A. B., a male infant weighing ten pounds, was born Most textbooks describe gastric cancer under on Dec. 25, 1904, in the most favorable surrounding one type the pyloric cancer. Tumor, dila- and with good inheritance. The labor had been short, tation, absence— of hydrochloric acid, presence the delivery easy with low forceps. A slight ecchy- of lactic acid, coffee vomit, continual was on middle of grounds mosis noticed at birth the finger the are the hand. On the the cried loss of weight and cachexia symptoms right following day baby and are so that the and vomited some mucus. An portrayed, typical diagnosis considerably bloody is But an under the chin and on the back made by the laity. only early diagnosis ecchymosis appeared such of the neck. On the third day several more hemor- gives a therapeutic chance, and to arrive at rhagic spots appeared and when the child was sixty it must be remembered that gastric cancer pre- hours old copious bleeding began from the base of the sents a picture in its early stages which is definite, cord at the navel. At this same time also is passed a and depends strictly upon its location. large, tarry stool made up of decomposed blood, it Two clinical types are to be distinguished vomited fresh blood, bled slightly from the nose and cancer and cancer of the lesser curvature.— from a minute scratch on and several pyloric the scrotum, to the old view cancer is as common in more on the The tem- Contrary ecchymoses appeared body. the latter as in the former and its char- was 101°. The child now a des- situation, perature presented acteristic demands perate appearance, and the outlook was of the very symptomatology recognition. worst. The symptoms of pyloric cancer also vary Nitrate of silver in the solid stick was applied to the according to the mode of origin, whether it forms bleeding points at the navel, and styptic iron was also on the base of a simple ulcer or is primary. The used. Both had only a temporary effect, and the carcinomatous ulcer is accompanied frequently blood soon poured out again through the black clots. from beginning to end with hyperacidity, con- Continuous pressure with the thumb alone served to tinuous or Late if the A of alimentary hypersécrétion. stop bleeding. heaping teaspoonful gelatin ever is there diminution in the Motor dissolved in an ounce and a half of was then acidity. water while lactic acid to the infant from a bottle, and was taken, insufficiency develops early, given eagerly late if at all. Pain is as a rule and a 1 to 1,000 solution of adrenalin was to appears severe, applied in the navel. Pressure with the thumb was kept up from and it is this form of cancer that hemorrhage time to time. The same amount of gelatin was given is most frequently profuse. twice more at intervals of two hours. The bleeding The primary pyloric cancer, on the other hand, at the navel ceased after two hours, no more ecchymotic often presents but slight motor insufficiency at spots appeared, the bleeding from the nose and from the start, but this seldom wholly fails. Free the stomach did not recur, and at the end of twelve acid falls and after several a movement of normal hydrochloric slowly gradually hours, tarry stools, as is shown by weekly tests. A relative acid color was passed. The temperature at this time had which Gluzinski fallen to 99.6° and after this became normal. insufficiency is present, showed Recovery was an cancer. was and the career of the important sign of beginning He uninterrupted subsequent " infant has been normal. demonstrated this by testing the stomach fast- ing "; again, after an albumin test breakfast (two Hemorrhagic disease of the newborn is generally hard boiled, finely divided eggs and 100-200 cc. admitted to be an infectious, self-limited disease, water); and third, after a test midday meal, all tending to death or recovery in a few days, and given on the same day. If hydrochloric acid was generally, as in this case, accompanied with fever. absent one or more times it was suggestive. Where the hemorrhages are so profuse and occur Tabora considers this test most helpful. The from so many different tissues the outlook is test is less valuable for the ulcer type of cancer, generally bad. How much of the good result because there hypersécrétion is often present. can be attributed to the gelatin, it is impossible The positive result of the test, therefore, speaks to say, but the prompt recovery after its use is for cancer, but the negative is not against cancer. certainly suggestive. The benefit from the local Slowness of secretion of hydrochloric acid is often use of adrenalin is also worth noting. manifest, and constitutes another peculiarity of gastric cancer, though not of so much value as the relative insufficiency of Gluzinski. The acid Medical progress. may form during the night, and so be found in the fasting stomach, and yet be absent even for PROGRESS IN GASTRO-INTESTINAL DISEASES. one or two hours after a test meal. On account BY ELLIOTT P. JOSLIN, M.D., BOSTON. of the motor insufficiency and disturbed secre- tion lactic acid is formed. Hemorrhages are THE pathology of gastric cancer. frequent, but less profuse than in carcinomatous Tabora ' reviews the cases of gastric cancer in ulcer and of the coffee ground variety. Pain is. the late Professor Riegel's Clinic at Giessen in an less severe, a palpable tumor fails generally at instructive manner. We recommend those es- the start, which is the opposite of carcinomatous pecially interested in this subject to read the entire ulcer, in which a clear resistance in the pyloric article. His opinions are based on a study of region is more common. This is due to the infil- 212 cases treated in the hospital during the last trated margin of the ulcer, the adhesions and five years, and of some others seen transitorily. pyloric spasm. In both forms of pyloric cancer These cases came under observation as a rule at early loss of weight occurs on account of the an unusually early stage on account of the in- early disturbance of motility, but cachexia may fluence of Riegel. fail, especially in carcinomatous ulcer. 1 Deut. Med. Woch., 1905, p. 576. Though it may be impossible to differentiate

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A positive history of This explains why cancer may develop not only ulcer is of value, but a negative history is not, at the pylorus, but also in the prepyloric portion. because it is so common for ulcer at the pylorus The case is different in the aehylic stomach. In to be latent. The similarity of the symptoms it the pylorus is an open door and the food is in ulcer and carcinomatous ulcer at the pylorus known to leave the stomach more quickly than is due to the similarity of the histological structure normal. The pylorus remains little disturbed, of the pylorus in the two conditions. (Boekelman.) but the lesser curvature, which we now know to The hydrochloric acid secreting cells are increased be almost perpendicular in the erect position, is in both conditions. In a primary pyloric cancer subject to continued irritation, and on account they are as a rule diminished. of its rich blood supply offers a good field for the Cancer of the lesser curvature of the stomach development of cancer. In a normal stomach, is most difficult to diagnose. In the majority of to be sure, the lesser curvature suffers as much, instances it is primary, accompanied with achylia but the pyloric portion suffers still more. The from the start and the motility is intact. By the place of predilection in the aehylic stomach is progress of the growth the stomach may become therefore the lesser curvature, in the normal rigid, and peristalsis be lost though tonic con- stomach the pylorus. Achylia in cancer of the traction of the stomach remains possible. Finally, lesser curvature is not a result of the cancer, and motor insufficiency may supervene, but with it so this symptom in these cases loses much of its the almost paradoxical condition of pyloric importance. insufficiency due to the rigid pyloric ring. This Lactic acid depends on hyperacidity and stasis is demonstrated by distention of the stomach simultaneously. It is most common in the sec- with air. Lactic acid formation is more frequent ondary anacidity of pyloric cancer, but also than in pyloric cancer, but is by no means an met with in cancer of the lesser curvature. This early symptom. A tumor is only to be felt where is because in the latter instance a slight stagna- the lesser curvature is low enough to permit tion can take place in the folds and recesses of palpation. Hemorrhages occur early and in the cancer. It is only of value when present; it small quantity. The subjective symptoms are is not an early symptom; it is not pathognomic. mild. Pain is rare. Pressure and nausea are Tabora mentions two cases of simple achylia in for a long time the only complaints of the patient, which it was present, but in these cases 40 cm., 60 and are no more severe than met with in many cm., 80 cm. were present one hour after a test forms of chronic gastritis and nervous dyspepsia. breakfast, just as one would expect in a healthy Loss of weight is slight, and cachexia waits for it. secreting stomach, but a condition which is sel- Tabora has known such cases to live even three dom found in achylia. or four years after the diagnosis was made. Coffee ground vomitus or washings do not The explanation of the disturbance in secretion always mean the.presence of blood. Therefore in gastric cancer is based on two theories, a patho- always control macroscopic with other blood logic-anatomical and a chemical. The first tests. Blood clots are: (1) Large, clumpy and attributes the achylia to a mucous gastritis; by in balls, black, red, size of pin to cherry. (2) the chemical theory the hydrochloric acid is Brownish color and striped appearance. (3) secreted, but unites with the cancer or the prod- Very small, less than head of pin of intense black ucts of the cancer. Tabora considers both color, seen with difficulty, and their character responsible for the absence of hydrochloric acid. recognized only under the microscope. In cancer of the lesser curvature neither theory These tiny clots are never found in simple would apply, for often this develops when gas- achylia, because they would not have time to tritis can be excluded and ulcération of the growth form. This last type is the earliest sign of cancer fails. In such instances the cancer appears to of the lesser curvature, especially if in combina- have developed in the course of an achylia gás- tion with the lactic acid bacillus, even if no lactic trica, and there is no reason why this should acid is present, because this shows stagnation in not take place because achylia is so common. some portion of the stomach must have taken It is not improbable, however, that the achylia place that is presumably in the cancer. predisposes to cancer since the achylia is an ex- It is—commonly considered that cancer produces pression of a weak stomach, constitutional or a progressive loss in weight. In Tabora's expe- acquired, and it is a common observation that rience this applies in general only to those forms the mucous membrane in achylia gástrica is vul- with motor insufficiency. The typical cancer nerable. But why should the lesser curvature of the lesser curvature in the early stages causes be especially disposed to cancer in achylia? no notable loss of weight; months, even years According to the mechanical theory of the origin passing without harm to the general nutrition. of cancer, those parts of the body which are most It frequently happens that in the early, middle exposed to injury by their position, arrangement and sometimes even in the advanced stages, by

The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at MCGILL UNIVERSITY LIBRARY on June 28, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. forced diet a gain in weight is produced. The for free hydrochloric acid is negative, as a rule variation in weight, therefore, should not have gastro-enterostomy to offset the motor insuffi- too much influence in the diagnosis of cancer. ciency is alone possible. Bear in mind that in the early stages of ulcer If there is neither free hydrochloric acid nor and cancer of the pylorus, no definite diagnostic motor insufficiency, and the lesser curvature is signs are known between ulcer and cancer, and it in the normal position, then any surgical inter- is well to consider the possibility early of cancer. ference is hopeless and purposeless. In primary cancer of tne pylorus the diagnosis A general indication for surgical interference is more easily reached in the early stages. Such sometimes occurs without reference to the above a cancer offers the best chance for a real radical criteria, when very severe pain makes the life of removal. But even when in doubt as to the the patient so unendurable that by operation presence of carcinomatous ulcer of the pylorus, there is nothing to lose, and yet possibly some- operation is desirable because of the dangers thing to gain. from cicatrices and due to profuse hemorrhages LIVER. the ulcer, even apart from the ever-present pre- CIRRHOSIS OF THE disposition to the development of cancer upon Professor Naunyn2 recently contributed a paper the ulcer. Where resection is not possible, gastro- on Cirrhosis of the Liver at the meeting of the enterostomy, in Tabora's experience, notably German Pathological Association in Breslau. slows the growth of the cancer. Cirrhosis of the liver occurs in such varied forms The conditions are far more unfavorable in that it is often difficult to recognize any similarity cancer of the lesser curvature. An early diag- between the different varieties. Contrast the nosis is not possible, since the earliest signs and patient with atrophie cirrhosis who presents only symptoms only occur when the disease is well a latent ascites without jaundice, with liver and advanced. On account of the situation of the spleen recognized only with difficulty, or normal, cancer, its removal scarcely ever succeeds, though with the picture of a typical biliary hypertrophie the conditions are somewhat more favorable when cirrhosis showing bronzed jaundice, giant liver a gastroptosis is co-existent. Gastro-enterostomy and spleen, and yet no ascites. It is a compli- is not indicated because motor insufficiency is ment to the clinicians that they have trusted absent. Therefore a cancer of the lesser curva- pathology and believed in the unity of these ture presents little that is hopeful for the surgeon. various processes. In Krönlein's clinic of 264 cases of cancer an Much help was expected from functional diag- exploratory laparotomy was undertaken in 197. nosis in the study of hepatic disease, but thus In only 50 of these cases was the removal of the far levulosuria remains the only reliable test. tumor attempted. Of this number 14 died from Moreover, it is possible that the collateral circu- the operation, and the remaining 36, that is one lation in cirrhosis is accountable for the levulo- sixth of all the cases operated upon, lived on an suria, because in this way a portion of the lévulose average fourteen months longer than the 67 in when absorbed reaches the general circulation whom any attempt at operation was given up on without passing through the liver. account of their poor condition. Patients in whom The symptoms of cirrhosis of the liver are few, the cancer is situated favorably can live for years, namely, changes in the size of liver and spleen, and it is a question whether one has a right to as manifested by palpation and percussion, as- speak of an actual prolongation of life in the cites, digestive disturbances and jaundice. These above 36 instances. symptoms vary in intensity as do symptoms in The possibility of radical removal at the most any disease, but it is characteristic of cirrhosis is not above 1%, and the operative mortality that one or the other stands out prominently reaches the same height. Besides, there is the to the occlusion of all others. Naunyn classifies psychical moment. To persuade patients to be cirrhosis in four groups: operated upon who have unimportant complaints, (1) Incipient Cirrhosis of the liver; (2) com- one must direct their attention to the possibility mon ascitic cirrhosis; (3) biliary cirrhosis; (4) of cancer. When, as is the rule in such instances, hypersplenic cirrhosis. the exploratory laparotomy is resultless, and the Incipient cirrhosis is a necessary form clini- old complaints return, it is no longer possible cally. It comprises many alcoholic cases with to divert the patient's mind from the certainty gastro-intestinal dyspepsia, subjective sensitive- of the hopelessness of their disease. Further- ness of the liver, and a liver little or not at all en- more, the knowledge of the recurrence of cancer larged, often felt only at the end of repeated is widespread among the laity. Tabora has seen examinations, of hard consistency, and not tender more than one case which has lived months and like the congested liver. The spleen may be even years after an operation which accomplished enlarged by percussion. It is often felt only nothing, but brought the patient severe mental after many vain efforts. Jaundice is seldom suffering. marked, is usually absent, and ascites is either If free hydrochloric acid is shown with Congo absent or doubtful. Such cases explain Leich- paper in a patient suspected with cancer, and tenstern's precirrhotic splenic tumor. One should there is motor insufficiency, radical removal of the not assume that the spleen is affected first, because cancer is still possible, at any rate gastro-enter- on repeated efforts the liver can usually be felt ostomy is indicated. and is then characteristically hard. Even if the If with motor insufficiency the Congo reaction 2Verhand. d. Deut. Pathol. Gesell., September, 1904.

The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at MCGILL UNIVERSITY LIBRARY on June 28, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. liver is not felt, it only shows that it is not en- hypertrophie cirrhosis. Ascites appears in some larged, but not that it is healthy. cases just at the end. Hemorrhagic diathesis Naunyn thinks the terms ascitic and biliary is frequent. Jaundice is absent or extremely perfectly characteristic for the next two forms slight. The blood shows anemia. In some of cirrhosis. In 160 clinically observed cases of cases there is hypo- in others hyper-leucocytosis. cirrhosis there were 34 (21%) with marked Naunyn would restrict Banti's disease to those ascites (over 3 liters). In these 34 cases there cases of splenic anemia in which ascites appears was but one with marked jaundice, while among later. The ascites in these cases is not due to the whole number of 160 cases there were 13 the cirrhosis of the liver which may be present, with marked jaundice. Just as ascites and since this is not a pure cirrhosis, but rather a jaundice exclude one another, so, too, marked freshly formed lymphomatous growth in Glisson's enlargement of the liver and jaundice go together. capsule and in the acini, similar to that which In 160 cases there were 21 with very large livers, occurs in pseudoleukemia. He finds no evidence and marked jaundice was present in 12 of these. that pure cirrhosis develops in such a liver. There Conversely, an enlarged liver was present in 12 are no characteristic blood changes in Banti's out of 13 cases with marked jaundice. disease. The diminution of white corpuscles Though the clinical pictures of the two forms occurs in the plain ascitic form of cirrhosis just are different, this is no reason to consider the as well as in Banti's disease and the pseudo two diseases distinct. The same cause underlies Banti's cirrhosis. A way to differentiate the all the different forms. Further between the real Banti's disease from the pseudo Banti's typical cases one constantly meets transition cirrhosis is the toxemic destruction of albumin, stages. It is only necessary to refer to those rare which ceases as soon as the spleen is removed. cases in which there is a diminution in the size Such toxic albuminous destruction is only found of what was at first a large liver, and also to the in Banti's disease. The cases of splenic extir- many cases of mild jaundice and mild ascites in pation which result favorably are always cases livers more or less atrophie or hypertrophie. of Banti's disease. These transition stages are met with still more How can one reconcile the differences in the clin- in the hypersplenic type of cirrhosis.. Atrophie ical picture of all these different forms of hepatic and biliary hypertrophie cirrhosis may have the disease? In great part they can be referred symptoms which make up the clinical picture back to an accompanying cirrhotic cholangitis. of Banti's disease. Marked anemia and tendency It is not uncommon in the course of cirrhosis to hemorrhage are not uncommon in cirrhosis, for attacks to occur which simulate gallstone but they may occur with all forms, and Naunyn attacks. These are characterized by sudden, does not consider them characteristic of the hyper- severe pains in the liver region, which stretch splenic type. out over the abdomen to the back, and may be The spleen is quite constantly enlarged in cir- accompanied by biliary vomiting and fever. rhosis, and it is seldom that it is not felt. In The liver becomes sensitive to pressure, very 66 out of Naunyn's 160 cases it was plainly sensitive, begins to swell in the attack, and palpable, and was considered enlarged in 125. afterwards diminishes in size. Jaundice may Since the spleen is often found enlarged at autopsy appear or become deeper, to disappear again after when it has not been found enlarged during life- the attack. These attacks may be so similar to time, it is probably safe to consider it enlarged gallstone colic that they are diagnosed as chole- in 60% of the cases. It is not as commonly felt lithiasis, but they have to do with chole- in nothing the biliary hypertrophie form as in the ascitic lithiasis. Naunyn refers to three cases of cir- form. Naunyn considers the spleen extra large rhosis in which these typical attacks appeared, (hypersplenia) when its longitudinal diameter and in which the autopsy excluded gallstones. reaches 20 cm. or more. Such spleens are found The study of gallstones has taught that attacks more commonly in the biliary hypertrophie type like the above are the expression of an infectious than in the ascitic. It is said to be characteristic inflammation of the gall passages. One should of Banti's disease that the spleen is very large, speak clinically of a cirrhotic cholangitis just as but such giant spleens (30 cm. or over) Naunyn of a caiculous cholangitis. That in cirrhosis the has met with in 8 cases of atrophie cirrhosis, and gall passages are disposed to infectious disease not one of these cases belonged in Banti's group. is as obvious as it is probable that in cirrhosis In one instance the spleen was 39 cm. in diameter. the activity of the bile flow suffers. Numerous Perhaps the age of the patient has something to clinical and experimental investigations have do with the size of the spleen, since large spleens shown that any disturbance of the bile stream are more common in young people. favors the appearance of an infection in the gall Naunyn does not accept Banti's views. The passages. Various writers have associated cir- pure case of cirrhosis with hypersplenia Naunyn rhotic livers with purulent and ulcerativo cholan- would call hypersplenic cirrhosis or pseudo gitis. Naunyn has seen one such case, and in Banti's cirrhosis. These cases are characterized his opinion these are much more common than by an early appearance of a very marked anemia. has been thought. Cholangitis occurs without The deciding sign is the giant spleen 20 cm. to 30 serious atomical changes in the biliary passages. cm. in length. As a rule in the cases observed This is easily produced in animals by ligaturing by Naunyn the liver was also large, and its ana- the ductus choledochus, and injecting virulent tomical condition similar to that of atrophie or colon bacilli into the gall bladder. The animal

The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at MCGILL UNIVERSITY LIBRARY on June 28, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. dies within two days with all the symptoms of a The form of alcohol is not essential, and brandy is virulent infection, and yet one finds nothing but by no means necessary for a satisfactory etiology. an enormous and highly virulent quantity of Several cases seem to work together, alcohol colon bacilli in the bile. The bile passages show and syphilis. — nothing more than the desquamation of epithe- How does the alcohol act? Directly on the lium and slight hemorrhages, changes which are liver, or by way of the blood? Naunyn thinks easily overlooked at autopsy. Nevertheless, this the liver the seat of the trouble. One can speak is an infectious cholangitis, and it should always of gastro-intestinal cirrhosis since the substances be spoken of as such when large quantities of which harm the liver originate in the intestine. pathogenic microbes are found during life, or Naunyn does not believe in a specific hemato- directly after death, in the bile. From the clinical genous cirrhosis, but thinks that the substances point of view Naunyn believes that cirrhotic in the intestines act upon the liver by the way cholangitis is a frequent and important compli- of the blood. This seems proven because alcohol cation of cirrhosis, and cites as proof first the injected subcutaneously has the same action on attacks simulating gallstone colic, and second the liver as when taken by the mouth. Mertens the presence of fever in cirrhosis of the liver. has produced cirrhosis in rabbits in this way. Carrington found this in 40% of 44 cases, and Hemochromatosis is important in this connection, Naunyn in 20% of 33 cases. The fever is not because Kretz has recently found that hemo- high, though it occasionally reaches 104° for chromatosis never fails in cirrhotic livers. The periods of a week. It is often unaccompanied by view of Kretz appears well founded, namely, that discomfort. In the third place the jaundice in the alcohol causes disease of the red blood cor- cirrhosis suggests an accompanying cholangitis. puscles; these red blood corpuscles then collect It is present in one half of the cases, if those in in the liver, and are there destroyed, and lead to which it is very slight are included. Its similar- disease of the liver. A sort of hemolysis takes ity is very great to the jaundice of gallstones, place. Brauer's experiments agree with this which is due, as a rule, to an accompanying view. Brauer produced albuminocholia and a cholangitis. The fact that fever is more common desquamative cholangitis by acute alcoholic in the severe jaundice cases speaks for the cho- intoxication of animals. It is possible that this langitic nature of the jaundice. Finally, Naunyn alcoholic cholangiolitis comes through alcoholic believes that the complicating cholangitis is hemolysis. This would be an example of hema- closely related to the enlarging of the liver in togenous descending cholangitis which could be the hypertrophie form. Jaundice is more com- considered as a cause of cirrhosis, in opposition mon in this form, and when jaundice appears to the other and ordinary form of cholangitis, the liver swells. which is of an ascending type. The cholangitis above mentioned is a compli- (To be continued.) cation of cirrhosis, not its cause. If cholangitis produced cirrhosis then cirrhosis would much more commonly accompany gallstones. Naunyn Reports of Societies. has never seen a definite case of this kind. It is sometimes mentioned authors who favor by the BOSTON MEDICAL LIBRARY IN CONJUNCTION view that is the cause of cholangitis cirrhosis, WITH THE SUFFOLK DISTRICT BRANCH OF that is before the cirrhosis ap- jaundice present THE MASSACHUSETTS MEDICAL SOCIETY. pears. This in fact did occur in 15 of Naunyn's cases, and in fact two years before the cirrhosis Meeting of March 8, 1905. was the course of cirrhosis diagnosed. However, Dr. John H. McCollom read a paper on is usually very chronic, and it is difficult to say that cirrhosis was not present when the jaundice THE EXPERIENCE OF NINE YEARS IN THE TREAT- appeared. Furthermore, jaundice is not a pre- MENT OF DIPHTHERIA WITH ANTITOXIN. cursor of biliary cirrhosis more frequently than of ascitic cirrhosis. Jaundice appeared first in DISCUSSION. one of his 13 cases of cirrhosis. Dr. David W. Cheever: I am probably the only only biliary in The cause of cirrhosis first of all is alcohol. person this hall who was a pupil of Dr. John Ware, now fifty years ago. Of Naunyn's 135 male cases, 83 were steady " " The term "membranous which formed, the and 18 soakers 35 women croup drinkers, steady "; title of his essay, alluded to, was then the term were constant only drinkers. When one considers in use. The name came in later. truth diphtheria how frequently, especially with women, the I remember at our then medical society a cast of is concealed, these facts are striking. Syphilis the trachea and bronchi, made up of false membrane, was present in 19 cases. Typhoid was noted in being exhibited from the autopsy of an unfortunate 13 cases, only 4 of these being drinkers. Malaria young physician who died of membranous croup, was present in 8 cases, and of these 5 were drink- while on a hunting expedition in the woods. Remedies were ers. Six of the 35 women had 7 to 14 children. then calomel, antimony, sulphate of to loosen the membrane and to it No form of cirrhosis has a peculiar etiology. zinc, expel by Alcohol one as much as it does the other. vomiting. precedes I remember sitting all night by a child with mem- Of 13 cases of biliary cirrhosis 8 were drinkers, branous who " croup, slowly strangled before my eyes, and of these 4 soakers." Naunyn cannot like the tightening of the Turkish bowstring. explain his biliary forms by infectious disease. Then came tracheotomy, and he was lucky who

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