CANADIAN PRACTITIONER AND REVIEW.

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Emulsified cod liver oil as contained in Scott's Emulsion appears in a form so closely resembling the product of natural digestion as it occurs within the body-that it may well be administered as an artificially digested fat food of the very highest type. In combination with the other ingredients involved-glycerine being an emollient of inestimable value-Scott's Emulsion offers to the physician a valuable, exquisite and rare accession to his prescription list.

Scott & Bowne, Chemists, Toronto, Ontario.

Sixteen Years of Successful Treatment have won the Endorsement and Recommendation of Many Eminent Physicians.

STAMFORD, CONN., offers exceptional advantages of location for skilful and scientific methods in the treatment of Nervous and Mild Mental Diseases; Drug and Alcoholic Addiction and General Invalidism. The Cottage P an insures quiet and rest and pleasant associations while the environment is that of an ideal summer and winter resort.

Employs methods, in the treatment of the above mentioned ailments, in strict conformance with professional standards. For Illustrated Prospectus, address

Dr. Amos J. Givens, Summer St., Stamford, Conn.

Physician's Consultation by Telephone.

In the States of the German Empire there is a tariff regulating the charges to be made by the physician, giving a high and a low mark. To this has been added lately the following remark: Physician's advice by telephone is to be charged as a visit to the office.—Ex.

A Plea for the Tablet.

"In the first place, compared with pills, tablets have no insoluble coating nor, when properly made, have they any insoluble excipient added to their composition. For example, antikamnia tablets are made by simple compression, and, therefore, if the secretions of the human system affect the medicine administered, it is bound to be absorbed in the quickest possible time, which is always an advantage. Comparing tablets with capsules, greater accuracy in dosage is assured, as experiments have proven. For example, forty tablets of Bisulphate of Quinine made on a machine, adjusted to five grains each, weighed 19934 grains on a torsion balance. The most careful druggist knows it would be impossible to do this in filling capsules. The objection some have to tablets is readily overcome by crushing them before administration, and we are glad to know that the Antikamnia people take the precaution to state that when very prompt effect is desired the tablets should be crushed or chewed. Antikamnia itself is not unpleasant to the taste, and the crushed tablet can be placed on the tongue and washed down with a swallow of water. It so frequently happens that certain unfavorable influences in the stomach may prevent the prompt solution of tablets, that this suggestion is well worth heeding. This, however, does not apply to Antikamnia Tablets, for they disintegrate at once, as soon as they come in contact with moisture. Drop a tablet in a glass of water and be convinced of this. Proprietors of other tablets would have better success had they given more thought to this question of prompt solubility. Antikamnia and its combination in tablet form are great favorites of ours, not because of their convenience alone, but because of their prompt and uniform therapeutic effect."-The Journal of Practical Medicine.

Women medical practitioners have not at all increased in numbers in Germany as expected from the opening of schools and universities to co-education some few years ago. Indeed, the removal of all opposition has only tended towards the timehonored consequence of negativing the desire.-Ex.

BY H. B. ANDERSON, M.D., L.R.C.P. (LOND.), M.R.C.S. (ENG.).
Associate Professor of Clinical Medicine, University of Toronto.

Considerable attention has recently been given to the secondary involvement of the cervical lymph nodes in cases of gastric cancer and its diagnostic value in obscure intra-abdominal conditions. In the British Medical Journal, April 29th, 1905, W. Mitchell Stevens reports a case of latent cancer of the stomach in which the diagnosis was made from the coincidence with the general symptoms of enlargement of the left supraclavicular glands. Autopsy confirmed the diagnosis and showed that the infection had been transmitted by way of the thoracic duct. which was extensively involved by the growth. The writer refers to the clinical value of this sign and says that although particular attention was called to it by Troisier years ago, comparatively few cases have been reported. In the same journal on June 24th, 1905, Nathan Raw reports a case of carcinoma of the pancreas, with enlargement of this set of glands, in which the thoracic duct was probably the means of carrying the infection, although this was not demonstrated by the autopsy. Apropos of the preceding articles, T. Gillman Moorehead, in the Journal of July 6th, says that he "was previously under the impression that this channel of dissemination was well recognized and not in need of further demonstration." He then cites two cases of cancer of the stomach met with during dissection wherein extensive in

* Read before the Toronto Clinical Society, December, 1905.

volvement of the thoracic duct, with enlargement of the left supraclavicular glands, occurred. Herbert E. Durham, in the same issue, mentions another possible means of involvement of these glands, viz., where the peritoneum has been invaded the infection may be carried by the lymphatics passing up behind the costal cartilages. He refers to some experiments on peritoneal infection in animals, in which the spread was shown to take place rapidly through these channels. It does not appear, however, how this route of transmission can explain the greater tendency to invasion of the left. as compared with the right supraclavicular nodes.

Having, like Dr. Moorehead, been under the impression that enlargement of the supraclavicular lymph nodes by way of the thoracic duct, was not uncommon in intra-abdominal tumors and that its clinical significance was generally recognized, I was surprised to learn that so few cases have been recorded. I wish. therefore to briefly report two cases coming under my observation:

CASE 1.-Enlargement of the left supraclavicular glands in a case of disseminated crude tubercle of the liver.

C. R., aged 59, farm laborer, admitted to St. Michael's Hospital, under my care, November 29th, 1899.

Family history was unimportant. Patient took alcohol occasionally and used tobacco in moderation. Had never suffered from any serious illness except influenza four years previously.

Two months before entering the hospital patient had been working in a cold, damp silo, when he contracted what he considered to be a severe cold, with chills and fever. The latter had been recurring every morning between one and three o'clock, the shivering lasting for about an hour, followed by fever and profuse perspiration. Feeling exhausted he would then fall asleep; next day he would be dull and stupid.

Temperature ranged from 99 deg. to 104 deg. Patient slept well. but showed considerable emaciation and complained of feeling very weak. He suffered no pain. but could not breath deeply without some discomfort. Examination of the circulatory and respiratory systems revealed nothing of importance. Stomach showed a moderate degree of dilatation. Examination of the stomach contents after a test breakfast showed total acidity, 70; free HCl, 40; no lactic acid and no Oppler-Boas bacilli. Repeated examinations of the blood for the plasmodium malaria were negative. Leucocytes were 10,000 per c.mm., of which the polymorphonuclears formed 92 per cent. Urinalysis was negative. The liver was palpable an inch below

the costal margin in the mammary line. On palpation of the epigastrium, 2 in. below the ensiform cartilage, a lump could be felt. This lump was smooth, not painful to pressure and moved up and down with respiration, being evidently in the left lobe of the liver; no umbilication could be made out. The lymphatic glands above the left clavicle were enlarged, but they were painless and distinct from each other. On December 4th, Dr. Bingham removed one of these glands and microscopic examination showed tuberculous caseation. The condition was therefore, considered to be tuberculosis of the liver, with secondary glandular involvement, though the primary seat of the disease or the point of entry of the organisms could not be determined. The patient continued to grow worse and died February 24th, 1900.

The autopsy was performed by Dr. Dwyer. The liver contained many masses scattered throughout its substance, varying in size from a walnut to a hen's egg. The primary source of the trouble could not be determined, the liver showing much the most advanced process, unless an old fibrous pleurisy, which was found in both sides, be excepted.

Subsequent examination of the liver showed the condition to be a tuberculous cholangitis. Many of the caseous masses were practically free in smooth-walled cavities, which were considered to be the dilated ducts, and surrounded by a thin mucopurulent-looking fluid. The fluid contained myriads of tubercle bacilli. This case is interesting, owing to its rarity and from the fact that the diagnosis was arrived at by removal of one of the enlarged glands. The condition of the thoracic duct. however. was not noted at the autopsy.

CASE 2.-J. M., aged 49, teamster, entered St. Michael's Hospital under my care August 22nd, 1905. Family history unimportant. He had never suffered from any serious illness. Had used tobacco and alcohol in moderation.

Patient had been running down in health for the past four years. but had been able to work until a month before entering the hospital. For some time past he complained of feeling weak across the stomach, and the taking of food was followed by severe pain. No vomiting ever occurred. Bowels were constipated. He had often noticed of late that the stools were tarry in color. About five weeks before entering the hospital he noticed enlargement of the glands above the left clavicle. These were quite tender on pressure. He was sure that they were smaller when he entered the hospital than they had been sometime previously.