is a very useful combination. Hyperacidity calls for the neutral cordial of the A.A. list, one or two tablets two or three times per diem. As soon as the flux is controlled the patient should be put on an easily digested and nutritious diet. To his stomach nothing should be offered which could in any way prove irritating. The juices of meat, fresh eggs, koumiss or buttermilk, fruits (stewed), predigested and dextrinized milk, and gruel, may be followed by the more easily assimilable cereals and farinaceous foods. The hypophosphates may be given freely, but the writer prefers the triple arsenates with nuclein, adding thereto small doses of zinc phosphide. Free bathing, gentle exercise, attention to the liver and the daily use of saline laxatives, will enable the patient to regain his strength in short order. PAPERS St. Joseph ......... .St. Joseph ......Omaha ....Omaha Omaha ..Omaha Committee on Arrangements F. E. COULTER............... ....Omaha Omaha MEETING, READ AT THE SEMI-ANNUAL DIAGNOSIS OF DIASTOLIC HEART SOUND. LeRoy Crummer, B. S., M. D., Omaha, Neb. Associate Professor of Medicine, Creighton Medical College; Physician to St Joseph's Hospital. N THE differential diagnosis of valvular heart disease the rhythm or phase of the heart's action in which a given phenomenon occurs is of the first importance when we come to check up the results of our previous examination by auscultation. Concerning the occurrences in systole, I will have nothing to say, as a full discussion would consume too much time for the limits of a single paper; but I do want to consider carefully the diastolic events, as it seems to me that considerable confusion exists in most of our minds concerning murmurs and other sounds heard in this interval. Diastole includes the events taking place from the closure of the arterial valves to the next beginning muscular contraction of the ventricles. Auscultatorily this includes the second sounds of the heart and the long pause. Physiologically this is a period of rest for the heart, the only direct muscular action being the contraction of the auricles in the latter portion, the blood flowing passively into the ventricles, save at the end of diastole. The organic murmurs which may occur in this interval are either regurgitant, due to failure of the aortic and pulmonary valves to hold the blood in the arterial systems; or obstructive, due to narrowing of the auriculo-ventriculo valves. Inasmuch as tricupsid stenosis and pulmonary insufficiency are the rarest even of the right heart lesions, we may dismiss them from our consideration, as it is not probable that any of us will ever see a case. There are, however, several kinds of accidental murmurs which are heard in this period, one of which at least originates within the heart's chambers. A further source of error is certain forms of pericardial friction sounds which may very closely imitate either form of organic murmur. In addition to the murmurs we must pay close attention to the sounds; not only is the condition of the second sound-accentuated, diminished or absent of importance, but we must be on the outlook for reduplicated, newly built and interpolated second sounds, which are of even more diagnostic significance than murmurs. Aortic insufficiency is the one valvular lesion in which the keystone of the diagnosis is the murmur. We have this lesion dependent on two causes: endocarditis and degenerative changes in the aorta. The signs in addition to the murmur are enlargement of left ventricle with strong apex beat and the Corrigan pulse. The murmur is heard frequently, by no means always, in greatest intensity in the aortic interspace. It may be heard anywhere over the precordia, usually loudest somewhere, on a line joining the second right interspace with the apex. The junction of the third left costal cartilege with the sternum on this line is more frequently than any other, the point of maximum intensity. In the endocardial form the murmur is loud, blowing, beginning right at the end of systole, decreasing in intensity but lasting up to the beginning of the next systole; the second aortic sound is usually absent. It is the arterio-sclerotic form which offers difficulties in diagnosis. Here we may have to search the entire precordium, not for the point of maximum intensity of the murmur, but for a place where the murmur is to be heard at all. The murmur when heard has not the blowing character of the rheumatic form, but is hollow and indistinct; in fact I can only compare it to the sound heard when a shell is held to the ear. This tone is so nearly like the roar developed in many stethoscopes, that if we examine with the binaural stethoscope alone we will frequently overlook it entirely. This difficulty is further increased by the fact that save in the most severe cases the second sound at the aorta is retained. The presence of a general arterio-sclerosis should lead us always to look carefully for this form of aortic regurgitation; but it occurs with the arterial changes. limited to the aorta itself. This form of aortitis is diagnosed when there is dullness under the upper part of the sternum, or when the pulsation can be felt by inserting the finger in the jugular notch. The second aortic sound is usually retained, and may even be strongly accentuated; only when the valves are entirely destroyed by the sclerosis is the second sound absent. A new second sound may be heard over the enlarged aorta or the vessels of the neck in the absence of a second sound over the valves, or as a form of reduplication when there is still a sound created at the valves. This new sound is indicative of impaired elasticity of the aorta, and only when this impairment is of the highest grade is this new second sound entirely absent. In mitral stenosis we have a lesion which is not always accompanied by murmur. For the production of murmur we have two requirements: a change in the caliber of the tube through which the blood flows, and a certain rapidity of flow or head. In mitral stenosis either of these two factors can be deficient enough to prevent the occurrence of a murmur. First, there may be a physiologic and anatomic stenosis, and yet not sufficient narrowing to cause a murmur under the low pressure with which the blood is delivered from the auricle to the ventricle; second we may have almost complete closure of these valves-the so-called button-hole stenosis -and no matter how much the auricle hypertrophies it can not force the blood through fast enough to produce a murmur. We have then a mur mur only in those cases of mitral stenosis in which the narrowing of the valvular orifice is of moderate grade, and where the enlargement of the auricle is sufficient to force the blood along at an increased pressure. In the absence of a murmur the diagnosis of a stenosis is still possible, in fact in most cases easy; for murmur or no murmur we have the associated signs of mitral trouble; enlarged left auricle and right ventricle with consequent increased tension in the pulmonary circulation; these signs are common to all lesions at the mitral, but are usually more prominent in stenosis. In addition there is the peculiar pulse of this lesion; a compensatory vaso-contraction to fit the arterial system to the lessened amount of blood, which shows in the pulse as a small pulse of high tension, but no arterio-sclerosis. A second sign, in doubtful cases, is the change in the width of the complemental space, before and after exercise, in cases with mitral stenosis. The width of the complemental lung space depends on the elasticity of the lungs. In mitral stenosis the possible reserve force is always low. With the heart working its best there is always a tendency to an excess of blood in the pulmonary vessels; on moderate or even slight exertion this tendency becomes a fact, and with the stasis comes a diminished elasticity of the lung. In the given case we estimate the width of the complemental space in various places, then have the patient exercise, and again determine the complemental area; in health or in other forms of heart lesions the space will be slightly diminished, but in mitral stenosis it will be nearly if not quite obliterated. On auscultation we have certain changes in the normal sounds which may aid us in drawing our conclusions. In mitral stenosis we frequently find three heart sounds instead of two; these occur in three-four time and not in two-four time, as in simple reduplication. This extra tone can be heard best at the apex, or only there, and the second of the sounds is the accentuated one. On exertion the first sound may be replaced by the typical pre-systolic murmur in some instances, thus showing that the tone is really pre-systolic in time. According to the best evidence the first of the three sounds is due to the muscular contraction of the hypertrophied left auricle; the second or accentuated sound is the real first sound, and the third is the transmitted accentuated pulmonic second. The gallop rhythmus of kidney disease is also in three-four time, and is distinguished by being heard equally over the entire cardiac area. The other reduplications due to asyncronous contractions of the ventricles are not easily mistaken, as they are always in two-four time; however, this form of splitting of the second sounds is by no means uncommon in mitral stenosis, and whenever present should lead us to make the most careful examination of the mitral. An accentuated second pulmonic may be the only sign found on a superficial examination, but a careful examination will show enough of the other signs to justify a diagnosis of mitral stenosis; as a rule accentuation of the second pulmonic is more frequent and more pronounced in stenosis than in regurgitation at the mitral. The accidental murmurs of diastole, or better the murmurs occurring in the time not due to organic changes in the heart or blood vessels, are not as numerous as those in systole; but it would be a mistake to believe, as most of the books teach, that they do not occur. We have the following in organic murmurs heard in diastole. The Biermer murmur. 2. The transmitted bruit a diable. 3. The diastolic portion of a pneumocardiac murmur. Resting upon an organic basis but still presenting difficulties in diagnosis at times are two sounds: nurs. 1. The Flint murmur. 2. The diastolic portion of a percardial murmur. The Biermer murmur is among the rarest of functional heart murIt was described by Biermer in connection with pernicious anemia, and is only heard in grave anemias when the red cell count is below 1,000,000. It is pre-systolic in time and sounds exactly like the murmur of mitral stenosis; we may even have signs of a dilated right heart, or an accentuated second pulmonic sound. The diagnosis is extremely difficult and rests on a blood count below one million and the extreme instability of the murmur, being present at one examination and absent the next. The marmur depends on the second of our factors necessary, or the production of murmurs-a changed rapidity cf flow of the blood. The bruit a diable is in reality a venous hum originating in the large vessels of the neck, continuous in time and transmitted from there so it may be heard over the base of the heart. Here, owing to the complicated sounds of systole, the murmur is masked during this time, and is only appreciated during diastole. It is also dependent on a certain grade of anemia, and the diagnosis depends on finding a continuous murmur under the clavicle, and carefully following this in the direction of the base of the |