pain, and, so far as the lungs were concerned, nothing abnormal was detected. There was a distinct aortic-systolic murmur and rapid and forcible cardiac pulsation. The urine was examined for albumen, with a negative result. Not feeling satisfied with this, I examined it microscopically, and found numerous granular casts. I examined the urine on four occasions without finding albumen, but on none of these were casts absent. This, I need scarcely remark, is very exceptional. At the last examination the urine was found to contain numerous spermatozoa. The patient grew steadily weaker, and the pain beneath the second intercostal space remained constant, while the paroxysms of angina became more frequent. On April 12, 1 P.M., there was orthopnoea; pulse 140; respiration 40; with an expectoration of a thin, almost serous, light coffee-colored sputum, on the surface of which floated a beer-like froth. In the course of an hour he expectorated nearly six ounces of this material. An inhalation of five drops of nitrite | of amyl had the effect of increasing the cough without mitigating the pain or dyspnoea. The man died the same evening. The autopsy was made twenty-eight hours after death. Rigor mortis was very marked; the pericardial sac contained about two ounces of serum; the veins upon the surface of the heart were distended with blood; the cavities of the heart contained fluid blood, - in greater quantity on the right side; the pleural surfaces of the right lung were united by a strong band of adhesion, which began in the second interspace about an inch from the right border of the sternum, and, following the direction of the interspace, passed upward and outward, to terminate on the posterolateral surface of the lung, a little below the apex. This band of adhesion at its widest portion (the centre) was about two inches in diameter. It will be observed that this adhesion was directly beneath that portion of the chest-wall where, during life, the patient complained the most of pain. The lung beneath the adhesion was healthy, as well as throughout the rest of its extent; the left lung was entirely free from adhesions, and perfectly healthy; the walls of the heart were pale, flabby, and almost fawn-colored, but of normal thickness; the cavities of both sides are somewhat dilated; the weight of the heart, with about two inches of the aorta, is fourteen and a quarter ounces; the internal surface of this portion of the aorta is elevated in uneven ridges, no portion of the intima appearing free from disease, this roughening of the surface being most marked about an inch from the aortic valves. The mouths of the coronary arteries are constricted almost to the point of occlusion. The kidneys are decidedly granular, which condition gives rise to the question whether the general edema from which the patient suffered, ten years ago, was due to an acute parenchymatous nephritis, recovered from but followed by the chronic interstitial inflammation. The right kidney weighs three and one-half ounces; the left, four and one-quarter. In the latter a cyst, the size of a large pea, was found near the upper end of the posterior surface. On removing the capsules, portions of cortical substances adhered to them. Specimen No. II., that of dilatation of the coronary orifices, was removed from the body of a colored man, æt. 49. I have been unable to obtain a complete history of the case. He was admitted to the Episcopal Hospital on February 13, 1879, and when he came under my care was suffering with the symptoms of combined heart and kidney disease in their last stages. Most prominent among these were universal anasarca and ascites. The heart's action was feeble and its sounds muffled, but unaccompanied by murmur. The urine contained albumen in moderate quantity and a great number of highly-granular casts: these were so numerous that, in the specimen examined, on moving the slide about, there was always at least one cast to be seen in the field of the microscope. The man died on April 15, 1879, from increasing dropsy and gradual failure of the heart's action. At the autopsy the mitral valves were found to be slightly thickened, but apparently competent. The left ventricle was filled with a large currant-jelly-like clot. A large patch of atheroma, about the size of a Lima bean, was found on the internal surface of the auricle, just above the larger leaflet of the mitral. The left ventricle was dilated and its walls hypertrophied; the left auricle was also dilated. The cavity of the right ventricle was not dilated, nor were its walls hypertrophied; contrasted with the hypertrophied left side, it even appears smaller than normal. The right auricle was dilated; the valves of the right side were in no way affected; the aortic valves were competent. The internal surface of the aorta, just above the valves, is the seat of extensive atheroma, which continues for three inches upward,-that being the extent of the artery examined. The orifice of the left coronary artery is greatly dilated, being the size of a three-cent piece; the right coronary is also dilated, but not to the same extent. Both these vessels are given off at a higher point than usual, especially the left one, which arises about three-fourths of an inch above the free border of the semilunar valves. The aorta itself is greatly dilated, its circumference measuring three inches and three-fourths. The heart, with three inches of aorta, weighs twenty-two ounces. The kidneys were intensely congested, dark blood flowing freely from them on section. The left one weighed six ounces; the right, a trifle under six. The liver was somewhat stained with bile, but otherwise healthy. The lungs were ædematous, and there were pleuritic adhesions on both sides, more extensive on the left. In neither of the two specimens do the coronary arteries present the sole or even the most conspicuous lesion, but in one of them (that with contracted coronary orifice) all will admit that, in its effect upon the heart, it is probably the most important pathological change; and I hope to be able to show that it is at least probable that this is also the case with the other specimen,-that with dilated coronary orifice. In the specimen of contracted orifice the most conspicuous change is a very great degree of chronic endarteritis; there is also some cardiac hypertrophy, the heart weighing over fourteen ounces. In the other specimen the cardiac hypertrophy is much greater, the heart alone probably weigh- | ing over twenty ounces. The valves appear to be competent, and in neither case was there a valvular murmur. In Case I. there was a murmur, and a very distinct one, but it was undoubtedly caused by the great roughening of the aortic intima. These specimens appear to me to possess a great degree of interest in connection with the etiology of cardiac hypertrophy. The circulation in the coronary arteries is generally looked upon as exceptional, in that it occurs during the cardiac diastole. It is supposed that this is due to the fact that during the heart's contraction the pressure upon the blood-vessels ramifying in its substance is too great to permit of circulation. Doubtless this is true, but a moment's reflection will show that throughout the body the circulation is most active during diastole. This is plainly demonstrated by the sphygmograph. The pulse is synchronous (or nearly so) with the systole, and the pulse is produced by a wave motion, a distention of the artery; and the portion of the sphygmographic tracing that corresponds to the pulse is an almost vertical line. As we approach the heart this line becomes more and more vertical, that is to say, the onward movement of the blood becomes less and less during systole, until finally, in the coronary arteries, there is no onward movement whatever at that time, and the circulation is altogether diastolic. It is evident that, other things being equal, the activity of the coronary circulation is in direct proportion to the degree of aortic tension. If, as in Case I., the coronary arteries, from disease of their orifices, fail to yield to the aortic tension, compensatory hypertrophy cannot take place, and speedy death ensues. On the other hand, if the coronary arteries yield too readily to the aortic pressure, the hypertrophy progresses too rapidly, its limit is soon reached, and dilatation and degeneration, with their attendant dropsy, are soon followed by a gradual failure of the heart's action. There is a limit between these points, and it is conceivable that in some cases a | moderate amount of aortic regurgitation might be conservative. In Case II. there does not appear to be sufficient cause for the great degree of cardiac hypertrophy; the gross appearances of the kidney are not those of cirrhosis, but rather of the form of renal disease that is usually found with cardiac valvular disease, which has been denominated cyanotic induration. An undue supply of blood to the heart from relaxation of the coronary vessels cannot well be excluded from an attempt to explain the hypertrophy present, and this renders the case one of great interest. Cystic and tubercular kidneys. Presented by Dr. H. F. FORMAD. These kidneys are from a girl aged 19, German; occupation, milliner; family history good. A year ago she contracted a cold, had high fever and cough, and, although she soon left her bed, was never well since, and began to lose flesh. Her menstruation became irregular and scanty, and finally ceased altogether. She never had hæmoptysis. I saw her for the first time six months ago, diagnosed phthisis, and treated her accordingly. She had also cystitis,-ascertained by the symptoms which accompany this affection, and by microscopic examination of the urine. The latter was carefully examined nearly every week up to the time of the patient's death, but at no time could any indication of kidney-disease be demonstrated. Albumen was found at times in very small amount; quantity of urine was usually about normal; suppression never occurred. The autopsy confirmed the diagnosis. Besides, it revealed tuberculosis of the spleen and a fatty liver; but, in addition, there was found intense kidney disease, which it was impossible to diagnose during life. The right kidney is reduced to a quarter of the normal size; weight one ounce; capsule adherent; ureter and pelvis completely obliterated. On section, the glandular structure is seen to be perfectly destroyed and replaced by cysts,-one the size of a walnut, and several smaller ones. The cysts are smooth internally, and filled with an odorless, reddish fluid containing albumen. The left kidney is enlarged to nearly double the normal size; weight ten ounces; capsule not adherent. On section, the parenchyma is of a dark-red color; numerous grayish nodules were seen; also a few small softening cysts. Microscopic, Examination. The walls of the cysts of the right kidney were found to be lined by long columnar epithelium; the fluid of the cysts contained large and small epithelium,-both columnar and squamous, together with fragments of broken-down uriniferous tubules and Malpighian glomerules, leucocytes, and cholesterin. The left kidney showed a typical parenchymatous nephritis, the whole parenchyma, moreover, being infiltrated by embryonic cells, obscuring, in circumscribed spots, the glandular structure. In these spots the cells are collected in dense groups, and are imbedded in a reticulum free of blood-vessels, thus resembling miliary tubercles. No tube-casts could be observed in the uriniferous tubules; their absence here, as well as in the urine, is an interesting feature in this case. The view of Prof. Tyson, that there is a frequent coexistence of cystitis and cystic kidneys, has in this case an additional support. that the child had not expanded the lungs thoroughly, and that it would probably improve in time. It took the breast well, and the mother (a healthy woman) had plenty of milk. When about two weeks old it began to cry violently and persistently, as though with some severe pain. This continued from time to time until August 24, when the child was sick and suffering; it was hard to say why, for it did not look badly. It was rather small, but not emaciated; the bowels were moved every day, and the stools were well digested. It was very drowsy, and lay with the head drawn backward, breathing with some effort; but it had had a full dose of morphia on this day. The respiratory sounds were natural; the heart beat rather violently, and over a larger area than usual, but there was no abnormal sound; the abdomen was somewhat full and tympanitic, but not hard or painful on pressure. It took the breast freely. There seemed to be some fault in the digestion, and that possibly the child might be cer-hungry. The main symptom was the screaming, as though with some severe and steady pain, often for two or three hours at a time. A trial of feeding was advised, and equal parts of milk, cream, lime-water, and thin arrow-root water were ordered; also a carminative of paregoric, aromatic syrup of rhubarb, bicarbonate of soda, and mint-water. After this the screaming still went on, so as almost to madden the mother, and the infant began to grow thin and weak. Inunctions of cod-liver oil were used. Deodorized tincture of opium was given, one or two drops at a time. It was seized with coryza and cough, and began to sink. I do not believe that tube-casts ever are retained any length of time in the tubules of the kidneys. Charcot and some other writers on kidney-diseases assert that casts formed in the convoluted uriniferous tubules are prevented from passing out with the urine through the constriction of the loops of Henle. I have several times observed, in sections, that these constricted portions of the tubules are capable of considerable distention or widening when filled with casts, new-formed cells, or any urinary concretions. The tubules are made up of an elastic substance, which can easily be distended wide enough, tainly, to allow the passage of such soft and compressible bodies as the urinary casts, especially under the high pressure which is exerted upon them by the column of urine. I am also led to believe that there is not a loop of Henle connected with every glomerule or every convoluted tubule. Henle himself does not assert the invariable accompaniment of a loop to each glomerule, although this is erroneously taken to be the case; it has, however, never been proven. Examining some sections made across the whole of a cat's kidney by the cutting-machine, after the method of Dr. Seiler, it appeared to me that a uriniferous tubule started from the glomerules and passed down to the papilla, without diminishing in its course in calibre, and without forming a loop of Henle. If this is frequently the case (and probably it is), then my argument that urinary casts formed in the convoluted tubules can always easily pass out with the urine has an additional support. The investigation of my friend George H. Rose, to whom I suggested to work up this subject, points also decidedly to the affirmative of the above suggestion. An account of a case of congenital malposition and immobility of the intestine. By Dr. ARTHUR V. MEIGS. The ante-mortem notes of the case were furnished me by my father, Dr. J. Forsyth Meigs, who attended the child for some time before it died. The child was born about the middle of June, 1874. When born it was rather weak, and did not very thoroughly establish its respiration; it was somewhat bluish for the first ten days of its life, and cried but feebly. The nurse thought the action of the heart too strong and too frequent, and that the breathing was not natural. The accoucheur who attended the mother believed September 12, it was very ill, had become quite thin, and was feeble and took very little food. Pulse was 168, and respirations 84. Loud, coarse râles were audible all over the chest and some distance from the body. The respiration was distinctly bronchial. The case looked like one of acute tuberculosis or catarrhal pneumonia. From this time the child sank, and died on the 13th or 14th. I made a post-mortem examination September 15, 1874. The body was very small and emaciated. Lungs. Neither was very fully expanded, but the left crepitated throughout. There were spots at the lower edges of the upper two lobes of the right lung, which were hard and dark-colored and did not crepitate at all. Both apices were crepitant. Heart. The walls of the auricles were only about one-eighth to one-sixteenth of an inch thick; the foramen-wall was entirely closed. The walls of the ventricles were from onethird to one-half an inch thick, that of the right being slightly thicker than the left. The mitral, tricuspid, and aortic valves were healthy. Liver, healthy. Intestines.-The duodenum came off from the stomach as usual, passed under the liver, and descended to the level of the right kidney, where it made a sudden reverse turn and passed back parallel to its downward course. For about three inches before and three after it made the sharp bend the intestine was tightly bound down, being almost absolutely immovable. The small intestine, after leaving the region of the kidney, instead of passing behind the colon as usual, made a bend forward and passed in front of it, slightly to the right of the median line. Where the two intestines crossed each other they were tightly bound down; the mesentery being very short, they had consequently little motion upon each other. The rest of the small intestine was healthy. The lower half of the transverse and half of the descending colon were tightly adherent to the posterior wall of the abdomen, there being almost no mesentery. The rectum and lower half of the descending colon were greatly distended with gas. There was not the slightest apparent narrowing of the calibre of the intestine anywhere. - This child died from the condition of its intestine. It never thrived, but suffered constantly from intestinal trouble, so much so as to cause the attending physician to suspect some obstruction of the bowel, which proved to be the state of the case, for at the point where the small crossed in front of the large intestine the two were so closely fastened together that it would have been impossible for both to have been fully open at the same time. If one was patulous, it encroached upon and pressed in the walls of the other; so that if both were at work at the same time, a considerable amount of ingesta passing up the small intestine, the large also doing full work, one of the streams must have been stopped or greatly impeded. Then there was the great immobility of the intestine at different places. The jejunum had hardly any mesentery at all,-both before and after it made its very sharp reverse at the region of the kidney. The large intestine also was, as stated in the notes, less free than usual in about half its entire length. That the child should have had such violent pain as to make it scream so continually is strange. I cannot explain it. Perhaps this condition of things may help some one to explain the mechanism of the production of colic. The collapse of the lungs, which was the immediate cause of death, may possibly have been produced or, at least, increased by the continual and violent crying of the child. This suggestion I would call especial attention to, as an additional argument in favor of the theory which is advanced by my father, Dr. Meigs, in an article in the American Journal of Obstetrics and Diseases of Women and Children for uary, 1879, that prolonged violent crying may produce collapse. Another curious feature was the fact that the right ventricle was thicker than the left. I cannot understand why this Clinically, the tumor impressed the touch as being a scirrhoma. It was hard, nodulated, movable. The history of it began in a nodule accidentally discovered. Three years has been the length of time required to gain its present bulk. The interest attached to this growth, so far as I myself am concerned, lies not farther in the histological direction than suffices to enable me to know it as a neoplasm, in other words, as a something about which I know myself to be profoundly ignorant; in still other words, as an abnormality which has in itself no anatomical or physiologico-pathological data which enable me to understand and rationally treat it. It is an unexplainable tumor, in contrast with a hundred others that I feel I know a good deal about, hernial tumors, for example; odontoceles, hydroceles, ranulæ, sebaceous cysts, etc. It is one of a class of tumors that I am not any wiser about than when, twenty years ago, I commenced to study these things. Not but what I have somewhat enlarged my vocabulary in the direction of big words, but I am compelled to the admission that I have not yet found myself enabled to learn of a clinical difference between fibroma and encephaloma,—that is to say, I treat the latter by the mechanical act of cutting it away from the body, and that is the way, too, that I treat the former. A hernia, on the contrary, I reduce; a hydrocele I puncture; for the cure of an odontocele I pull out the tooth that is the offence. The histological study of what I have taken the liberty to designate as unknown tumorsthat is, every tumor which has not in itself its own explanation; all that kind of tumors of which the fibro-plastic is the type-seems to me to lead to little outside of the gratification of a kind of optical ambition, if it lead not to turning the microscope in the direction of the arcana of cause. There is, for example, a vice erratically, and without reason, called carcinoma. The specimen upon the table is an illustration of it. Were the specimen a myxoma, it would still be an illustration of it. Were it a fibroma of simple concentric deJan-velopment, I would accept it, from lack of better information, as a spoke of the same wheel. Can histological study find out the reason for a fibroma as it finds explanation of a sebaceous cyst? Can it find out why a simple fibroma, when removed, may come back with great increase in the cellular element? Can it explain why a myxoma, which is a fibro-plastic growth, returns, when extirpated, as sarcoma or as encephaloma? One true good, certainly, is to be credited to this study; it has demonstrated that no diagnostic skill can point the line of demarkation between fibroma and encephaloma. I have brought the specimen to the table, not, of course, with the idea of showing anything different from what is seen here every meeting-night, but in a sense of personal weakness of judgment in the direction in which it leads. At the last meeting of the Society I presumed to criticise the practice of one of the members from the stand-point of what I deem to be a reasonably solid footing. At this present meeting I desire to acknowledge myself exposed, and this for the reason that, after three years of study of the case before us, I am not clear in my mind that the course pursued has been the best one. Can the practice which shows a nodule let alone for three years; a marriage permitted; a baby allowed to feed nine months at a diseased breast; finally, the milk dried up and the gland amputated,--can this practice be faulted by any experience wider than that which has influenced the course pursued? Dr. H. LENOX HODGE stated, in answer to the questions of Dr. Garretson, that in a case of a tumor of this character he would consent to marriage. The growth, if let alone, would probably increase in size during lactation, on account of the larger amount of blood going at that period to the breast. As the tumor was distinct and separate from the proper structure of the mammary gland, no injury to the child was to be anticipated. If there was any tendency hereafter to the development of such a growth in the child, it would probably be due to inheritance at the time of conception, rather than to nursing at the breast. Report of the Committee on Morbid Growths. "The mammary tumor presented by Dr. Garretson is found to consist, histologically, of round-, oval-, spindle-, and stellate-shaped cells, in which a relatively large nucleus is seen; an intercellular substance, partly fibrous and partly structureless or granular, is present. Here and there through the nodule are observed the atrophied ducts and acini of the gland; the ducts, when seen in transverse section, are found to have their lumen obliterated by a proliferation of the lining cells. "A section taken from the gland in the proximity of the tumor shows a slight infiltration, of a similar new formation, into the glandular tissue. "The tumor may be considered as myxomatous in nature. There is also an infiltration of the surrounding tissue by the myxomatous element. "June 26, 1879." REVIEWS AND BOOK NOTICES. A CLINICAL TREATISE ON THE Diseases of THE NERVOUS SYSTEM. By M. ROSENTHAL, Professor of Diseases of the Nervous System at Vienna. With a preface by Professor CHARCOT. Translated from the Author's Revised and Enlarged Edition, by L. PUTZEL, M.D. New York, Wm. Wood & Co., 1879, 8vo, pp. 278. Among the merits of this book worthy of special mention are its uniformity of plan and systematic divisions and subdivisions, the well-chosen amount of space and attention which are devoted to each disease, the careful presentation of the subjects of symptomatology, diagnosis, and prognosis, and the numerous concise reports of original pathological and histological observations. Proper prominence is given to Brown-Séquard's clinical as well as to his physiological researches. Compression-myelitis is well discussed in several valuable, practical chapters. Diseases of the medulla oblongata are very properly considered under a separate class. A treatise on nervous diseases, with a classification throughout based on the localization of lesions, cerebral and spinal, is, we think, a desideratum. Some attention and even prominence is given by the author to this subject of localization, but here he is not in every particular level with the knowledge of the day. Under the head of "Special Symptoms depending upon the Seat of the Hemorrhage" (encephalic), one of his subdivisions is the too broad one of hemorrhage into the cortical substance, in which he says psychical troubles play the chief part. The terms middle and posterior lobes are not to be recommended. Ecker's classification of the lobes of the brain into frontal, parietal, temporo-sphenoidal, and occipital is the best for descriptive purposes. In treating of tumors of the brain, in a chapter very valuable in many respects, he makes, with reference to locality, twelve subdivisions, the first four of which are tumors of the convexity of the brain, of the anterior, of the middle, and of the posterior lobes. As he evidently subscribes in the main to the views of Fritsch and Hitzig, and of Ferrier, it would have been far better to have adopted a classification like that employed by the latter, into the psychical, motor, and sensory regions, etc., of the convolutions, and into the divisions of the centrum ovale. The convexity of the brain may mean portions of either frontal, parietal, or occipital lobe, of psychical, motor, sensory, or vegetative zones. The sections in which he treats of tumors of the pons and cerebellum, and of the peduncles, cerebral and cerebellar, are the most satisfactory. "Tendon-reflex” is not sufficiently brought forward in his symptomatology. In a work intended largely for the general practitioner |