The return to solid food should be extremely slow. Exercise should be of the most mild character for several weeks. SOME POINTS TO REMEMBER IN MAKING EXAMINATIONS AND DIAGNOSIS OF DISEASES OF THE CHEST.* By B. A. CAUDLE, Hopkinsville. First, certain facts regarding the relation of the boundaries and lobes of the lungs, and the pleural sacks, to the external surface of the thorax, must be clearly in mind preceding an examination of these organs. The lungs are situated in the thoracic cavity. Each lung is conical in shape and presents for examination an apex, base, two borders and a surface. a The apex forms tapering cone, extending well up into the root of the neck, 1 to 1 1-2 inches above the level of the first rib, (or clavicle). A portion of the lung that's often neglected in our examination of these organs. The base of the lung rest upon the convex surface of the diaphragm. The right lung extends 1 to 1 3-4 inches above the clavicle, from which the anterior border runs downward, forward and inward, passing nearly behind the right costo-sternal articulation, to the mid-sternal line, to the level of the second rib. From this point it runs vertically downward to the level of articulation of the sixth rib with the sternum, where it turns sharply to the right and becomes the lower border. The lower border follows the sixth rib to the right mammary line. cuts the eighth rib in the mid-axillary line, and the tenth rib at the scapular line, and the upper border of the eleventh rib close to the spinal column. For brevity remember front sixth, side eighth, back tenth rib. In older people the lower border of the lungs extends one rib lower down. In children one rib higher up. The left lung and its articular border, as far down as the fourth rib correspond to those of the right lung, except that this border lies farther from the mid-sternal line. At the level of the fourth rib the anterior border curves outward, downward, and then moderately inward to the sixth rib, exposing a somewhat semicircular area of the pericardium, which is accountable for dulness on percussion, in this area (so-called exposed cardiac dullness). From this point downward (the sixth rib) the lower border runs outward and around to *Read before the Christian County Medical Society. the spinal column. Its course corresponding in all respects, to that of the right lung, save that it lies a trifle lower. The right lung is broader than the left lung, owing to the inclination of the heart to the left side, it is also shorter by an inch in consequence of the diaphragm rising higher to accommodate the liver. Now that we have the topographical posi-· tion of the lungs well in mind, we are ready to proceed with our examination. We should inspect the chest closely, observing whether the front back and sides look alike, normal or abnormal, whether we have an equal amount of expansion in both lungs or not. If one side seems much larger than the other, I usually measure them; then, too, it is a good plan in order to determine the amount of expansion. If the expansion is less than two inches in the male and two and one-half inches in the female, it is below the normal average, and may be indicative of many things, in acute troubles like pneumonia, pleurisy, or a fractured rib, the expansion is hindered by the pain it causes. It may also be due to phthisis, and should arouse our suspicion, especially if restricted to the upper third of the chest. If one side of the chest expands normally and freely and the other side hardly expands at all, it is proof positive that something is wrong or abnormal, and should cause us to continue our examination till a satisfactory conclusion is reached, the restricted expansion on either side may be due to an old pleurisy with extensive adhesion or to effusion or pus in either pleural cavity. We now count the respirations. The respiration rate in the born is 44 to 50; at five years of age 22 to 28: in the adult 16 to 22; in health it is faster standing than lying down, during the day than at night, especially is asleep; after meals than when fasting, during excitement and exercise than when quiet. The normal ratio between pulse and respiration is 1 to 4. 4 pulse beats to 1 respiration; in disease the ratio may be as high as 1 to 8. new It used to be reckoned, before the days of fever thermometers, that every degree of fever ran the pulse up ten beats, and this with the feeling of the skin and volume of the pulse was the older practitioner's way of telling how much fever their patients had. We now know it was a very imperfect and unreliable guide by which to guage the tempera ture. VOCAL FREMITUS. If a hand is laid on the chest while a patient speaks with ordinary or more than ordinary loudness, a peculiar buzzing or vibrating sound is felt by the palpating finger, (called vocal fremitus) or voice vibrations. The vibrations originate in the vocal cords and are conducted by the columns of air in the trachea and large and small bronchial tubes, through the substance of the lungs to the chest wall. The intensity of the vocal fremitus depends upon two factors, first the loudness and pitch of the voice, and the varying conductivity, and, second, the thickness of the media through which the vibrations must pass. To study vocal fremitus the patient is told to articulate certain words, one, two, three, and ninety-nine. Solid lung tissue conducts the sound vibrations with great facility. Consequently the vocal fremitus is greatly increased in pneumonia and tuberculosis. However, pulmonary cavities, if thin walled and near the surfaces of the chest wall, may afford a very distinct fremitus, and can be explained by the cavity acting as a resonator for the sound of the voice. With marked dullness over the chest we naturally think of one or three troubles, pneumonia, pleurisy with effusion or tuberculosis. As stated earlier in this paper, consolidated lung tissue is a great conductor of the breath sounds, consequently with pneumonia and tuberculosis we have an exaggerated vocal fremitus. But with pleurisy with an effusion in the pleural cavity, unless you have bands of adhesions connecting the lung and pleural tissue you have a marked or total diminution of vocal fremitus. In the last few years I have aspirated the chest twenty-one times for effusion of the pleural sack, and I do not now recall a single instance in which the vocal fremitus was not markedly diminished or absent. Vocal fremitus is a diagnostic means that I am satisfied is not used enough in our examinations of the chest. PERCUSSION. I will now speak briefly of percussion. The percussion sound over the lungs becomes less resonant in proportion to the diminution in the amount of air underlying the part of the chest percussed. Consequently collapse or consolidation of the lungs or the presence of fluid in the pleural cavity renders the percussion sound over such areas more or less dull. Consolidation of the lungs are found in pneumonia and phthisis. In order to cause appreciable dulness the consolidation must be at least one and one-half to two inches in diameter, and lie just beneath the chest wall or near the surface of the lungs. Many pneumonias of children centrally located in the lungs, surrounded by normal lung tissue and involving small areas are practically impossible to locate by percussion. Auscultation is by far the most valuable means at our command to determine normal or abnormal conditions in the chest,provided, we breath properly, or inflate the lungs, while we are making our examinations, but as you all know and there are so many people, when we tell them to draw a deep or long breath, fix the respiratory muscles and swell up like a bull frog, and quit breathing at all I find it a good plan when we meet with this kind of person, to have them cough or count 21, 22, 23. In auscultating the chest there are three kinds of sounds which are heard, normally, in certain parts of the chest. Two of these are types, the other two are combinations of the first two, they are, bronchial, vesicular, Bronchial and broncho-vesicular, breathing. breathing is heard over the trachea, just above the supra-sternal notch, described as blowing or tubular and is not heard only over or near the large bronchi in a normal chest. When heard it is usually indicative of some consolidation of the lung tissue (such as we have in pneumonia or phthisis, with consolidation or with a large cavity having free communication with a bronchus. Broncho-vesicular breathing is neither bronchial or vesical, and is sometimes spoken of as intermediate. It may be heard in the healthy chest over the lower portion of the manubrium, and over the interscapular region at the level of third dorsal vertebra, being due to the larger bronchi being within auscultating distance and a thin portion of lung tissue intervenes between the ear and large bronchi. Vesicular breathing is described as soft, breezy sighing, resembling the rustling leaves in a gentle breeze, and should be heard during the whole of inspiration. It is necessary to become thoroughly familiar with these three varieties of breathing and the special character which serves to differentiate one from the other, also to know as well in what part of the chest they are to be heard. In many cases of pulmonary diseases the principal and important physical sign consists in finding one kind of breath sound where another should normally exist, for instance, should you hear bronchial breathing over the trachea just above the suprasternal notch you would think nothing of it, but should you get distinct bronchial breathing in the infrascapular notch, especially of the left side, you would be very suspicious of tuberculosis. One other point I believe is worth mentioning, and that is, after you have gone over both lungs pretty carefully and think you have located the trouble, go over the lungs closely again, especially the lung that you do not suspect as being diseased, and compare inch by inch, both by percussion and especially auscultation, the findings in both lungs, thus by comparing the two sides, you will notice that the breathing is not quite as vesicular in the diseased lung as in the normal one, and by comparison of the two sides you can make out some obscure incipient trouble that you would not find otherwise. NEWS ITEMS AND COMMENTS DR. E. M. WILEY. The funeral service of Dr. Edward Maxwell Wiley, who died January 11, 1915, was held at the family home, 149 Woodland Ave. The Rev. I. J. Spencer, pastor of the Central Christian Church, of which Dr. Wiley was a member for many years, conducted the funeral services. Interment was made in the Lexington Cemetery. The active pallbearers were: Dr. J. P. Warder, Dr. L. C. Redmon, Dr. C. B. Wilmott, Dr. C. A. Vance, Dr. W. S. Wyatt, Dr. E. B. Bradley. The honorary pallbearers were. Dr. David Barrow, Dr. W. Ó. Bullock, Dr. F. H. Clarke, Dr. J. A. Stucky, Dr. B. L. Coleman, Dr. Geo. B. Sprague, Dr. T. H. Kinnaird, Dr. B. F. VanMeter, Dr. W. B. McClure, Dr. D. J. Healy, Dr. C. W. Norris, Dr. C. L. Wheeler, Dr. C. C. Garr, Messrs. H. H. Barnes, Alex Hall, Rudolph Harting, Roger Wilson, James G. Denny. President -elect J. C. Lewis appointed Doctors Charles A. Vance, R. Julian Estill and L. H. Mulligan as a committee to draft resolutions, and Doctors Redmon and John W. Scott as a committee to purchase a fitting floral design. Brief eulogies were paid the memory of Dr. Wiley by Doctors J. W. Pryor and B. F. VanMeter. A resolution of respect was reported by the committee as follows: "In the announcement of the death of Dr. Edward Maxwell Wiley, the members of the Fayette County Medical Society have learned with keen susceptibility and unaffected sorrow of the passing of one of their most beloved and ablest members-their daily and intimate professional associate through the changing fortunes of many years. This sentiment is voiced in no conventional phrase, but comes home to each with a deep sense of direct personal loss and affliction. "Dr. Wiley wah born on a farm near Madison, Indiana, of a family which has given more than one distinguished name to the country, in June, 1850, the son of Milton and Anne Elizabeth Bowen Wiley, and was consequently 64 years of age at the time of his demise. From what we have known of him through a period approaching half a lifetime of intimate social and professional association, all of his years were replete with usefulness and benefit to his fellowman. He was educated at Hanover College at Madison, in his native state, which has given, despite its limited pupilage, such an undue proportion of brilliant names to the professional and scientific life of the country. He was graduated as a physician from the Medical College of Indiana, at Indianapolis, in 1876, and at once entered upon the active duties of his profession in Trimble County, Kentucky, some years later removing to and establishing himself at Harrodsburg, which town from an early date enjoyed, as it still maintains, a marked reputation for the skill and ability of its medical faculty, among whom he rapidly found place in the front rank. It was while practicing at Harrodsburg that his growing reputation recommended him to the attention of Governor William O. Bradley, who, although the first Republican Governor of the State, tendered him the responsible position of Superintendent of the Eastern Kentucky State Hospital at Lexington. This position he accepted, and for nearly four years directed the administration of its many varied departments with singular force and ability. Here his gifts and abilities seemed to find adequate field of endeavor. He left it at the end of his term in many erspects a different institution, and his keen judgment and insight, the strength of his gloved hand, left an influence for the better in many ways, the impress of which is even now markedly apparent. "It may fairly be said that the full tide of his mature professional life but now began in a comparatively new community amid new associates where he had to recommend him only his natie worth and the reputation he had been able to make in the seclusion of the hospital. It was a brave fight he entered upon and gallantly did he bear it. Steadily, year by year, did his practice extend with his growing reputation, nor had his capacities been measured or taxed when he fell, apparently at the beginning of a masterly career, which already placing him in the very front rank among the physicains of Lexington, would have placed him in no great time in a position of more than State-wide reputation. He fell in the hey-day of his activities, when a long and distinguished career seemed promised to open like a vista before him. "Dr. Wiley was unquestionably, from what has been said, a physician of far more than ordinary skill and judgment. He was rarely excelled as a diagnostician and in resource. His manner and bearing was of such rare quality that on entering the sick room, a burst of cheer and sunshine seemed to come with him, bringing courage and hope, and a silent tear will furrow the cheek of many a one who in the past as among his patients, has been the beneficiary of his skill and soothing ministrations, on hearing that his generous spirit has entered the Great Beyond. now "Unmoved, as we believe we are by any sentimentality of sudden affliction, it would not be difficult to point out many qualities possessed in striking degree by Dr. Wiley, not often found associated in a single character. But among them all, two stand out in transcendent prominence, as we so vividly recall him—these were his innate courtesy and lofty courage. No provocation could ' move him to a vulgarity, no motive lead him to a littleness, no danger could bring a tremor to his hand or a pallor to his cheek. This man would have been, as he was, a gentleman had the accident of birth brought him forth in a hovel. His fine instincts would have asserted themselves amid any surroundings. He freely gave to all alike--the humblest in common with the exalted, the same gentle, the same lofty, but an obtrusive courtesy that the inborn dignity of his character exacted from others. Modest in asserting his own opinions formed incisively on the judgment of a clear mind, no argument nor persuasion could divert him a hair's breadth from that wihch he believed to be right. His professional life il lustrated this day by day, while his small and modest participation of things political equally well bears out this assertion. His modest means, as his services, were ever open to the needy and distressed; the friend and encourager of the young and the timid, a heart beaming with kindness and an eye that with rare intuition overlooked no opportunity to extend the helpful hand or to utter the cheering word of encouragement-unselfish, unmarred by jealousy, steadfast, loyal, he disdained to wear the mask of any virtue he did not possess. He could overlook and condone the faults of others without tainting himself by the contact. "Assuredly, if one noble life can in any degree enlighten and uplift those about him, then the world is the better for the career and the achievements of Edward Maxwell Wiley. "Therefore be it resolved: That a copy of these resolutions, duly attested, he tendered to the family of Doctor Wiley; that as a mark of respect we attend the funeral in a body and wear the usual emblem of mourning for thirty days. "R JULIAN ESTILL, New Method of Round Ligament Fixation.-In Goodwin's method the abdomen is opened in the usual way, the round ligament separated, and by means of a ligature carrier, which has been thrust through the rectus muscle. drawn to the surface of that muscle. The loop of round ligament is held up by an assistant and the surgeon, either with scissors or scalpel, commencing at the site in which the ligament has been drawn through cuts for about three-quarters of an inch in length in the direction of the fibers and toward the pubis the rectus muscle and underlying tissues, including the peritoneum. The assistant then holds at the upper angle of this incision one side of the loop of round ligament and places and holds the other side in the lower angle. While so held the loop arches over the incision made in the rectus, one pillar being in the upper, the other in the lower angle. The surgeon, working under this arch, sutures together with catgut the edges of the incision in the rectus lying between the pillars held in the upper and lower angle, being careful to bring together the fibers of the muscle in the same apposition they were before incised. This leaves the loop of ligament resting on a bridge of muscle three-quarters of an inch long, one end of the ligament passing into the pelvic cavity through a small opening in the lower angle of the incision and the other through a similar opening in the upper. It is impossible for the ligament to get away from its moorings and drop back into the pelvic cavity. Although it is not necessary, the end emerging from the one descending into the pelvic cavity may be anchored at its site by passing one suture through it and the rectus muscle. Infection of the Fetus. Masay experimented with the streptobacterium fetidum injected gravid guinea-pigs with it. The placenta was no obstacle to its passage into the fetus, and it actually seemed as if the fetus served as a kind of "fixation process," the germs congregating in it and forsaking the maternal organism. Two hours after the injection of the germs they were evident in the fetal blood. Emptying the uterus thus clears out the hosts of germs that have congregated in the fetus. This suggests that abortion is a natural phenomenon of defense. It is possible that the germs in the maternal organism may go at once to the fetus apparently without infecting the mother. COUNTY SOCIETY REPORTS Bell-The regular meeting of the Bell County Medical Society convened in the parlor of the Pineville Hotel on Friday afternoon, November 13th, 1914, with Edward Wilson presiding. The meeting was called to order at 1:30 and the regular program taken up in usual order. Under the head of new business, the matter of paying the Secretary a small salary, enough to defray the expense of stenographic work necessary, was discussed and laid over until next meeting. Under the heading of case reports, Mason Combs reported a case of "Appendicitis with Distended Gall Bladder." T. T. Gibson reported a case of "Fibrous Adhesions of Bowels, with Constrictions." Edward Wilson reported case of "Appendicitis." E. M. Harrison a case of "Cancer of Uterus, with Accidental Cutting of Ureter during Operation." B. A. Cockrell reported a case of fall from a tree resulting in fracture of femur and complicated by severe heart lesion. L. L. Robertson reported a case of double foetation. Mason Combs presented his paper on "Appendicitis by making a verbal report, and discussion of the subject, which elicited an animated discussion from a number of those present. This being the last meeting of the year to be held in Pineville, Edward Wilson, the retiring President, had arranged for an elaborate entertainment and smoker to be held in the diningroom of the Pineville Hotel, and promptly at 3 o'clock, all the members present were escorted to the dining room, where the enchanting strains of music and the beautifully laid and decorated table, brought a smile of gladness to every face. While seated at table, and before the meal was served, the accommodating photographer was ready to take a picture and every one was commanded to smile and look wise. The hotel had supplied a well selected menu, which was served in good taste, and all those present lived up to their splendid reputation in performing gastronomie feats. The different courses were interspersed with a layer of medical mountain oratory, tha twould have brought a blush to the cheek of the immortal Patrick Henry, or Henry Clay. After all this array of fuss, fun, and feathers," each one present left bearing away a beautiful carnation, presented as a climax to the menut, and feeling that the retiring President, had lived up to the motto of the Bell County Medical Society. To do things as well, if not better, than any one else." O. P. NUCKOLS, Secretary. Bell The Bell County Medical Society met In regular session at the offices of J. P. Edmunds, |