ment. Begun as it was late in the course of the disease, i.e., at the end of the second or the beginning of the third week, it still was efficacious. I am convinced that early bathing here would have warded off these nervous symptoms, and the entire course of the disease would have been less severe. His temperature was at no time after admission to the hospital very high, but the patient was certainly thoroughly infected with the typhoid poison. The cold affusions were used at a temperature of 65° F., and on the second day his mental condition was better. Six days later his tongue was moist, there was but little subsultus tendinum, the abdominal distension had disappeared, his bowels had to be moved by injections, and he was passing sixty-one ounces of urine in twenty-four hours. From that time on the case was similar to one of ordinary typhoid, but later the patient developed an abscess over the sacrum which retarded his convalescence somewhat, and which was doubtless due to an infected bedsore, which originated before he entered the hospital. ever, who died on the sixth day after admission (the could present the advantages of this method of treatfifteenth day of the disease), the drop in temperature after the baths was most marked, varying from 2.8° to 4°. This case was complicated by pneumonia. Another patient, who was seven months pregnant, received twenty-six baths. She eventually recovered and was delivered at term. The fetal heart-beats were counted daily and varied from 180 per minute, when the disease was at its height, to 140 when the patient left the hospital. One of our nurses, twenty years old, contracted the disease, undoubtedly in the wards, and died from an attack of bronchopneumonia during the sixth week. came of a tuberculous family, was herself extremely anemic, and an examination of her blood showed only thirty-five per cent. of hemoglobin. She received ninety-five baths in all, given over a period of seventeen days. The symptoms attributable to the typhoid infection were subsiding, when the bronchopneumonia invasion took place; and although her temperature for the first ten days of treatment varied from 104° to 106° F. in the rectum, she was quite comfortable, and did not become delirious until the beginning of the bronchopneumonia. She CLINICAL LECTURE. TRICUSPID REGURGITATION; SENILE BY H. A. HARE, M.D., OF PHILADELPHIA; PROFESSOR OF THERAPEUTICS IN the Jefferson meDICAL The last case I will cite is that of a patient whom I have no doubt whatever was saved by the application of the Brand baths and cold affusions to the head and shoulders. He was twenty-seven years old, unmarried, and lived in a boarding-house. I first saw him October 20, 1896, when he had an attack of grippe. In four days his temperature became normal and he said that he felt perfectly well. Nine days later he appeared at my office with a mouth temperature of 104° F. and a pulse of 120, when a diagnosis of typhoid fever was made. Forty-eight hours earlier he had taken a long ride on his bicycle. For eleven days he was treated at home, but he grew constantly worse in spite of all that I could do for him. I had advised his early removal to the hospital lips a little more closely, we notice that in them the dusky so that he might be bathed; but objections were made by a relative. It was impossible on account of the expense to bathe him at home, as two male nurses would have been necessary. The day before he went to the hospital his condition was as follows (and I might say it was only because his condition was so desperate that his friends gave their consent to his removal) Temperature by the rectum, 105° F.; pulse 150, weak and irregular. Facies drawn, skin suffused, tongue dry, and abdomen distended and tender. He had diarrhea, with involuntary evacuations, subsultus tendinum was most marked, and delirium was active at times, but continually muttering. On admission to the hospital he was immediately given Brand baths and cold affusions. He eventually recovered. This case shows better than any other I THE first patient that I show you is, as you notice, somewhat cyanotic. His respirations are a little more labored than is normal, and he sits up in bed rather than reclines. His chest is deep and well developed, his neck is that of a powerful man, and his face shows that he has been much exposed to the weather. When we examine his color of his face becomes more marked. His finger nails are also blue and livid. On closer inspection we find, also, that the jugular vein, particularly that upon the right side, is pulsating, and that this pulsation occurs with the systole of the heart, which indicates that the right ventricle as it contracts not only forces blood into the pulmonary artery, as it should do, but that regurgitation takes place into the right auricle, and from there into the right jugular vein. In examining the jugular vein in any case of heart disease to determine whether or not pulsation is present, you must always be careful to avoid mistaking a transmitted impulse from the carotid artery to the tissues in the neighborhood of the vein for true jugular pulsation. In this case, however, the pulsation is so marked that there can be no doubt as to its causation. The symptoms which the patient presents are chiefly those of cardiac 1 A Lecture delivered at the Jefferson Medical College Hospital, February 8, 1897. dyspnea, and we naturally proceed immediately to an examination of his heart for the purpose of determining positively what the cause of his distress may be. On listening to the apex, the spot to which we always first direct our attention in studying lesions of the heart, I hear a murmur, systolic in point of time, or in other words, occurring with the first sound of the heart, and this murmur is of a peculiar metallic sound and rather short and sharp. However, when I listen over the aortic cartilage I hear this murmur even more clearly than I did at the apex, and therefore the first impression might be that this is a case of aortic rather than mitral disease, particularly if it is borne in mind that a murmur is usually loudest at its point of origin. But the jugular pulsation makes me suspect that the man has something else than aortic disease, and that the only reason I hear the murmur loudest over the aortic area is because I have approached nearer to its seat of origin, namely, the tricuspid valve. When I place my stethoscope over the fourth interspace on the right side, I hear the murmur more clearly and more definitely than before. Indeed, it seems as if the murmur was transmitted directly to my ear from its point of origin. It is evident, therefore, from the symptoms and from the location and character of this murmur that the patient is suffering from tricuspid regurgitation. This becomes still more certain when I find that the murmur is clearly transmitted to the back upon the right side. I can also see that there is marked pulsation in the hepatic area, and, as you know, true hepatic pulsation is never present except in cases of tricuspid regurgitation. It must be remembered, however, that in some cases when the heart is acting powerfully and the liver is somewhat enlarged, and particularly if the heart is displaced somewhat to the right, the ordinary cardiac impulse may be transmitted to the liver. In order to exclude such a possibility in this case, I place one hand under the floating ribs anteriorly and the other hand over the same ribs at the side, and doing so I find marked expansile pulsation of the organ. An entirely different sensation is imparted to my hands from that which would occur if the liver were simply jarred by a transmitted cardiac impulse. One of the most annoying symptoms from which this patient suffers is excessive cough, and, on listening to his chest, particularly at the base on both sides, posteriorly, I find a large number of moist râles, which are due to the fact that the pulmonary circulation is impaired, owing to the failure of the tricuspid valve, and as a result he has a certain amount of stasis or congestion of the lungs. At first glance it would appear that the first thing to do for the relief of the patient is to administer some narcotic or sedative that will allay to a great extent this excessive cough. It renders his condition most pitiable as it gravely interferes with respiration and circulation, and during his coughing attacks he becomes very cyanotic and oppressed, the jugular veins swelling to such a degree that it seems as though they would burst. Although we are tempted for these reasons to administer such drugs, we are forced to bear in mind, on the other hand, that these remedies, by stopping the cough, may prevent the patient from expelling from his lungs the mucus which gradually accu mulates in them, and under these circumstances he would rapidly drown in his own secretions. When he entered the wards his breathing was far more labored and the action of his heart was irregular and feeble. If I had given him digitalis in the presence of an arterial pressure, already somewhat high, I would have stimulated the heart, but at the same time increased the labor of this organ by increasing the arterial pressure. I ordered for him instead of digitalis, strophanthus tincture in 5-drop doses and of a grain of nitroglycerin three times a day, and he is greatly relieved. You must understand that the condition of tricuspid regurgitation is a comparatively rare condition, and many of you may pass through a lifetime of practice without meeting with a case. When you do meet with one it will usually be secondary to disease of the mitral orifice or to the presence of emphysema or some other process in the lung which interferes with the transmission of the blood from the right to the left side of the heart. This obstruction results in dilatation of the right ventricle and failure of proper approximation of the tricuspid leaflets and consequent regurgitation. Very much more rarely will the condition of tricuspid regurgitation be primary, as it is in this instance, for rheumatism rarely involves these valves primarily, and in this patient we have sought in vain for any history of rheumatism, or strain, or for other cause which could have resulted in the development of the lesion. The second case that I show you is also one of tricuspid regurgitation, which is, however, apparently secondary to a mitral regurgitation, and which is almost as interesting as the one we have just examined. In this case the murmur is not so loud, there is no pulsation of the liver, the jugular veins are not markedly distended, and the condition of the patient is moderately comfortable. The third case is one of senile gangrene. The patient was admitted to the wards about four weeks ago with dry gangrene involving the little toe of the left foot, a distinct line of demarcation having formed just where the toe joins the body of the foot. At this time his pulse was exceedingly feeble, and an examination of his blood vessels showed them to be markedly atheromatous. His nutrition was fairly good for an old man of sixty-three, and aside from his inability to walk, and some paroxysms of severe pain in his leg about four inches above the ankle, he was otherwise in good condition. There were no abnormal heart sounds. It was evident that we had to deal with a case of senile gangrene, because of the atheromatous blood vessels and feeble pulse, and for the reason that an examination of the urine by the resident physician failed to demonstrate the presence of albumin or sugar. In this connection the case is also of interest as illustrating the necessity of frequently examining the urine when the diagnosis is obscure, for, about ten days later, an examination revealed sugar, and another quantitative examination made a few days later revealed it again in small amounts. It is only proper for me to mention the fact that the man had no other symptoms of diabetes than glycosuria, which of itself is not, of course, absolutely pathognomonic. He had no thirst, no excessive hunger, no itching, and no boils. The disease gradually progressed, notwithstanding stimulant treatment, but his pain markedly decreased. His third toe next gradually became gangrenous, and forty-eight hours ago, in the course of twelve hours, the entire foot, with extraordinary rapidity, became gangrenous almost to the ankle, the rapid process being a moist gangrene, in contrast to the dry or shriveling gangrene which first developed. Simultaneously with this sudden increase in the local disease the patient's temperature rose to 104° F., and he speedily became partially comatose, answering when sharply spoken to, but sinking into slumber before he had finished his reply to the question. A few hours later, as it was seen that his coma was deepening, I decided to perform upon him what the French physicians have recently been so enthusiastic about, namely, intravenous washing of the blood, which consists in introducing a canula into a vein of the arm, and injecting very gently through it, by means of a fountain syringe, a normal saline solution, which is supposed to wash the blood of poisons and cause their elimination by the kidneys. Shortly before performing this operation I found that the patient's arm when raised remained in the position in which it was placed, or, in other words, he had developed a spastic rigidity of the muscles, and while the injection was being given he had a tonic convulsion, in which his respirations rose to sixty a minute, and were slightly Cheyne-Stokes in character. His pulse became almost extinguished, although during the early stages of the injection it was remarkably strong and full. The convulsion soon ceased, and in the course of half an hour the patient had a very profuse sweat, which saturated the bedclothing. On leaving him for the night I informed his wife and children that I did not expect him to survive more than an hour or two, but to my great surprise yesterday morning I found him quite conscious, encouraged about himself, and fairly bright. The fever had disappeared, but the gangrenous process was rapidly extending up the leg, and his feeble pulse and irregularly acting heart told me that the end was not far off. The fourth case is of peculiar interest, not only because of the difficulties in its diagnosis, but because a comparatively new method of diagnosis has decided what the condition of the patient is. She is nineteen years of age, a light mulatto, who has a long history of general debility and anemia. A little over two weeks ago she had an attack of dizziness followed by fever, these symptoms being preceded for a number of days by general wretchedness. Her temperature has at times risen as high as 104° F., and has been controlled by either bathing or sponging, usually the latter. She has been obstinately constipated from the first, and her stools have had nothing characteristic of typhoid fever about them. There have been no spots on the abdomen, and I have not found any considerable enlargement of the liver or spleen. There has been only a moderate amount of tympanites and the tongue has not at any time been distinctly typical of typhoid. The fact that she seemed to be in a typhoid state, however, rather pointed to the presence of enteric fever. An examination of her abdomen shows it to be but slightly tumified, the skin being perhaps a little more dusky than is natural. What is more important is the fact that the skin here is rough and appears like cutis anserina, a condition which I have often noticed in cases of tuberculous peritonitis, although it is of course in no way characteristic. With the idea that it might be a case of tuberculous peritonitis, in which case an operation would be demanded, I asked Dr. Keen to see the case in consultation with me and we decided in view of its uncertainty that we had better wait until other symptoms developed, as there did not seem to be the fluid present in the abdominal cavity that is usually found in many cases of this disease. The decision as to the character of the case was determined, however, by what is known as Widal's agglutination or clumping test, which rests upon the fact that the bacilli of Eberth, which, as you know, are the characteristic micro-organisms of typhoid fever, cease their movement and become agglutinated or "clumped" when brought into contact with the blood serum of typhoid fever patients. I asked Dr. J. C. Da Costa, Jr., one of the assistants in the medical clinic, to make this test for me, and he reported that agglutination took place in less than a minute. We have decided, therefore, in view of this test, that the patient is suffering from enteric fever and not from tuberculosis. That this test is reliable is proved not only by the reports of Wyatt Johnson of Montreal, and Greene of Minneapolis, but by numerous other clinical observations both in this country and abroad. It is interesting to note, however, that in one instance both Professor Coplin and Dr. Da Costa have seen this agglutination result in the case of a patient who was not suffering from any symptoms of typhoid fever but who had a double aortic murmur. This may have been due to the fact that the patient at some comparatively recent period had recovered from typhoid fever and therefore gave the reaction. CLINICAL MEMORANDA. A CASE OF TUBO-ABDOMINAL PREGNANCY, PROFESSOR OF POLYCLINIC; OF NEW YORK; MRS. G. R. was referred to me by her physician, Dr. Thomas D. Pinckney of Williamsbridge, N. Y., who gave the following history of the case: The patient was married fifteen years ago, having a child normally a year later. A second child was born a year afterward, following which the mother suffered from peritonitis and was confined to bed for three months. Her lochial discharge continued for ten weeks. She menstruated every three weeks after getting up, and did not become pregnant again until seven years had elapsed. She then had an 1 Read before the Obstetrical Section of the New York Academy of Medicine. instrumental abortion performed when she believed herself five weeks pregnant. Considerable hemorrhage ensued, but no special reaction of an inflammatory character seems to have occurred. Menstruation began in three weeks. About five years later she again became pregnant and a second abortion was accomplished at five weeks gestation. The last abortion was followed by fever, pain, and the expulsion of pieces of flesh.” The flow ceased in two weeks. The patient said that she never felt well afterward. She had "an uncomfortable feeling in the lower part of the abdomen, chiefly on the left side." This was in February, 1896. Menstruation returned and was normal in character. During April her menstrual flow was very scanty, but it continued for eighteen days. The discharge was brown, "like coffee stain.” She had a slight flow May 1st. During that month she began having sharp, cutting pains in the left lower part of the abdomen, which were sometimes followed by fainting spells and always by great exhaustion. The pain, though more dull in character, continued until August. She felt life August 13th. She had been growing larger, with a feeling of tightness in the abdomen when on her feet. I first saw the patient in consultation with Dr. Pinckney, on Saturday, October 31, 1896. She was pale, emaciated, and the face wore an anxious expression. She had had morphin at times for a considerable period, and the mouth and tongue were dry. She was suffering severe pain, due to the fetal movements. Dr. Pinckney had heard the fetal heart, to the right of the umbilicus, some time before. The patient was removed to the Mothers' and Babies' Hospital that afternoon. After free catharsis had been obtained, I made an examination under chloroform. The abdomen appeared enlarged to the size of a five or six-months' pregnancy. There was some slight bulging in the left lower quadrant, and along the right middle and upper quadrants. The fetus was clearly mapped out as lying in a line parallel with the maternal vertebræ, and with its dorsum to the right, the entire body being chiefly in the right half of the abdomen. The head was not outlined, the position being determined by the location of the limbs, back, and fetal heart. The fetus did not feel nearer to my fingers than in many normal cases of pregnancy I have examined. The left lower quadrant of the abdomen held a mass that could not clearly be made out. It was neither elastic, cystic, boggy, or firm. While it might be placenta, I could not affirm it. was no vascular murmur to be heard in or about it. The cervix was soft, spongy, enlarged, and patulous up to the internal os. In connection with the anterior lower segment of the uterus, which felt soft and somewhat elastic, it suggested a pregnant uterus of about five months. The fundus could not be outlined, for reasons shown when the abdomen was opened. There Being able to exclude an intra-uterine pregnancy, the history pointing most emphatically to an extra-uterine gestation, I determined to follow a conservative course, and on November 7th, dilated the cervix, having decided that in any case it was not just to the patient to permit the pregnancy to continue. The uterine cavity was found to be small in extent, and was lined with a soft and easily detached membrane. This was removed and the cavity lightly packed with iodoform gauze. The abdomen was then opened, Dr. J. A. Bodine kindly assisting me, in connection with the hospital staff, and the placenta was found just under the omentum, covering most of the space below the umbilical line, and somewhat to the left. The fetal surface of the placenta lay immediately beneath the abdominal wall, the cord arising from the middle of its upper surface. A layer of blood coagulum covered most of the abdominal contents in front. This was of recent origin, with older clots of a liver-like character lying between the uterus, placenta, and intestines. The head of the fetus lay just behind the fundus. Delivery was accomplished without difficulty, the left shoulder, and then the head and body being born. Under Dr. Mitchell's skilful handling good resuscitation was secured. The child was lying outside the amnion. The placenta was extremely convex, almost balloon-shaped, with, as I have said, the fetal surface lying uppermost. False membranes bound it on all sides, uniting it to the anterior wall and fundus of the uterus on the right, to the colon posteriorly, and to the peritoneum on the left and lower anterior part. Its vascular supply came from the left Fallopian tube, apparently from the outer half, the pregnancy evidently having started in this tube. Aside from being bound down like a balloon held to the earth, the placenta was quite free above and could be considerably displaced. The hemorrhage caused by its removal was not very great. It weighed one pound, three ounces. The cord was about eighteen inches long. Iodoform gauze was packed in the left lower pelvis and the wound closed up to the gauze. The abdominal operation lasted threequarters of an hour. The patient suffered severe shock, due chiefly to the great vital depression resulting from her prolonged sufferings. Hot saline injections were retained, and the next morning her condition seemed favorable, but at eleven o'clock she succumbed from general exhaustion. The uterus was removed post-mortem. Its limitations could not be made out by abdominal palpation previous to operation, as it was covered by placenta. Its weight was 111⁄2 ounces; length, 5% inches, and width, 31⁄2 inches. The thickness of the wall through the middle plane was I inch, the diameter of the cavity from the external os, 4 inches; the circumference of the body, 91⁄2 inches, and the diameter of the cervix, 1% inches. The placenta was nearly spherical and was 634 inches in diameter, 1% inches thick in its thickest part, and weighed 1 pounds when the blood had been removed. I The membrane which lined the uterine cavity was lightly attached to the body wall. I have examined sections of it under the microscope, and it proves to be distinctly decidual, though possessing some of the appearances of chronic endometritis, to the extent that there are still remnants of utricular glands, rather a diminution in number, while the columnar epithelia have lost their normal regularity of shape and arrangement, being desquamated, disintegrated, or supplanted by connective-tissue endometrium may be obtained with the curette, examined with the microscope, and decidual tissue recognized if present; such tissue may be a remnant of an abortion, a part of the decidua surrounding an ovum, or due to an extra-uterine pregnancy; the use of the microscope in connection with the clinical history will determine to which variety the specimen belongs, and if to the third, will confirm the presence of an extra-uterine gestation. 1 Amer. Jour. of Obstet., vol. xxvi, No. 3, 1892. 1895, adding at the end: " Ayers has carefully considered this subject, and is of the opinion which I have given above, viz., that decidual cells are alone due to the influence of pregnancy." Strahan, in his work on "Extrauterine Pregnancy," which won the Jenks prize, says: "The lining mucous membrane also undergoes development into a true decidua. Indeed, it has been suggested by an authority that we should dilate the cervix and ascertain the presence or absence of the decidua as a crucial |