The ear receives the distinct impression of a spindle shape,-an impression which is perfectly distinct and indubitable, though the author can not explain how it is produced. It is of importance, because deviations are observed in some diseases. (2.) The ear distinctly perceives the circular contraction of the œsophagus. Ordinarily the energy of this contraction is not very marked, but increases whenever there is an impediment to the downward passage of the morsel. (3.) The sound which is distinctly perceived during deglutition is that of a smooth slipping, though sometimes a glugging. Deviations in disease are easily recognized. (4.) The act of swallowing takes place with a certain rapidity, in a very short, but still measurable, space of time. (5.) The auscultator distinctly perceives that the morsel is carried perpendicularly downward. Hence attention to the following points is required: the sound accompanying deglutition, the shape of the morsel, the energy of the contraction, the rapidity with which deglutition is affected, and the direction in which the morsel is propelled.

In disease.-The deviations from the normal in cases of disease are the following:

I. As to the sound: the entire absence of the sound is frequent, and denotes serious abnormities. If the sound is heard down to a certain spot, while it is suddenly absent below, we can safely conclude the existence of one of the following lesions: rupture of the œsophagus, foreign body, possibly a dilatation (Divertikel), or most frequently stricture. At the same time we learn the seat of the lesion. A rubbing sound is sometimes heard along with the normal slipping sound, similar to pleuritic friction sound, but fainter. This is produced by croupous or diphtheritic processes in the course of typhoid, puerperal, and exanthematic diseases, by fibroid or polypous excrescences, by pustular eruptions in the œsophagus (confluent variola), by large ulcers with detached lower margin, in spasmodic dysphagia. A slightly whistling or hissing sound was observed by the author in a case of rupture. A rustling sound is sometimes perceived in pseudo-membranous processes, and ceases after vomiting. The slipping or glugging murmur may be accompanied by a metallic sound in case of pneumothorax of the left side. Α sputtering and running noise replaces the normal sound in cases of considerable dilatation and relaxation of the tube, in

callous strictures when the muscular fibres are compressed or atrophied, in paralysis, and in all those protracted catarrhs accompanying ulcerations and new-formations, which cause relaxation of the muscular coat by serous imbibition. Sonorous regurgitation takes place in cases of recent stricture, especially those of a spasmodic character, occurring in paroxysms, and known as "œsophagism." It may be as loud as is normally heard in auscultation of the pharynx. A scratching sound may be artificially produced by the œsophageal probe, and, heard by the stethoscope, is of great importance in determining the exact spot of the abnormity.

2.

Deviations in the shape of the morsel always take place when the contraction of the tube is wanting or without energy, as well as wherever the configuration of the oesophagus has suffered a change.

3. The energy of the muscular contraction may be increased or diminished. The former takes place wherever deglutition is impeded; the ear perceives a forcible contraction in that portion situated just above the seat of the impediment. Increased energy of contraction sometimes gives the ear the sensation of a jerk or blow, when the morsel arrives at a certain spot. This symptom is a valuable diagnostic mark, pointing with certainty to an ulceration, erosion, a pricking body, or an otherwise inflamed spot, though it is extremely difficult to find its exact position.

Diminution of the contractile energy takes place wherever the muscular coat is degenerated in structure, or has otherwise lost its contractility and elasticity.

4. The rapidity of deglutition is never increased; it is diminished in almost all cases of œsophageal disease.

5. Deviation of the direction of the morsel to one side is rare; it occurs when by lesions of neighboring organs the œsophagus itself is turned aside, as was observed in a case of scirrhus of the thyroid. More frequently the direction is reversed: regurgitation, which may be complete, and either immediate (recent strictures, foreign bodies, tender ulcers, œsophagism) or after some delay (in cases of longer standing). This, even when delayed, is accomplished without vomiting, i. e., without the co-operation of the abdominal muscles. Or the regurgitation may be incomplete, the morsel rising only a short distance in the canal, and then resuming its downward passage. This is dis

tinctly heard. The author observed it in cases of small excrescences, slight callosities, obstruction by tuberculous bronchial glands, and incipient stenoses.

Regurgitation is sometimes accompanied by a loud noise: sonorous regurgitation; this has been noticed in stenosis of the cardiac orifice of the stomach, opposite the 7th and 8th dorsal vertebræ.

A necessary caution is to choose the time for auscultation when the œsophagus is empty. When it is filled auscultation is not practicable, except in reference to incomplete regurgitation.

In another chapter the author adduces clinical examples, and in an appendix treats especially of the diagnosis of strictures.

15. Phlegmonous Inflammation of the Sub-mucous Cellular Tissue of the Stomach. By E. R. HUN, M.D., Albany, N. Y., [New York Medical Journal, April, 1868.]

and T. GRAINGER STEWART, M.D., F.R.S.E., Edinburgh.

[Edinburgh Medical Journal, February, 1868.]

M. L., æt. ten years, inmate of Catholic Orphan Asylum. Health always delicate. Complained of not feeling well, Friday morning, Jan. 31st, and asked permission to remain in bed. At about 11 o'clock, one of the sisters, thinking the child had a cold, or some other slight indisposition, administered a dose of castor oil, which was soon afterwards vomited. The patient continued to vomit everything she swallowed, until Sunday morning, February 2d, when I saw her for the first time.

I found her lying on her back; eyes sunken, and surrounded by a dark areola; pulse scarcely perceptible at the wrist, and very rapid; hands and feet cold and blue; some headache; slight tenderness over the epigastrium; tongue moist and coated with white fur; temperature 96.5 degs. F. Had a natural motion of the bowels yesterday evening. Can retain nothing on her stomach, having tried water, beef tea, whisky, and ice. Vomits almost immediately what she swallows, mingled with a greenish fluid, which she says is intensely bitter. I advised mustard applications to the ankles and wrists, a mustard poultice to the epigastrium, and one tablespoonful of equal parts of milk and lime-water to be taken every half hour.

She retained the first two spoonfuls, but rejected the third. From this time she vomited continually, remaining perfectly conscious, but sinking rapidly, and died at 5 A. M., Monday.

Autopsy, six hours after death.-External appearance of the body, natural. Thorax: the right lung was firmly adherent to the walls of the thorax; otherwise natural. Abdomen: the stomach appeared very heavy and large. Upon removing it and opening its cavity, it was found to be empty, but the walls were fully half an inch in thickness, and consisted

of the mucous lining and peritoneal investment, with an intervening layer of purulent deposit. A milky liquid could be pressed out from the cut surface in abundance, which responded to the chemical and microscopic tests for pus. A large number of inflammatory granular corpuscles were observed, under the microscope, mingled with the pus corpuscles. This purulent infiltration of the connective tissue extended over the whole circumference from the cardiac to the pyloric orifice of the stomach, and the line of division between the gastric and duodenal mucous membrane was marked by an abrupt ridge caused by the lifting up of the former by the sub-mucous purulent exudation. The gastric mucous membrane was of rather a deeper color than usual, and the peritoneal coat, although somewhat injected, presented a smooth, shining appearance, without any inflammatory product. A microscopic examination showed the termination of the gastric follicles surrounded by pus corpuscles, while no trace of the muscular fibres could be found, except just under the peritoneum, thus demonstrating that the inflammatory action involved only the connective tissue intervening between the mucous and muscular coats. All the other abdominal viscera were examined and found normal. A firm adhesion existed between the convex surface of the liver and the diaphragm. In looking up the authorities in regard to the above rare and interesting case, I find that ROKITANSKY states that "idiopathic inflammation of the cellular tissue of the stomach, resembling pseudo-erysipelas, and passing on to suppuration, is a very rare phenomenon; it not infrequently occurs as a secondary process, analogous to the metastases of specific acute dyscrasiæ. The parietes of the stomach appear thickened; the stratum of sub-mucous tissue is distended with pus; it is soft and friable; the superincumbent mucous membrane is reddened, and at intervals tense. After a time it gives way at these points, and by numerous irregular cribriform openings, the pus exudes into the cavity of the stomach." LEBERT, in his work on patholological anatomy, speaks of a “rare disease, usually acute," under the head of Phlegmonous sub-mucous inflammation of the stomach," gives an account of four cases, with a description of the post mortem appearances. Two of these cases were idiopathic, one metastastic (following puerperal peritonitis), and in one which he calls "Phlegmon propagé" the patient, having suffered for a long time from a chronic gastric disorder, was suddenly attacked with erysipelas of the face, followed by pultaceous stomatitis and death in nine days. The autopsy revealed purulent peritonitis, and distinct purulent deposits in the sub-mucous cellular tissue of the stomach. Both J. P. FRANK and J. FRANK refer to phlegmonous inflammation of the stomach, and HABERSHON reports a case, with the autopsy, in his work on diseases of the alimentary canal.

Dr. T. GRAINGER STEWART reports a parallel case occurring in a female æt. 28; in general healthy, but had twice suffered from gall stones. Her symptoms were (Oct. 14) vomiting of green and yellow bile, flatulent distension, and pain in the upper part of the abdomen, neither acute, nor aggravated on pressure.

These symptoms were at first relieved by treatment, but on the 19th Oct. she had a relapse, and died on the 29th. In the autopsy the stomach was found of its natural size, distended with air; contained a small quantity of fluid. Its walls were throughout greatly thickened—the thickening tolerably uniform. On section, pus escaped from the cut surface, mostly from the sub-mucous cellular tissue. The mucous membrane was thickened, dense, and almost coriaceous, of a reddish-gray color. Its tubules and stroma contained pigment, but did not appear otherwise altered. The muscular coat was in some parts firm and continuous, in others partially disorganized. The peritoneal coat was inflamed and thickened. There was no pus in the subperitoneal cellular tissue; in the submucous it was in parts infiltrated, in parts collected in little sacs of various sizes.

16. On Inosuria. By Prof. FR. MOSLER, Greifswald.

[Virchow's Archiv f. path. Anat., xliii, p. 229. May 1st, 1868.] In connection with a case of diabetes insipidus reported by Dr. HELLWIG in the same number of the Archiv, which was shown to be caused by a tumor in the fourth ventricle, Prof. MOSLER reports another case of the same, which likewise seemed to depend on a lesion of the brain, and in which special attention was paid to the analysis of the urine.

The characteristic features in this case were the presence of inosit in the urine, absence of grape sugar, traces of albumen, considerable increase of the quantity of the urine, and low specific gravity (1000-1005); also diminution of urea (23.8 grammes in 24 hours).

According to NEUBAUER, CLOETTA found inosit in the urine in a case of Bright's disease, but not in normal urine. NEUKOMM found it in greatest abundance in the brain, sometimes in considerable quantity in the kidneys, and finally in diabetic urine, together with large quantities of sugar; while VоHL observed it, in a case of diabetes, gradually to take the place of the sugar. Inosit seems to occur in the urine but rarely. GALLOIS tested the urine of 102 patients, but found inosit but 7 times,-5 times in diabetic urine in company with sugar, and in 2 out of 25 cases of albuminuria. SCHULTZEN found it in the urine of a man with carcinoma over the fourth ventricle, and of another with a large sarcoma of the base of the brain, compressing the fourth