the galvanometer and resistance coil. The constant battery current passing through, the primary induces no current in the secondary. Changes, though in the strength of this primary current as the result of sound vibrations on the microphone, set up induced currents in the secondary and these are recorded by the galvanometer. Switch 1 opens and closes the primary circuit; switch 2 serves the same purpose in the secondary.

"In healthy people an electrocardiogram -the film picture-is obtained by leading off the current through the two hands, or one hand and one foot, which, under the conditions outlined above, assumes, in the majority of instances, a certain form. The term 'typical' or 'schematic' is used instead of 'normal,' since slight deviations

from it may occur in people with normal hearts. When any muscle is excited to contract the active portion is always electrically negative to the part at rest. This is true therefore in the heart, and electrical changes show the course of excitation.

"The curve for each heart-period presents constantly three principal waves upward, indicating an electrical negativity of the base of the heart as regards the apex at three different times in a single cardiac revolution. These three elevations have been designated by Einthoven as P, R, and T. The curve presents also, in many instances, two slight excursions or waves downward-depressions-indicating a negativity of the apex of the heart as regards the base at two different times in each cardiac revolution. These two depressions,

though less constantly present than the three elevations, have been designated by Einthoven as Q and S.

"By the course and height of these waves, as shown in the record, the physician can tell by the unaided eye whether the heart undergoes normal or abnormal electrical changes; in the latter instance an analysis of the abnormal appearances of the record throws light upon the disease of the heart muscle which is present.

"To obtain these records the electrodes are connected with the right and left hands. Waves with the apex upward indicate that the base of the heart or the right ventricle is negative to the apex or left ventricle, and is therefore exerted at that time. Waves with apex downward have an opposite significance. Wave P is due to the excitation of the atrium. Waves Q, R, S and T occur during the excitation of the various portions of the ventricle or auricle.

"As to the distance at which observations may satisfactorily be made, at the present time knowledge is uncertain, but such is the delicacy of the apparatus that already a patient a mile or more away has been electrically examined by physicians. This possibly is a distinct advantage of the system. Many cardiac patients are too ill to be removed from a hospital ward, hence the necessity of connecting the ward with the station by wiring to the heart station; again, in many instances, an electrocardiographic apparatus can be set up in a physiological laboratory when one is not available in the hospitals in the same town. To meet these requirements wires may be laid connecting various wards of the different hospitals with the heart station, which may be situated either in one of the hospitals or in a physiological laboratory in the same town. Einthoven, as has already been stated, laid wires between the Leyden Hospital and his laboratory, a distance of one and one-half miles, and took tracings in this laboratory from patients in the hospital wards. The main difficulty lies in the prevention of induced currents en route, but that such 'telecardiograms' are feasible, has been fully demonstrated.

"When the record is being made, the patient sits in a comfortable chair or lies on his back with all his muscles relaxed, since muscular tensions and contractions may modify the curve. He should breathe quietly. Tremor of the hands of a patient may modify the curve and is said sometimes to give a splintered appearance to

the tracing in the films. The wires reaching from the patient to the station must be carefully laid to keep the current from being disturbed by induction from alternating electric currents. The galvanometer is extremely sensitive to induction effects, especially those coming from the alternating current.

"What this instrumental investigation signifies, not only for the discovery of disease but for determining its nature, it is as yet too early adequately to judge, but many physiologists and clinicians believe that it will prove to be a very valuable aid to the medical profession. While the galvanometer, the photographic recorder and the auxiliary instruments have in this country furnished already data of importance in connection with animals as well as human beings, the work in Germany has been far more extensive since more stations have there been established.

"The films have aided in the study of such diseases as neurasthenia, tachycardia, hemorrhages in dogs, poisoning by such compounds as chloroform, digitalis, strorhanthine, even the toxin of diphtheria. These are merely some of the causes which affect the heart current, each producing a different movement that is depicted on the film, thus giving film, thus giving a visible proof of disease possibly unknown before. By filing the electrocardiograms of each patient and also of animals which have been utilized for experiment, the discovery has been. made that certain diseases produce certain heart movements. Thus a new way of locating and correctly defining certain ailments is opened by these mechanical recorders of the human body.

"The records taken by the electrocardiograph are especially valuable in the analysis of the various forces of irregularity of the heart. They also reveal certain changes in the muscle of the heart difficult to detect by other methods. Much experimental work is being done on the hearts of animals and the effects on the electrocardiogram noted. The forms of electrocardiogram which result from such experimental injuries to the heart will be of great service in interpreting the abnormal curves obtained from human beings in disease."

After the American College of Surgeons "finds" itself and gets in practical operation, doubtless it will eliminate certain features proposed by enthusiasts. A new broom may sweep too clean.

Preventive Gastroenteritis in Adults.

The Significance of Pain in the Lower Abdomen.

By SAMUEL FLOERSHEIM, M.D., 808 Lexington Ave.,

NEW YORK CITY.

Acute gastroenteritis, particularly that which occurs in the warmer months of the year, is a preventable disease. Prevention lies in the exercising of the primitive laws of hygiene as they relate to diet, clothing, exercise, etc.

Clothing.

Underwear that is most appropriate for summer wear is one of medium weight of silk and wool. When the atmospheric temperature rises, the outer clothing can be changed for lighter grades. The constant changing to underwear suitable to the atmospheric conditions prevailing is well enough if one is at home, but should he have occasion to be far from his usual place of abode many changes of temperature often occur from the time of leaving and arriving. Should the heavier underwear by chance be the one of selection in the earlier part of the day, the danger of contracting

"cold" is not so imminent as the reverse would be. The ideal underwear is one of medium weight to be worn all the year around; and, to sustain comfort, outer clothing appropriate to the weather may be selected. The underclothing should never be changed in texture at any time.

Exercise.

It is well when the temperature is rising rapidly or is high that there be little exertion. Long walks, climbs or other arduous tasks are ill-advised. If convenient, from noon to 4 P. M. should be spent in repose in the shade.

Baths.

On warm days these are usually taken cold upon rising; again, should the weather be very warm, between 2 and 3 P. M., and later about 8 P. M., when the evenings are hot and uncomfortable. Cool baths abstract body heat, thereby increasing comfort during a hot spell. Baths lasting from five to fifteen minutes cause no reduction of the body temperature.

Atmospheric Conditions.

When the air is humid there is more discomfort experienced, even though the thermometer does not register as high as on a clear day. Humidity is the uncomfortable

element that is experienced during the heated months of the year. High temperatures are the better borne the lower the humidity. Keeping in the shade will be a factor in the prevention of overheating that may terminate in illness.

Diet.

As the temperature rises the number of calories taken should decrease. The daily intake for the average male during ordinary efforts at physical labor is about 2,500 to 3,000 calories. During the warm months of summer this amount is often agreeably reduced to one-half.

Avoid the rough foods difficult of digestion and those which are heat producers or that require lengthy digestion. Soft foods are prone to decompose quite rapidly.

The foods usually contraindicated in hot weather are: red meats, pork, fats, strong hot soups, fatty chicken, large amounts of butter or cream, oatmeal, parsnips, cucumbers, sprouts, fried foods in general, fatty gravies, hashes, pickles, heavy beers, alcohols in large amounts, stout, heavy malt extracts, corned beef, duck, geese, rich puddings, hot strong coffee and tea, stews, cabbage, cold slaw, liver, kidneys, iced drinks with or after hearty meals.

The foods wholesome for hot weather may include the wheat and rice cereals, milk, biscuits, bread, cake, most fresh. vegetables, such as potatoes, turnips, carrots, cauliflower, asparagus, mushrooms, tomatoes, beets, string beans, dandelion, chicory, radishes, green peas, oyster plant, olives, iced tea or coffee, buttermilk, fermented milks, custards, jellies, nuts, fruits, melons, water, fruit juices, ice cream, water ices, soda waters, and other cooling and refreshing drinks. The sea foods, such as clams, crabs, lobsters, etc., are to be employed only if perfectly fresh.

PAIN IN THE LOWER ABDOMEN.

Pain in the right iliac regions may signify: Inflammation or growths of the appendix or cecum, or adhesions of both; disease or growths of the ileo-cecal valve; ulcerations, abscess, tumors or intussusception of the lower portion of the ileum; retro-cecal abscess; typhoid fever; disease or tumefaction of the ilium (bone); impacted ureteral (kidney) stone in the right side; hydronephrosis of the right kidney; prolapsed or wandering kidney of either side; kinking of the right ureter; disease of the right tube or ovary; inguinal adenitis; neuritis and disease of the iliac vessels; threatened or actual ruptured tubal pregnancy.

Pain in the hypograstic region finds as

causes:

Typhoid fever; enteritis; ulceration and growths of the ileum; dysentery; diseases of the iliac bloodvessels; lumber adenitis; internal hemorrhoids; ulceration of the rectum; obstinate constipation; urinary bladder inflammations; urinary calculi; overdistended bladder; floating kidney; patent and distended urachus; hard fecal masses in the small intestines; volvulus of the sigmoid; distended and inflamed sigmoid, and tumors of the same; cancer and other malignant and benign growths of the uterus, ovaries and tubes; prolapsed tranverse colon which is either diseased, kinked or adherent to different abdominal organs or parietes by pericolonic adhesions or malignant growths. An extensively enlarged spleen may be found in this area, as well as a prolapsed stomach, which may have a gastric ulcer or cancer. Pain in the left iliac region has for its cause either:

Inflammations of the sigmoid or growths of the same; volvulus or adhesions; kinking of a portion of the large intestine; obstinate constipation; left uterine adnexa disease; left inguinal adenitis; phlebitis of the left femoroiliac vein; neuritis (as on the right side); calculus impacted in the left ureter; hydronephrosis; floating kidney; internal hemorrhoids; growths in the small intestines, and on the ilium (bone); rupture or over-strain of the abdominal muscles on the left side; beginning left inguinal hernia.

Pain in the lower abdomen may have as its cause general constitutional conditions, such as general atheroma of the abdominal blood-vessels, gout, rheumatism, acidosis, diabetes, chronic malaria, chronic infections or excessive putrefaction or fermentation in the intestines. We can also class spastic constipation, hysteria and neurasthenia as causes of pain in the lower abdo

men.

in which toxic gases are evolved; or in some cases it may be due to a particular article of food, such as fish or shell fish, or fowl which have been permitted to hang too long, developing ptomaines. These or other food conditions which we are unable to discover, are causative of the pathologic conditions which I would discuss.

The diagnosis is not always easy; the trouble may come on in a variety of ways and be confounded with some febrile disturbance or acute inflammatory disease of some organ. There are a variety of ways in which the symptoms manifest themselves. The attack may be preceded by a feeling of malaise for some days; the patient does not feel exactly up to the usual standard of health, is "yawny and stretchy," and disinclined to exertion; possibly is suspected of having malaria, and is dosed with quinine accordingly, without benefit; or the attack may develop in a few hours, and the patient. may suspect that it is dietetic, but cannot say what has been eaten that could have caused it. The disorder does not run any definite course as to duration. The emunctories of the body, the liver and kidneys, may show conspicuous disorder, but this should not mislead us; the spleen may be enlarged, or the lungs congested, or all of the conditions may be present in the same case. Conspicuous in these cases is gaseous. distention of the bowels, sometimes attended with acute pain. The pulse is of greater or less frequency, and the temperature erratic, being high in the afternoon and low in the morning, low in the afternoon and high in the morning, for several days on a high plane and then on a lower, with no regularity as to time. Sometimes it is down to normal or sub-normal and

Illustrative Cases.

By JOHN N. UPSHUR, M.D., 210 W. Grace Street,

RICHMOND, VA.

It is comparatively easy for us to guard. against the causes of disease which assault

us from without; but when the cause comes from within the organism it is much more insidious and usually takes us unawares. In the rush and hurry of modern life the stomach is not able to measure up to the demand made upon it, and there is lack of preparedness of the food when it passes from the stomach into the intestine for absorption and assimilation. These are all predisposing factors in fermentative action

better; about 2 P. M. the rise begins, and by midnight will register 103 degrees F. and up. The bowels may be constipated or relaxed; if the latter, they are more or less foamy. Some nausea is present and aversion to food; there is mental depression, at times drowsiness. The stools may be decidedly pale and pasty. The tongue is covered with a white fur, red at the edges and tip, sometimes a fiery red, and very sore, as if denuded entirely of epithelium, and so sore that taking of nourishment is painful. The patient is nervous and restless, sleeping badly. The gaseous distention may be most conspicuous or only detected by palpation and percussion. The cases cited are illustrative.

A. B., aet. 38. Physician, and a hard-worked one; of previous good health. Was taken ill September 25, 1912; was seen first on the 27th. The conspicuous symptoms were: furred tongue, abdominal tympany, muddy complexion, pulse 112 of low tension, at times abdominal pain distressing in character in the left abdominal zone, mental depression, thought he had typhoid fever and insisted on administration of anti-typhoid serum, which was refused; he was restless and wakeful at night, some nausea, and occasionally vomited. As the case progressed the temperature showed the erratic course mentioned above. There was congestion in the lungs, enlarged spleen, and liver progressively increased in size until it extended to the sub-mammary line above and 3 inches below the ribs.

m.m.

Blood examination showed the Widal test negative, and no malarial organism. A week later, hemoglobin 85, leucocytes 5,500 per cu. Urinalysis sp. gr. 1,015, slightly acid, albumin moderate, phosphates diminished, a few blood corpuscles, renal tubules considerable. Diazo test strongly positive, a few hyaline casts. A week later, sp. gr. 1,004, albumin a trace, chlorides slightly diminished, indican slight excess, phosphates diminished, slight trace of acetone, an occasional blood corpuscle, a few pus corpuscles. Nutrition was difficult because milk increased the amount of gas and caused pain. Reliance was placed on chicken broth and pre-digested foods. Dilute hydrochloric acid was also administered, and strychnia as indications required. This attack lasted until November 1.

C. D., aet. 36. Merchant. Was brought to me by his physician on April 30. He had been ill for two weeks, and was brought to the hospital on a stretcher. Intestines gaseous, although distention was not marked; pulse about 100 and thready; skin cool; tongue looked like a piece of raw beef and was so sore as to interfere with his taking any but liquid nourishment with comfort. His habits were industrious and temperate. No evidence of trouble with liver or spleen. Hiccough was incessant except when he was asleep, which was only when under the influence of an anodyne. Blood examination negative; urinary analysis showed urine alkaline; microscope showed numerous oxalate of lime crystals. Patient had a good mercurial purgative; was then put on dilute hydrochloric acid every four hours; lemonade was freely given to allay thirst; a detergent mouth wash was used; liquid nourishment, consisting of the white of egg, lime water and milk, pre-digested foods, chicken broth, etc. Sleep procured by 1⁄2 gr. of codein

sulphate hypodermically at bed time. His improvement was marked and rapid, and in two weeks he was able to return home. In this case, as in the first, marked benefit resulted from intestinal irrigation of the bowels with normal salt solution and milk of asafetida, causing expulsion of gas and relieving distention, greatly to the comfort of the patient.

ADIPOSITAS UNIVERSALIS.

An Inquiry Into the Modern Status of Its Etiology, Pathology, Symptomatology and Rational Treatment.

By ADOLFO LURIA, Ph.D., M.D.,
3611 Lexington Street,

CHICAGO. ILL.

Fourth Paper.

Pathology.

Adipose tissue is developed and deposited in obesity chiefly on the anterior and lateral sections of the abdomen, the loins, the hips, the buttocks, the breasts, the neck, cheeks and under the chin, and this deposition is not always symmetrical and uniform. It also accumulates in the flexures of the joints on the palms of the hands and the soles of the feet. It grows between the muscles and it fills up the spaces that separate their fibers. The kidneys and pancreas may be buried in an avalanche of fatty masses. The stomach and intestines become dilated. The liver is enlarged and loses its shape and contour, is flabby to the touch, pale in appearance and on incision it oozes oil or fat globules from the incised surface because the lymphatic cells are gorged with fat without being actually in a state of fatty degeneration. The secretion of bile is greatly diminished and the gall bladder and larger ducts are either empty or filled only with mucus; when this condition is complicated by chronic alcoholism or any other disease of the liver, fatty degeneration is the inevitable result.