a chain. In progressive cases we find besides these also bacilli of various length and thickness. The finding of the bacilli, even when there are great many of them, does not at all negative the simultaneous presence of free HCl. I wish to lay great stress on this as the text-books, the one thoughtlessly copying from the other, have always assumed that the free HC1 acts as an antiseptic. There is no truth in this. As a matter of fact, in my study of the gastric condition of tuberculosis, in nearly 200 cases I found that every one suffered from zymosia gastrica and that in every case there was free HCl, with but one or two exceptions, that could be explained away.

Organacidia gastrica ab amylo is a chronic conditon which we find in the rich and the poor. The rich eat too many cakes and candies and the poor eat too much potatoes and bread.

Organic Acids.

The symptoms are produced by the presence in the stomach of irritating, acrid, volatile, fatty, organic acids. The most usual is the succinic acid, which is characteristic of mold. Aside from these are the fatty acids: acetic, butyric and propionic acids. These acids produce, when in contact with mucous membranes, not only painful sensations of a degree corresponding with the degree of irritation, but also always produce the contraction of the muscularia subjacent to the mucous membrane. Such contractions produce pain which, likewise, will vary in severity, according as to the degree of contraction. The stronger the contraction the stronger the pain; the weaker the contraction the weaker the pain. These acids produce symptoms wherever they reach and, as they are of a volatile nature, their range of damage is great.

Anatomy teaches us that there is normally an unobstructed road from the stomach to the frontal cells on one hand, and to the conjunctivæ and middle ear on the other hand. Therefore, the irritation proceeds in all these directions and produces symptoms everywhere. On this basis we can explain the beneficial results in ophthalmology and otology, when only the digestion is properly looked after. This is the anatomical road: from the stomach through the esophagus into the pharynx. From here through the eustachian tubes into the middle ear and through the posterior nares into the nose. From the nose they reach up into the frontal cells through the open

ings of the cribriform plate of the ethmoid bone. Again, the nose communicates with the conjunctivæ through the lachrymal canal. In this way we must trace and connect cause and effect. We know the effect upon us when passing strong fumes of ammonia, vinegar, etc. They give us headache, irritation of the nose, lachrymation and irritation of the throat. Should it makes any difference if the noxious matter comes from the stomach in an ascending route?

Symptomatology.

The symptoms can now easily be reasoned out. There is irritation of the mucous membrane of the entire passage from the stomach to the frontal cells and, therefore, there will be pain of greater or lesser severity along the entire tract. The pain may be described by the patient as only a slight, indescribable sensation, soreness or rawness; but sometimes as actual pain, cramps and colic. The patient therefore complains of rawness, soreness and pain in the stomach, along and behind the sternum, or between the shoulder blades, which indicates the esophagus; of dryness in the throat-pharynx area, and perhaps also pain in the ears. The most common and distressing symptom is the pain in the head, which is of the frontal or supraorbital type; he also suffers from dizziness. If the volatile irritating acids are not too concentrated, their passage into the nose will very slightly irritate the nasal mucous membrane, which gives rise to sneezing. Thus is to be explained the sneezing soon after meals. Where the organic acids are abundantly present, there will be severe pain in the stomach expresed most strongly at the gastric sphincters, especially at the pylorus, producing here severe cramps. The cramps are due to the violent contractions of the muscles which form the sphincter of the pylorus. This is the most usual seat of the pain, because it is the most common seat of irritation. This latter is caused by the fact that the pylorus is the most dependent part of the stomach. Therefore, following the laws of gravity, the irritating chemical agencies fall to the lowermost portion and here exert their most violent action. But, as it is the normal response of all sphincters to contract upon being irritated, also the cardiac opening will spastically contract and the patient will therefore refer his pain to the area of the back corresponding anatomically to the location of the cardia.

The Appetite.

The behavior of the appetite in this class of patients offers, seemingly, the greatest problem. Notwithstanding the severity of the symptoms, the appetite may be most excellent. Paradoxical as it apparently seems to be, the trouble has always been with the improper understanding of the cause of appetite. And, surely, Pawlow has only confused us still the more with his experiments of mock feeding and the very erroneous deductions he made from them. I have devoted a whole monograph to the question of appetite, which was published in American Medicine, August 25, 1905. In this monograph I proved that what we call appetite is a sensation caused by the contraction of the pyloric region and, most likely, also of the duodenum. All of Pawlow's theories fail us when we attempt to find an explanation for the recurrence of the sensation of appetite in patients in whom the entire stomach has been resected.

My view of the cause of appetite is, that it is a certain unpleasant or even painful

sensation the abatement of which we come to learn is incident upon the partaking of food. In other words, the baby grows up to know that, among the other unpleasant sensations, there was one which would be stilled by food. Appetite, therefore, is an unpleasant sensation of varying degrees, and the question is, what produces it? All the views hitherto expressed fail to find applicability uniformly in every case, as dwelt upon in my above-cited article. The theory advanced by me is, that the sensation we call appetite is caused by the contraction of the muscular coat of either the pyloric region or of the duodenum, or of both; the stronger the contraction the stronger the sensation we call appetite, and the weaker the contraction the less is the appetite.

This theory applies in all cases and excellently explains the reason why in the presence of severe pain and cramps the appetite is great, and why, on the contrary, in the absence of contraction, as is the case in insufficientia pylori, there is little or evanescent appetite. The average pains and cramps induced by the violent muscular contractions, are also, because of these, accompanied by an excellent appetite. That is why, in organacidia gastrica the patients have a good, an excellent appetite; the patients in this disease suffer from the presence in the stomach of the irritating acids which cause the violent muscular contrac

tions, and which, besides causing the pains and cramps, also cause the increased appetite. Therefore, the greater the irritation by the acids the greater the muscular contraction, and therefore the greater the appetite. A good and strong appetite, an appetite of which the patient ordinarily boasts, is most apprehensive; it is pathological.

The "Taste" as a Symptom.

The taste in the mouth depends upon the specific condition of the stomach. In gastrosia fungosa the taste is foul, musty, also described by some as brown or yellow. In zymosia gastrica the patients complain of a bitter taste, as yeast tastes bitter. Always the taste is worse in the morning, on getting up. Owing to the irritation of the pharynx and the consequent sensation of dryness, the patient complains of thirst and he drinks a good deal. This, in turn, has to be eliminated and the more the patient drinks the more frequent is the micturition. Let us well bear these symptoms in mind lest we mistakenly pronounce a person to suffer from diabetes when he really suffers from organacidia gastrica. My past experience recounts many of these in

cidents.

Gas Production.

In zymosia gastrica there is also an excessive production of CO, in the stomach, which gives distention of the stomach and belching. This is interpreted by the patient as heaviness, a load or weight in the stomach. Indeed, also the physician believes that this sensation comes from the presence in the stomach of really solid contents, which view, of course, is erroneous. As the gas ascends and is stopped in front of the first esophageal constriction, i. e., at the constriction immediately at its beginning because of the spastic constriction here, the accumulated gas in front of the constriction is felt by the patient and described by him as "a lump." Because this is a gaseous lump and can therefore not be appreciated by the usual physical means, this lump of actual existence has unfortunately been described as a globus hystericus.

(To be continued.)

The super-doctor is that rare individual who is not only a good diagnostician but a skilled therapeutist as well.

Many pelvic operations fail because the blood supply to the parts has been cut off to a great extent.

THE ELECTROCARDIOGRAPH.

Diseases Discovered by Electric Currents of the Human Body.

By DAY ALLEN WILLEY,

BALTIMORE, MD. Reported from the Clinical Laboratory of Prof. Lewellys F. Barker, Johns Hopkins Hospital.

The physician examines the heart of a patient more often and more carefully than any other part of the body because he wants to be assured if it is healthy or diseased. Usually he makes his diagnosis by

But an invention has at last been perfected by which a physician may clearly hear the heart pulsations of a patient though he may be in the hospital ward or in sick room a mile away. In the phrase of the layman this electrocardiograph is called a "heart telephone." Through the earpiece the physician can count the pulsations or notice whether they are regular or irregular, as accurately as if he had his finger on the patient's pulse. In addition, the electric circuit connecting with the patient operates a miniature moving lens by which pulsations are depicted on a mov

ment consists of a galvanometer and its attachments.

This original idea in medical science was the achievement of Dr. Lewellys F. Barker, a member of the staff of the noted Johns Hopkins Hospital, at Baltimore. Here it was first demonstrated to be a success by a series of tests conducted under the supervision of Dr. Barker. Since its introduction at Johns Hopkins Hospital, the heart station has been installed in institutions in New York and other American cities, and considered an improvement over the Einthoven method in vogue in Germany, although it is similar in some respects.

This detailed description, as prepared by Dr. Barker, indicates the really wonderful advance it makes in medical science:

"In most galvanometers the magnet is the movable part and the current to be measured passes through the stationary coils.

In Einthoven's instrument an opposite arrangement has been made; the magnet is stationary and the current passes through a movable 'thread' or 'string' really an extremely fine wire. This movable conductor of the current is very attenuated, being a thread of 0.001 to 0.003 mm. in thickness. Two kinds of threads may be used-one of quartz, coated with silver to make it conduct, or one of platinum. A very good platinum thread is one 85 mm. long with a diameter from two to four microns-from one-third to one-half the diameter of a red corpuscle-so delicate that it can be clearly seen with the naked eye only when powerfully illuminated against a dark background. Such a thread is too light to be weighed even with extremely sensitive balances, though its weight has been calculated by Einthoven to be about 0.00262 or 0.00685 milligrams. The ends of the thread are held stationary, so that the thread swings like the string of a musical instrument, hence the designation 'string galvanometer.' Since the magnet Since the magnet must be strong, it is customary, in the better instruments, to use an electromagnet. The string is suspended midway between the pole-shoes, and it operates on the principle that when an electric current is passed through a magnetic field, it undergoes a deflection perpendicular to the lines of magnetic force, which pass between the two poles of the magnet; thus, when a current passes through the string of the Einthoven galvanometer, the current is deflected and with it the string. The deflec

tion will be to one or the other side according to the direction in which the current passes through the string; the stronger the current which passes through, the greater the deflection and vice versa. The thread of the instrument is so delicate that it is suitable only for the measurement of very feeble currents which cause only slight oscillations of the string; a tyro working with the instrument may easily break the thread by permitting too great a deflection. from the passage through the string of too strong a current.

"In order to study accurately the oscillations which result from the passage through the galvanometer of the feeble action-currents originating in the heart, a magnifying and photographically-recording apparatus is essential. The nuclei and poles of the magnet are pierced in the middle and two microscope tubes inserted in the openings. One of these is provided with an objective for focusing a strong electric light upon the string; the other is a projection microscope, consisting of an objective or of an objective and an ocular which throws an enlarged image of the illuminated string upon the slit of the photographic apparatus, or upon a white ground on which the movements of the thread may be observed with the naked eye.

"The strangest feature is that quartz dust can be treated in such a manner that it can actually be converted into a wire which is probably the tiniest in size that has ever been made-1-1250 of an inch in diameter.

"Thus it is that the physician can actually see and record, by this image on the screen, the oscillations which the 'string' undergoes as a result of the electric currents which are generated in the human heart during the excitation of its muscles which precedes every beat. The rapidity of the string movements, their extent, as well as the regularity or irregularity of rhythm observed, reveal information desired regarding the condition of the muscle of the heart, although the patient may be in a distant room connected only by wiring with the heart station.

"The manner in which pulsations are verified and recorded is remarkable. When the string is oscillating to the action-currents of the human heart, only the larger oscillations are discernible by the naked eye even in the magnified projected image. In order to discern the smaller movements and to obtain curves as permanent records, photographic registration is essential. The

magnified image of the string is projected, by means of a powerful electric light, upon a slit in a dark box which contains a moving photographic film. The slit opens and shuts when required by electric signal, and the movement of the film can be begun or stopped at will.

"Ordinarily a film half the length of an ordinary kodak film will suffice for one observation, but when for any other purpose observation of all the electrical results of the heart muscle over a considerable length of time is desired, much longer films may be employed. A recording apparatus which will permit a photograph 75 meters-250 feet-in length to be taken without intermission may be installed. Smaller portions of this long film may be used and clipped off for development, as desired. Since the long axis of the slit in the box is placed horizontally and the string of the galvanometer moves either to the right or to the left, the record on the film which moves vertically in front of the slit is in the form of a curve in which the waves are up and down. Such a curve is called an "electrocardiogram." A lever connected with a chronometer marking fifths or tenths of a second, oscillates before one end of the slit, so that exact timing of the 'excursions'

-movements—in the curve is possible.

"One can, if desired, also record simultaneously on the same film, a sphygenographic curve of the carotid pulse by placing before the slit a lever connected with a tambour and receiver. But another idea for this purpose is registration of the carotid pulse by means of a telephone and second smaller galvanometer, the string of which is projected on the same slit. If desired, a third galvanometer may be used in connection with a microphone, and an electrophonographic record, or 'cardiophonogram' of the heart sounds, be made simultaneously with the electrocardiogram and carotid sphygenogram upon the film.

"This means that by the aid of the galvanometer and its auxiliaries, the conditions of the heart and arteries can be investigated simultaneously in at least three different ways: 1, as regards the electrical changes in the heart-muscle; 2, as regards the pressure changes in the carotid artery, and 3, as regards the sounds produced in the heart during activity, or while it is at rest. Yet, as stated, the patient may, while the examination is being made, be at a considerable distance from the heart station.

"Thus the electricity in the body of the patient in the hospital in Leyden, Germany, one and a half miles away, has revealed important facts regarding the condition of his heart to the physicians working in Einthoven's laboratory of physiology.

"In operation, the connection of the patient with the heart station is naturally of much importance so that the current he generates from the heart movement may be transmitted without loss if possible. The patient places left arm, left foot and right arm in three electrodes, which consist of zinc pans filled with normal salt solution, 8 grams too one liter. From each of these, wires are conducted to three switches, by means of which any two of the electrodes can be connected to the main circuit. They are connected with a wire which is attached to the station galvanometer.

"This gives all the variations-right arm and left arm, right arm and left foot, left arm and left foot. In the wiring of these, care is taken that in arranging for the different derivations the so-called 'body-current' is not changed. The wire from the left foot always goes into the same main wire and the left electrode occupies the same position in the circuit as the right arm does; otherwise an inverted electrocardiogram will be obtained due to this wiring defect. This precaution is taken because some disease conditions cause an inverted electrocardiogram. From these switches the two main wires lead to the galvanom

eter.

"In most instances, when the patient is connected to the galvanometer, there is a large permanent difference in potential between the two parts of the body where the electrodes are attached. This deflects the fiber far to one side and must be compensated for. A commutator is placed in the circuit which serves the purpose of connecting in and sending in either direction around the main circuit, a current from a battery reduced to sufficient strength by a resistance coil. This is sent in the opposite direction to the 'body current' and serves to neutralize the primary body potential-compensation of the zero current.

eter.

"For making phonocardiograms simultaneously with electrocardiograms, the microphone is wired to a smaller galvanomThe wiring of the microphone is simple. It is connected with a dry battery in a circuit with the primary of an induction coil. Wires from the secondary lead to the junction points of the wires from