Not differing from tuberculosis elsewhere, the first definite change provoked by the bacillus in the larynx is an infiltration of the mucosa and submucosa by a diffusion of small, round, mononuclear cells, interspersed among which are collections of epithelioid and lymphoid cells in the form of tubercles, which are deposited, in large part, in the connective tissue beneath the epithelial and structureless layers, and hence near enough to the surface to change its aspect in form and feature. Accordingly, the recognition of early changes in tuberculosis of the larynx will be promoted by keeping in mind: First, the disposition of tubercles and tuberculous nodules to assume a globular form, which gives the surface of the infiltration, also termed hyperplasia, a mammillated aspect. Secondly, their disposition to excite verrucous and granulomatous formations which, though ordinarily delayed till the stage of ulceration, may make an earlier appearance and give the surface a
DENVERIts with the conscious risk of a chcharge of unwarranted temerity that I venturItventureo eenter ved as amaster. My only excuse is tatwentyodd years of special personal study of the subject procedure of auscultatory examination became, of a sudden,ught with acoveted wealth of information concerningrecognition of idisorders wholly due a new point of view the application of an omethod. The clinical results thus obtained suggest the experience of the farmer whose twenty bushels to the acre under the tillage of his ancestors has increased a hundred per cent. with the application of a new line of thought to his labor. I am the more encouraged to believe that my personal sense of enlightenment, derived through the procedure to be described, is founded on objective facts because of experience with several patients who presented themselves shortly after having secured from real medical experts a report of perfect physical condition. That
THE modern student and practitioner is confronted with the most difficult and abstruse questions, relating to the chemistry and physiological action of mineral springs, questions that are almost the despair of one of only ordinary scientific training. The chemical analyses of waters on which so much stress has been laid, ever since analytical chemistry has been employed to determine their character, are now themselves in process of passing into history. A glance at recent publications of the chemical division of the United States Geological Survey shows how completely the modern chemist has changed his notation to conform with the latest discoveries in the science of molecules, radicals, atoms and ions.2 The definition of a mineral water varies with the point of view of the chemist, the geologist, the physician, and the dealer. Each has his standard, and no arbitrary line depending on total content of minerals or salts in solution can be drawn between so-called pure waters and those commonly denominated as mineral waters. Indeed, the most popular and commercially valuable "mineral" water in America has almost a minimum of solid constituents. In what form and in what combinations the simplest salts exist in mineral waters or in artificial solutions demands the most serious attention. Take, for example, pure water and add to it sodium
SEVERAL cases of intrathoracic tumour, which had been mistaken for pulmonary tuberculosis and sent to Colorado on that account, have come under the observation of the writer. It is by no means desired to criticize those who made these diagnoses, for it is well known that, early in their course, these cases may simulate tuberculosis so closely and the physical findings be so similar or indefinite as, in some cases, to make differentiation extremely difficult or even impossible.
The clinic has been under obligations to the laboratory since the time of the first post-mortem descriptions of normal organs, and of pathologic changes in organs and tissues. Yet to-day one would pass over the founding of modern medicine by Rokitansky, Cohnheim and Virchow on pathologic and histologic anatomy, to the consideration of the more striking relations of the clinic to bacteriology, parasitology, physiology, physiologic chemistry, experimental therapy and laboratory diagnosis. It is not that pathologic changes in tissues are unimportant, but in the newer fields of research there has been so rapid a development of methods applicable clinically to the accurate diagnosis and to specific therapy and prophylaxis of infective and parasitic diseases, and the correction and regulation of toxic and antitoxic metabolic disorders of a non-invasive nature, that the earlier pathologic investigations must be considered of a former era. The laboratory has forgotten that the original stimulus for
S OF THE CLINICAL RECORDS. Case I.-B. B., male, aged 5I in I9o6; leather manufacturer. Referred by Dr. J. H. Musser, of Philadelphia. Diagnosis.-Coronary sclerosis. Strong and well since childhood except for chronic diarrhoea in I904 and I95. At -times pulse irregular. Slight discomfort over praecordia occasionally when walking up steep hills. Strongly built, stout, healthy-looking man. Heart found enlarged on percussion and on orthodiagraphic examination. A soft'systolic bruit replaced the first sound at the apex. First sound not ,audible 'in pulmonic' or aortic areas. Took the caribon '272 CARBON DIOXIDE BATHS IN CARDIAC DISEASE dioxide baths in i906 and I907. Developed heart-block in September, I907; pulse fell as low as 3I. The heart-block persisted about four months. He has had subsequent attacks. Living and at work in 1913. Case 2. A. B., female, aged 46 in I907. Referred by Dr. W. R. Steiner, of Hartford. Diagnosis.-Mitral stenosis, auricular fibrillation. Shortness of breath on exertion since I9Oi. In September, I906, walking on the level began to produce dyspnoea. Dilatation of the heart detected in December, I906. In February, I907, a few weeks before taking the baths walking about the house produced palpitation. Never had rheumatic fever. Stout woman of medium height. Cardiac dulness increased to the left. Thrill and diastolic murmur sometimes present at the apex. Cardiac action very irregular. Pulse weak. She made rapid and marked improvement while taking the course of carbon dioxide baths. She has had attacks of cardiac insufficiency since then, but is still able to leaid a fairly active life (I913). Case 3.-E. D., male, aged 56 in I906; clerk. Referred by Dr. J. B. Briggs, jun., of Washington. Diagnosis.-Chronic interstitial nephritis; diabetes. Diabetes discovered in I905. Patient on a regulated diet; had no sugar in the urine when the baths were taken in I906. He was perfectly well at that time. No enlargement of the heart detected on percussion. Sounds clear. Second aortic sound somewhat ringing. Pulse regular. Radial artery not thickened. Urine contained a slight trace of albumin and a few hyaline casts. He was under observation nearly two years and never complained of breathlessness on exertion or other symptoms of cardiac insufficiency. He died suddenly in December, i907. Autopsy showed a dissecting aneurism of the aorta which had ruptured. Case 4.-C. E., male, aged 50 in I906; shoe manufacturer. Diagnosis.-Coronary sclerosis; neurasthenia. Well and vigorous until i906 when he developed insomnia as a result of worry. His pulse became irregular (extra-systoles) at that time. He never had breathlessness on exertion or pain in the chest. A tall, large-framed, stout man. Peripheral arteries not sclerosed. Heart slightly enlarged on percussion. Sounds clear. Last seen in February, I913. He 273
In 1878 Cohnheim suggested that tuberculosis of the cervical lymph-nodes might be the result of primary tuberculosis in the buccal or pharyngeal mucosa or tonsils. In 1879 Orth in some feeding experiments with guinea-pigs produced tuberculosis in the cervical lymphnodes, and in one instance in the tonsils. Baumgarten con firmed these results in 1884. Cornil and Ranvier the same year described the lesions in tuberculous tonsils in their manual of pathologic histology, and Strassmann the same year mentions the frequency of tonsillar tuberculosis in phthisical patients (thirteen in twenty-one cases). This seems to have been the beginning of the special literature on this subject. In 1885 Abraham wrote on tubercle of the tonsil and in 1891 Dmochowski concluded that tuberculous deposits in the faucial and lingual tonsils often resulted from auto-infection. In 1892 Conoreur described the probable relation of tuberculosis of the tonsils to the same disease in the cervical
In 1911 Jolly and Ritchie1reported a case of Adams-Stokes disease which had been under observation for a period of six years and which showed in association with the complete heart-block a very rapidly beating auricle, the rate of the latter varying from time to time, but usually from 270 to 300 per minute. This condition they called auricular flutter. In adopting the term they refer to the work of McWilliams,2who, years ago, observed that the application of a faradic current started the auricle into a rapid flutter. In his account, McWilliams stated that the contractions originated in the stimulated area and extended rhythmically and coordinately throughout the tissue. In 1909, Hertz and Goodhart3reported a case with an auricular rate of 234 and a ventricular rate varying from 72 to 120. In this case the irregular and varying ventricular rate depended on a partial
