itself has grown more accurate with use, ontogenetically as well as biogenetically.

The vertical canals have little or no opportunity to exercise either a sensory or regulatory motor control, so that it would not be surprising if, even in the rare case of their involvement in labyrinthine suppuration, the sensation of dizziness should be interpreted according to its more active component, the horizontal canal. The same reasoning applies to cerebellar dizziness, which, in as far as it depends at all on labyrinthine sensations, is developed, as a central organ, mainly by external canal stimulation.

The term vertigo, indicating rotational dizziness, aptly fixes this connotation, but it should be borne in mind that dizziness sensations are, at best, vague and. defined with difficulty on account of the attendant disturbance of general consciousness.

NEW DRESSING FOR BURNS. Mixture of Lamb's Tallow and Castor Oil. J. D. Dodge, of Cleveland, Ohio, in the Eclectic Medical Journal, describes a new dressing for burns, which we reproduce in his own words:

I recently made an ointment, he says, by melting together equal parts of lamb's tallow and castor oil, heating the mixture until an empyreuma and blue smoke were produced. It has worked a somewhat miraculous cure. Being in the

depths of despair over my inability to induce a third degree burn to heal, I made and used this ointment with the most happy results. Two courses of skin grafts and three unguents had failed. I knew the unirritating qualities. of both lamb's tallow and castor oil. In combining them I got something with more body than the oil and less hardness than the tallow. In cooking the mixture to the degree necessary to produce an empyreuma, a highly acceptable food for the reparative cells must have been produced, for they went to work promptly and made new skin very rapidly. The

healing continued even when the mixture was not heated sufficiently to evolve the blue smoke, though not so rapidly, I think, as in the former case, and the extra heat certainly insures thorough sterilization, a matter of extreme importance. The lesion was ten inches in length and two inches wide, extending from the top of the right shoulder down the front of the arm, two or three inches below the elbow joint of a little boy of six years. I dipped the end of a roller bandage into the hot solution, and when cool enough laid it across the lower end of the denuded surface and clipped it off in situ. The whole sore was thus covered with overlapping plasters, which readily permitted the pus to exude into the superimposed gauze, which was also thoroughly sterilized. Prior to the use of this mixture the pus had been superabundant and of a dirty mud color, but under the new treatment it changed to white, and greatly diminished in quantity. A posterior binder's board splint to control the flexibility of the arm, wide enough to prevent the dressing from pressing unduly on the exquisite sensitive lesion, was used. Passive motion was daily given to prevent contraction of the elbow joint. I never saw anything heal more rapidly than this sore, which had so effectually balked under the other treatment. It acted as though the reparative cells were feeding upon the unguent as upon a veritable skin food. I have used it in one case since, in which both arms of a restaurant cook's assistant were badly burned. The healing was rapid, and no pus developed.

If this preparation would always do as well as in these cases, its value would be above that of fine gold and precious gems.

ATONY OF THE RECTUM. William M. Beach stated to the American Proctological Society that atony or sluggishness of the rectum signifies the inability to expel its contents by reason

of impaired musculative, ligamentation or innervation, and further that the musculature in the rectum proper, or that portion above the plane of the levator ani, is entirely involuntary, whose inertia. must therefore be due to some inherent factor.

On the contrary, the anal canal, which is made up for the most part of the voluntary fiber, has most to do with the expulsive act, the normal function of which depends chiefly upon the muscular automaton that is intact, proper innervation and psychic influence.

The physiologic rectum depends upon (1) an unobstructed canal; (2) firm ligaments, and (3) a well-developed rectal sense residing in the anal canal. Factors contributing to atony are (a) traumatism to the perineal body; (b) disease in the anal canal; (c) enteroptosis secondary to general systemic conditions or local anatomic anomalies; (d) the abuse of injections and drastic catharsis; (e) disease in adjacent organs, as prolapsed uterus, adhesions, neoplasms, appendicitis, prostatitis, circulatory disturbance, as engorged portal vessels and primary gastric diseases; (f) atony may be the sequel to luesis or senility. The treatment is that of constipation, being guided by the cause. Alterative, dietetic and mechanical agencies are to be invoked.

cases. The successive transformation may occur within some weeks or may take many years. When the process is diffuse and purely parenchymatous, it has the disposition rapidly to assume the chronic form.

There are cases in which a chronic nephritis is not recognizable for long periods, in which there is no demonstrable connection between an acute renal inflammation which has occurred many years previously and an existing chronic nephritis. In such instances we may have to deal with indurative processes of varying degree and intensity. Renal induration may either set in when the parenchymatous nephritis is still fresh, or it may not be called forth until it has progressed to a certain stage. It is also possible that latent or limited indurative metamorphosis is ocasionally present prior to the establishment of the parenchymatous inflammation, and that the latter stands at the foundation of a renewed or greater activity of the process of induration. Pre-existing indurative lesions, however, bear a primary and not a secondary character, as do the particular indurative occurrences under consideration.

Secondary renal induration, which finally leads to the sclerotic kidney, may form a terminal stage of either acute, subacute, or subchronic conditions of parenchymatous inflammation. After a time, the indurative process which has brought the parenchymatous degeneration to a standstill, may itself attain a certain degree of latency. It is during this period of comparative latency, which may occasionally endure for a number of years, that the existing renal lesions remain often unrecognized, and that the connecting traces between the original acute renal inflammation and an eventual conspicuous final nephritis become more or less obliterated. On account of the concealed syndrome during the latent period of induration, the final nephritis which evinces itself not

only by the urinary findings, but also by well-authenticated systemic phenomena, is often erroneously held to be a comparatively new affection. This is especially the case when the patient has just passed through an attack of illness. which may have stimulated the old nephritic process to renewed activity. At other times the manifest nephritic state has been described, especially by the patient himself, as being of spontaneous production.

An acute infectious disease may thus be the original cause of a chronic renal affection in which indurative processes predominate. Progressive renal induration occurs so frequently in the absence of any determining systemic factor and in individuals who had at one time been affected with an acute infectious nephritis, that I have to reiterate my opinion, expressed on a former occasion, namely, that the majority of chronic interstitial nephritides, not due to constitutional causes, is the consequence of an acute infectious disease.

The affected kidneys become readily subject to amyloid degeneration. This may ensue on top of the diffuse (parenchymatous) processes within a few months after the onset of the latter. The amyloid transformation, however, which interests us most on this occasion is that which occurs together with chronic parenchymatous or secondary indurative nephritis. Amyloid degeneration of the kidneys, always supervening in both organs, is never a primary process. It is nearly always produced in the wake of certain catchetic conditions, the underlying abnormal blood composition of which may have been evoked by long-continued renal disease. Not infrequently amyloid kidney is mistaken for parenchymatous or indurative nephritis. With the former it has, in common, the large amount of urinary albumin, with the latter the scanty number of morphotic elements in the urine; these

consist in the greater part of hyaline and finely granular casts. In the rarest of instances amyloid degeneration is traced. back to an acute nephritic attack.

CITRATED MILK FOR WASTED
INFANTS.

Results in a Marked Increase in Nutrition.

Frederick Langmead, in Proceedings of the Royal Society of Medicine, reports eighty consecutive cases of wasting infants fed on, undiluted citrated milk. Sodium citrate renders the curd in cow's milk more flocculent and soft, thereby overcoming the effect of the ordinarily hard, tough curd. Citration has usually been employed with dilution of the milk. But dilution increases the bulk of the mixture and tends to gastric distention. It also reduces the percentage of fat and sugar to proportions below that of human milk, and the process is complicated for the mother. The eighty cases reported consisted of forty-one girls and thirty-nine boys. The age at first. attendance varied from three weeks to four months. All the cases were much under weight when first seen and most of them showed gastric and intestinal disturbances. They were all fed on undiluted citrated milk and close account was taken of their weight from time to time. The amount of milk was graded to the child's age. Citrated milk was not used on children under three weeks of age. Two grains of sodium citrate are added to each ounce of the mixture. It is usually dispensed in a watery solution and the requisite quantity added after bringing the milk to a boil. The child is brought back every week to be weighed and inspected. Citration is gradually lessened at about five months and omitted at six months. Among its advantages are its simplicity, absence of manipulation, and cheapness. Objections have been raised to the amount of protein in whole milk, but Langmead believes the nature of the curd causes as much trouble as the protein. Constipa

tion was not noticed more than in any other method of feeding. In 150 cases he has not seen edema or urticaria due to increased coagulability of the blood. When this occurs it is probably due to too large doses. The results in the eighty cases cited were a uniform and often marked increase in weight in all cases, with improved or perfect gastric and intestinal efficiency-which tends to prove the value of this form of feeding for this class of infants.

FIRST HEART SOUND IN CHILDREN.

Forchheimer, in Annals of Pediatrics, states that all the factors entering into the first heart sound in children may, under certain circumstances, be followed by a change, the most important of which is called a bruit or a murmur. The division which Sahli makes of these has always appealed to me; it is as follows: (1) Organic and functional valvular murmurs. (2) Accidental murmurs. Both of these classes are of so much importance in children that a more or less detailed description is necessary. Whoever undertakes to make a diagnosis of a heart lesion in a child under three or four years of age in an offhanded manner and without due care and consideration, immediately stamps himself a dilettanté in heart diseases. Even the detection of bruits and their relation to the sounds may become difficult in these cases, due to the rapidity of succession of sounds, the peculiar rhythm in infants, and the intractability of children at the age of three or four years. But even when a bruit with the first sound of the heart is found, it is difficult to make out its significance. Traube first made the statement that the diagnosis of mitral insufficiency is the most difficult of all valvular diseases; the systolic bruit may follow an organic or a functional condition, or even be accidental. In addition the accentuation of the second pulmonary sound is of little value for diagnostic purposes, first, because it so frequently

occurs in children who have no heart disease, and, secondly, it exists in both organic and functional valvular conditions in older children. In older children it frequently is of no value in accidental bruits. Moreover, in children it is difficult to say positively whether this systolic bruit is stronger over the usual auscultatory locations of the pulmonary or the mitral valves. It is true we may be guided here by its conduction and frequently, but not always, by compensatory changes. Organic valvular systolic bruits acquired after birth are found in children at the apex in peri- and endocarditis, in mitral and tricuspid insufficiency, at the base in aortic stenosis, rarely in pulmonary stenosis. In congenital cardiac diseases they are found in pulmonary stenosis, stenosis of the mitral and tricuspid valves, defects in the ventricular septum and patency of the ductus arteriosus. An easy way for differentiating organic from other valvular bruits in children under three years of age has been given-one might almost say with a stroke of the pen-by Hochsinger. He says that under three years of age all bruits in the heart are organic. It is strange how widely this statement has been accepted. Even Romberg, in his excellent book (Die Krankheiten d. Herzen u. d. Blutgefässe, 1906, pp. 52, 185 and 220), comes back to it again and again and bases absolute differential diagnosis upon it. For the complete literature on the subject up to 1906, reference may be had to the excellent paper of Hamill and le Boutillier, which was read before this society-"Inorganic Late Systolic Pulmonary Murmurs in Infancy and Childhood" (American Journal of Medical Science, 1907, Vol. CXXXIII., pp. 55-66). I fully concur with these authors in the view they have expressed. If we disregard the reasoning employed by Hochsinger, experience will have taught us that in children under three years functional and accidental bruits are found very commonly.

Especially is this the case in infants, and principally systolic bruits. A further statement is made to uphold Hochsinger's view that organic bruits disappear because the lesion in an affected valve may disappear during childhood or later. This assertion can not be denied, as we all have seen what we considered organic bruits disappear, but this is extremely rare, especially when the frequency with which bruits come and go in children's hearts is taken into consideration.

VILLOUS TUMOR OF THE RECTUM. T. Chittenden Hill stated to the American Proctological Society that a villous tumor of the rectum is very uncommon and but few cases have been recorded in current literature. B. Merrill Ricketts reported a case before this society in 1907 and states that but "sixty-two cases have been reported, nine of which have been by six American authors." Since then I have been able to find but one case reported by Vautrin-(L'Review de la Gynecologia). His article is the most accurate and painstaking observation to be found on the subject.

It is rather difficult to arrive at any conclusion as to their relative frequency by studying the reported cases or by searching hospital reports, as these border-line tumors are generally very loosely classified. Probably the most accurate data at our disposal may be had from St. Mark's Rectal Hospital, London, in which twenty-five villous tumors are tabulated among 42,343 patients with rectal ailments.

The chief point of interest about these tumors is that a certain percentage of them show a marked tendency to undergo malignant degeneration. From the histories of the thirteen cases cited by Ricketts, including one of his own, we learn that three recurred and three did not. Those with a broad base later became malignant, while those with a pedicle did not. Of the other seven cases

no mention was made as to the final outcome.

Goodsall and Miles have had twelve cases-eight in men and four in women, of which number two ultimately became carcinomatous.

From careful study of these cases and several others the author believes that if there is a distinct pedicle without infiltration of the adjacent mucous membrane, tumors of this type are generally benign and if completely removed by ligation, or otherwise, there is but little likelihood of their recurring. On the other hand, if the base is broad, whether there be induration or not, a total extirpation of the rectum should be advised.

SURGERY OF BLOOD TRANSFUSION. Vein to Vein, Instead of Artery to Vein, Technique.

J. E. Jennings, in the Long Island Medical Journal, says that instead of an artery of the donor and a vein of the recipient being coupled, he attaches vein to vein by means of a good-sized glass canula coated with paraffin, and he has been able, by means of gravity, to pour the blood from the vessels of one subject into those of the other. It is feasible to get enough pressure in the long saphenous vein to carry the blood over in a good stream by having the donor in the half upright position, by exerting constriction in the upper third of the thigh and by opening the vein near the ankle. The saphenous vein of the recipient is opened in the same manner and blood allowed to flow into the proximal end, the patient being placed in the horizontal position with the leg elevated.

The rate of the flow of blood may be controlled by three factors: (1) The degree of elevation of the donor; (2) the degree of constriction of the thigh; (3) the caliber of the canula.

The technic is as follows: The subjects are placed upon a table ten to twelve feet long so arranged that one