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and intestinal fluids it is again precipitated in the form of insoluble phosphate. The authors have made researches which prove that, although the phosphate of lime is condensed in great quantity in the bones, the other organs contain only traces of it, the bile, however, affording a rather large proportion. Phosphate of lime is not capable of absorption, and it has been shown that when given to animals, whether in the soluble or insoluble state, it passes away unchanged in the stools. The authors consider that lime finds its way into the system in the form of carbonate, contained either in the solid food or in the drink, and that it forms phosphate of lime in the system by double exchange with the alkaline phosphates taken also with the food. So, as to the urinary phosphates, they consider them to be formed in the urinary bladder and the biliary phosphates in the gall-bladder. The conclusions they draw are the following:-1. That phosphate of lime is incapable of absorption except in very small quantity. 2. The organism consumes in general very little of this salt. 3. The circulation conveys only insignificant quantities of it, and the tissues, except the bones, contain only some traces. 4. Lime enters the organism in two states, viz., in small quantity as a superphosphate, and in rather a large proportion in non-phosphoric salts. These latter partly exist in the food as carbonate and partly are produced by the decomposition of the alimentary phosphate of lime by the acids of digestion, such as chloride of calcium, lactate of lime, &c. 5. The system forms its phosphate of lime by double decomposition, and finds in the food all the elements necessary to increase, according to necessity, the production of this substance. 6. The phosphate of lime in the urine is in the greater part an intra-vesical formation, and therefore the total amount of the urinary phosphates is not the direct product of disassimilation. 7. The artificial phosphates of lime, soluble or insoluble, are eliminated by the excretory passages without being utilised. 8. The addition of these phosphates to the food is an obstacle to nutrition; and, 9. The soluble preparations of phosphate of lime (superphosphates) act as acid principles.Ibid., June 15th, 1876.

In the succeeding number of the 'Bulletin' (June 30) the authors of the above-mentioned paper modify their conclusions (7) and (9) in the following sense:-7. Of the two constituents of the phosphates of lime, namely, phosphoric acid and lime, the first is absorbed in a certain proportion in the state of alkaline phosphate, and the second is eliminated directly and almost entirely by the intestinal passages. 9. The soluble preparations of phosphate of lime act primarily as acid principles, and then, by reason of the changes they undergo in the intestines, they act secondarily in a certain degree as phosphatic agents of another base.

On the Therapeutical Properties of a Spring at Vals, containing Iron, Arsenic, and Phosphoric Acid.-The spring at Vals named the Dominique contains a peculiar combination of iron, arsenic, and phosphoric acid, and flows from an ochraceous bed in the earth. The iron exists as a basic sulphate, the arsenic as a basic arseniate

of iron, and the phosphoric acid as a basic phosphate of iron. These deposits are formed by the passage and the deposit of the mineral water in the galleries where it is led to the outlet of the natural reservoir formed in the rock. The proportions of the constiturnts are always the same, and whenever the water is drawn for the preparations of the medicinal articles made from the dried salts, chemical analysis gives the same results. These articles, called "Dragées de Dominique," have been employed with success in intermittent fevers, affections of the respiratory organs, chlorosis and anæmia, and generally in cases of dyspepsia. The arsenic in this preparation is counteracted in its deleterious properties by the iron, and the beneficial effects are further enhanced by the phosphate, and the form in which the preparation is presented is an agreeable one and has a pleasant taste, the dragées being a kind of sugarplum. Various instances are given of the value of this preparation in obstinate dyspepsia, attended with vomiting, and the pleasant taste of the dragées enables the patient to crunch them in the mouth like ordinary sugar-plums. It is stated that they never cause constipation, as is usual with ferruginous preparations, while, at the same time, the tonic effect of the iron is increased by the presence of the arsenic. The good effects of an agent so well constituted are said by the editors of the Union Médicale to be incontestable, for the iron finds in the other elements, namely, arsenic and phosphorus, adjuvants which act as a vehicle to render it assimilable, which it might not be if taken alone. Arsenic, again, finds in iron a palliative of its poisonous properties, and acts freely as a remedy in intermittent fevers and neuralgia, and phosphorus is also presented as a tonic in this preparation in an advantageous form.-L'Union Médicale, August 24th, 1876.

On Bloodletting as a Therapeutic Agent. By Dr. C. B. NorTINGHAM, of Georgia, United States. In a paper read by Dr. Nottingham, at the annual meeting of the Georgia Medical Association held in Savannah, the author claims for bloodletting an important place among therapeutic agents, notwithstanding the disuse into which it has fallen in recent years. He examines the different reasons which may be urged against bloodletting, and discusses the question of the supposed change of type in disease, which, however, he does not admit. While condemning the indiscriminate and excessive bloodletting which was once practised, Dr. Nottingham still thinks that in certain cases it is a most valuable therapeutic agent, that it often subdues engorgement, abates violent arterial excitement, diminishes preternatural heat, controls pain, and relieves embarrassed respiration. In cases of suffocation and distress dependent on congestion of the lungs or engorgement of the chambers of the right side of the heart, in threatened or existent apoplexy from cerebro-vascular turgescence, in puerperal convulsions from turgescence:-in such cases Dr. Nottingham states that venesection acts instantaneously and beneficially. He thinks that the injurious effects of bleeding are due to the fact that the measure has been sometimes employed at au improper time, and he argues that in inflammations, for instance, it should be resorted to

at the commencement of the disease and not at the period when exudation has taken place, nor should it be used indiscriminately in the feeble and anæmic as well as in the robust, nor in typhoid conditions of the system. Guided by the lights of modern pathology and diagnosis he thinks that blood letting may still be practised with great advantage, and he says that "to the general practitioner a lancet is as necessary in his pocket as any article of the materia medica."-Richmond and Louisville Medical Journal, April, 1876.

On the Efficacy of Exutories (Setons, Issues, Actual Cautery, &c.) in the Treatment of certain Cerebral Affections. By Dr. V. POULET. Dr. Poulet advocates the utility of revulsives or exutories, especially in the form of cautery, in many internal maladies, and he adduces an instance in which this mode of treatment appears to have been attended with very beneficial results.

The patient was a gentleman in good circumstances, fifty-five years old, who had suffered for several years from a rather extensive eruption of eczema in the popliteal region of one of his legs which had varicose veins. In 1872, however, this eczema had entirely disappeared without any particular treatment, and without the supervention of any appreciable inconvenience, when, on a sudden, symptoms of vertigo developed themselves, together with gastric disturbance in the form of indigestion, and there were also cerebral symptoms of a rather serious character, the memory being lost, the speech often hesitating, the gait uncertain, &c. Remedial treatment was adopted with considerable success, and the patient seemed to be cured, when a relapse occurred, and the attacks of vertigo degenerated into true epileptic fits. It now struck Dr. Poulet that the best treatment would be to place a cautery precisely on the spot of the old varicose eczema, and he accordingly did so with the best effects, for the epileptic fits ceased, the brain resumed its healthy condition, the digestive powers were restored, and, in fact, the patient was completely cured. For the last three years there has been no return of the symptoms, and the patient conducts his affairs as well as he did before his illness. Dr. Poulet, while admitting that probably, in this case, no actual disease of the brain existed, thinks that some organic lesion was imminent, but that it was warded off by the treatment adopted.-Bulletin Général de Thérapeutique, June 15th, 1876.

REPORT ON PATHOLOGY AND THE PRACTICE OF
MEDICINE.

BY JOHN T. ARLIDGE, M.D., A.B. Lond., F.R.C.P. Lond.,
Physician to the North Staffordshire Infirmary, &c.

Pathology of Cardiac Murmurs.-In our last report on pathology (April, 1876), we took occasion to introduce to notice the hypothesis advanced on this subject by Dr. Leaming, of St. Luke's Hospital, New York. The terms of the hypothesis were then stated and three cases in proof were briefly narrated. We concluded by noting that he appealed in support of his views to certain experiments made by Dr. Halford, and reported in this Journal in 1860. We have now also to state that he likewise quotes for his purpose some cases recorded by Dr. J. S. Bristowe in the number of this Review for July, 1861. Having proceeded thus far with his essay, Dr. Leaming next presents to his readers the following classification of cardiac murmurs in accordance with their acoustic differences, and then proceeds to further elucidate and apply his hypothesis. The classification is as follows:

Valvular (all organic)

:

Aortic obstructive systolic.
Aortic regurgitant diastolic.
Mitral regurgitant systolic.

Intra-ventricular (more J Organic functional.

tra-ventricution amore (Inorganic functional.

The sound in valvular murmurs is a friction murmur, that of blood forced through an aperture. The intra-ventricular murmurs are mostly and distinctly chord vibrations. The contraction of the muscular walls of the heart and its fleshy columns, the friction of rushing blood among the chorda tendinea and against the tense mitral valve, being the occasion of sound vibrations, but is not the mechanism of the sound itself; for as great difference exists between these murmurs as between that of a whisper and that of the voice. The obstructive systolic aortic may be modified by irregular calcifications in the aortic valves, extending into the column of forced rushing blood. In this way a harsher character may be given to the murmur, or it may even become musical. Vegetation also attached to the orifice or valve may be thrown into vibrations in the column of blood, and produce a musical murmur; but these are rare, mere possibilities. When musical murmurs occur, they are almost always, if not always, vibrations of the chorda tendineæ, some of which are under extraordinary tension. These sounds or murmurs may be illustrated by a stringed musical instrument. The term "bellows sound" is incorrect, the only friction sound in cardiac murmurs proper occurs where the blood is forced through apertures or past obstructions. The "bellows sound" is heard at the aortic orifice when there is obstruction, as by lymph deposits upon the valve. It is at

first an uncomplicated, simple gushing sound. But in time the obstruction causes hypertrophy of the left ventricle, which, having taken place, irregular tension of the chorda tendineæ is the result, and vibrations out of unison with the first sound are carried with the current of blood, and both occurring in the systole, are mixed together and form what is called the blowing murmur. It is now a sound of mixed elements, friction of blood against a solid, and vibration of strings under irregular tension. The blowing, sawing, filing, rasping sounds have their origin and cause within the ventricle. They are intra-ventricular. They are heard over the base of the heart, but always with greatest intensity at the apex beat. Friction sounds are heard best over the orifices, or in the direction of the vibrating column of blood. The aortic systolic obstructive murmur is heard over the aortic valves, and in the course of the column of blood. The regurgitant aortic diastolic murmur is heard over the aortic orifice, and to the left and towards the apex beat. The mitral aortic regurgitant is heard behind on the left side near the spine. In this direction the blood is forced in regurgitation through the mitral valve, impinging first against the auricular wall lying against the œsophagus, and aorta, and intervertebral substance; hence the sound is conducted directly into the ear, giving the sensation of being shot into it. It may be heard a short distance from this point, being conveyed through the chest wall. It may be heard in front, at the apexbeat, by conduction through the substance of the heart, when there are no intra-ventricular murmurs to destroy it or take its place. It is one of the most certain of cardiac signs, and an unfailing sign of mitral regurgitation. Its discovery belongs to Dr. Cammann.

A great majority of cardiac murmurs, even of those accompanying organic disease of the heart, are in a manner functional. That is, the murmurs are not organic in the same sense that the valvular murmurs are, which are organic murmurs, because the structural change in the valve is part of the mechanism of the murmur. Intraventricular murmurs, even when the result of structural change in the heart, may be considered functional, inasmuch as they have their mechanism in vibrations of the chorda tendineæ, which are themselves unchanged by any diseased action, but simply vibrate, giving out sound of high or low pitch, soft or harsh, feeble or loud, according to the degree of tension of the individual strings, and the force of the heart's contraction. The cause of the irregular contraction of the heart muscles may be from disturbed nerve power, as well as from organic change.

In concluding his essay, Dr. Leaming notes the fact of cardiac murmurs disappearing when pneumonia or pleurisy supervenes, and attributes the phenomenon to the loss by the thorax of its acoustic properties, its ability to conduct sound to the ear when applied to it. (Significance of disturbed action and functional murmurs of the heart. By J. R. Leaming, M.D., New York, 1875. Pamphlet).

Amyloid Tumours of the Tongue and Larynx.-Dr. F. Ziegler narrates a case of multiple tumours at the base of the tongue and of great thickening in the posterior wall of the larynx, which was

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