Search

In Rapid Interpretation of Heart Sounds and Murmurs the emphasis is on clinical applicability of these signs in the diagnosis of heart disease. The current edition also contains two new sections on "dynamic cardiac auscultation"specific hemodynamic maneuvers to alter heart sounds and murmurs—and on their value in the evaluation and diagnosis of specific cardiac lesions. The text of the heart sound section in the fourth edition has been rewritten and expanded to include the tricuspid opening snap, diastolic "knocks," "tumor plop" sounds, and new illustrations. The heart murmur section has also been rewritten and expanded. For the various sections objectives, pretest questions and posttest questions (including answers) are provided. Drs Stein and Delman have greatly advanced understanding of the basic mechanisms and clinical applications of heart sounds and murmurs. Thomas Xenakis has provided readers with superb illustrations. The book and audiotapes will be invaluable to medical students and

Cochlear implants are auditory prostheses designed to stimulate electrically the remaining population of eighth-nerve neurons in the cochlea of profoundly deaf persons. 1 Surgical implantation of cochlear prostheses into the inner ear region of deaf patients has moved forward rapidly during the past two years, and, at present, about 500 patients have undergone this procedure. In the simplest terms, the external and implanted components function as a miniaturized transducer that converts sound into an electrical output that stimulates the auditory nerve. The signal is perceived centrally in the brain as a sound that varies with each environmental noise or spoken word. The device helps most adult patients, in that distinguishing environmental sounds and lip-reading ability are improved greatly. The role of cochlear prosthesis implantation in children is less well known and is controversial because of ethical considerations. The implantation procedure is not especially difficult, and the complication rate is low.

I read the comments of Dr Singer with great interest. Because of disunity of the patient's care among several institutions, no clotting studies were obtained. I cannot say, however, that the persistent bleeding was not related to puncture of the uterus with the sound in the presence of anticoagulants. Although surgery is performed frequently on patients receiving anticoagulant agents, bleeding points are ligated or electrocoagulated. In this instance, a uterine puncture that would have stopped bleeding spontaneously, as evidenced by common experience with punctures during routine curettages, did not stop bleeding for 72 hours, and the only outstanding factor was the administration of anticoagulant medication. Therefore, I believe that anticoagulation constitutes a relative contraindication for intrauterine-device insertion.

To the Editor.— Do you know of a snoring problem? Advise the use of a cervical collar at bedtime, the same kind that is used for treating a sprained neck. It works. Physiologically, the rationale is justifiable. The discordant notes of snoring are usually at the maximum when the sleeping perpetrator is lying on his back with the head sagging on the chest. This causes a bending of the trachea and a resulting compression of the respiratory tube. In this way, there is an obstruction to the ingress and egress of the breathed air. This, on the same principle by which the sound from a flute is explained, causes the harsh sounds emitted that we call snoring. The cervical collar will keep the chin elevated and so prevent the flexing of the trachea that causes the compression and results in the harsh emitted sound.

Brilliant illumination of obscure cardiac diagnoses by invading the heart with catheter and contrast materials may seem to cast into shadows the classical modes of inspection, palpation, percussion, and auscultation. Actually, however, from these shadows now comes a greater and more reliable diagnostic yield because the importance of the ordinary physical findings has been promptly and regularly verified by the invasive techniques. This yield has been further enhanced by instrumental recording of the pulsations, sound, and motions of the chest wall overlying the heart. For more than 40 years, Luisada has led investigations for making accurate permanent records of these otherwise fleeting phenomena and for correlating them with their physiologic and pathologic origins. The atlas shows the steady improvement from the rather primitive perspectives when Luisada first began to record the phenomena graphically. Luisada shows how filtration was developed to show selected parts of the broad vibratory spectrum emitted from

Despite the prevalence of prostate disease, the public knows little of its symptomatology, natural course, or current therapy. To counter this problem, The Prostate Book is written to inform the educated, inquisitive patient about his malady. In addition to factual details, the author also specifically addresses common patient fears and misconceptions. The description of urology as a science and an art emphasizes the various approaches of urologists to diagnose and treat prostate disease. The anatomy, diagnosis, and surgery of the prostate are discussed in some detail, although the text remains very readable for a college-educated layman. To assist the reader with technical terms, a glossary has been included. The photos and graphics are uncomplicated, pertinent, and clear. Especially well done is the use of the "apple" analogy when describing prostate anatomy and, later, prostate surgery. The occasional use of representative cases enables the patient to relate to the symptoms of

As the editors state at the beginning of this book, "this symposium has been developed with the express purpose of providing medical educators and students with a detailed physiologic understanding of the principles underlying the major cardiac acoustic events, whether normal or pathologic. The valid application of these principles will result in improved clinical recognition of abnormal function in the cardiovascular system." To this extent, the book succeeds admirably. The first 11 papers in this symposium deal with the origin of the various heart sounds, excluding murmurs, in normal and pathologic states. The data in these papers and in the other papers of this symposium were obtained by both noninvasive and invasive techniques. These first papers suggested that vibrations of the whole cardiohemic mass are caused by the sudden deceleration of moving columns of blood; these vibrations are perceived as sound. The next 14 papers deal with murmurs; innocent and

Surgical treatment of kidney stones is undergoing "very exciting" changes, according to Lynwood H. Smith, MD, professor of medicine at the Mayo Clinic in Rochester, Minn. Speaking at a National Kidney Foundation symposium in Washington, DC, Smith, a nephrologist, summarized recently reported results using two new procedures: percutaneous ultrasonic lithotripsy (PUL) and extracorporeal shock wave lithotripsy (ESWL). Both procedures are used only for stones that otherwise would have to be removed surgically. In PUL, a radiologist, using local anesthesia, first introduces a guide wire percutaneously through the flank into the kidney. The next day, using general anesthesia, dilators are placed over the guide wire. Once dilation is sufficient, a tube resembling a small cystoscope is inserted into the kidney's collecting system and up against the stone. An ultrasoundgenerating instrument developed by European urologists Peter Alkin, MD, and Michael Marberger, MD, is then passed through the tube and used to shatter

Dr. Luisada knows phonocardiography as a woodsman knows a path he has traced and retraced. His book continues to blaze a trail for the less experienced students of phonocardiography and presents the results of a lifetime of devotion to clinical and laboratory phonocardiographic investigations. This second volume of Dr. Luisada's comprehensive work on auscultation and phonocardiography consists of three parts: part 1 (Systematic Phonocardiography) discusses the abnormal heart sounds and their changes in different clinical situations; part 2 (Clinical Phonocardiography) describes the alterations of sounds and murmurs in various conditions; part 3 (Borderline Conditions) discusses phonocardiographic findings in the straight-back syndrome, the senile heart, the heart in pregnant women, the functional and innocent systolic and diastolic murmurs, unusual sound phenomena, and sounds caused by prosthetic valves or a pacemaker. Particularly noteworthy are the extensive bibliography and profuse, well-reproduced illustrations. On the debit side is the perpetuation of typographical errors that

Simply to read about heart sounds and try to form a mental image of sound from a verbal description is, for the novice, a frustrating experience. Phonocardiograms help, particularly to portray matters of timing. But nothing can match persevering bedside experience with a capable, articulate, and patient teacher. For the person who wishes to study cardiac auscultation on his own, Segal and Likoff have prepared a concise guide. Their text is coordinated with recordings available in high-fidelity 33 1/3 rpm longplaying discs and also on tapes at 3 3/4 and 7 1/2 inches per second. The authors concern themselves with more than merely heart sounds and murmurs, for examination of the precordium, the venous and the arterial pulses are also covered. The authors examine current theories of the genesis and transmission of heart sounds and murmurs in the light of evidence culled from a sound bibliography, and they adduce additional

Though strictures of the urethra are frequent, particularly among our seamen, a report of the case herewith submitted presents unusual complications which may be of interest to those especially interested in genito-urinary surgery.The subject of this report was admitted to the U. S. Marine Hospital, Chicago, June 19, 1898. He is a white, aged 52, a native of Wisconsin; occupation, marine engineer. Family history is good and his general health has always been excellent, barring the present lesion. He states that he has had a stricture of the urethra for 23 years, that internal urethrotomy was performed in 1893, after which he passed a sound himself occasionally, also that he made a false passage while passing a sound four days previous to admission.When admitted there was a small opening, about 2 cm. in diameter, which was gangrenous, at the middle portion of the scrotum, through which urine escaped

The ease with which the base of the female bladder can be transilluminated prompts me to call attention to the method. With an electrically lighted cystoscope in the fluid filled bladder, the perineum is retracted with a Sims speculum, and the room is darkened. The lamp is carried close to the base of the bladder, and therefore an instrument of the "convex" type is preferable; but if one also wishes to palpate the structures between the beak of the cystoscope, using it as a sound, and a finger in the vagina, then the "concave" cystoscope should be selected. The procedure has occasionally been found helpful: ( a ) in orientation, for example, by easily locating on one side of the septum a point readily visible on the other side, such as the orifice of a small vesicovaginal fistula; and ( b ) in seeing the relative thickness of the intervening tissues, for example, in

A man, aged 34, came into my office, July 31, with a handkerchief held over his left ear. The handkerchief was stained with blood, which was coming from the ear. The patient gave a history of bleeding from the ear since the previous Saturday, and complained of a hissing sound in his ear. He also stated that he had had a discharge of pus from his ear on and off for seven years. He saw his physician about his present condition the day before, who irrigated the ear, but as the bleeding continued as well as the hissing, he was referred to me. The external canal was filled with fresh as well as coagulated blood. When the canal was wiped out, the classical pearly white water fall was seen coming from the lower half of the ear drum. At first glance this looked like pus; a swab, after touching it

Bagley, Iowa, March 4, 1902. To the Editor: —An aid in the diagnosis of irritable or irritated urethral mucous membrane and in the so-called uricacidemics, especially in those where there is great benefit derived from a few passages of the cold steel sound, is what may be called the "umbilico-urethral reflex." The elicitation of this is an easy matter in lean individuals, but in fat persons, difficult, yet practicable. The manner of performance is a movement from above downward of the nail of the forefinger over the exact center of the umbilicus—"a scratching"—and done not quickly or lightly. This causes the above characterized patients to complain of a sharp, shooting, cutting pain, sometimes of momentary persistence followed by a desire to urinate—from the neck of the bladder to the meatus urethrae. I will not attempt to explain the observation, but believe it due to the complex innervation of the fetal

The Bangs sound syringe is practically a combination of sound and syringe. It consists of a series of sounds through the center of which is bored a small tunnel, just large enough to hold about 20 minims. The end is so constructed that the universal syringe can be applied to any of the sounds. The instrument would be ideal were it not for the fact that the syringe has the old fashioned leather packing, which must be renewed every few months. To avoid this, I have devised an adapter which fits into any of the sounds, but the other end of which is so shaped as to fit into any size Luer all glass syringe. With this adapter it is possible to use the Bangs sound with a Luer syringe. It would be well if in future the end of the sounds would be shaped like the adapter here presented

A patient whom I have been treating for stricture of the urethra, and in whom I have passed sounds for several months, came to my office in his usual good spirits, and in perfect health. After passing a No. 27 French sound, there was some little bleeding from the urethra, which I attempted to check with a solution of adrenalin chlorid, 1-4000, injected in the urethra with an ordinary glass syringe, filling the entire anterior urethra. The following symptoms occurred instantaneously: Lividity or pale lead color of the skin; the eyes set and glassy, the patient crying out, complaining of a bursting sensation in his abdomen, chest, neck and head, saying the top of his head would burst open; a tingling and pressure in hands, arms, legs and feet; vomiting of a projectile character, followed by complete collapse, without loss of consciousness, lasting for a period of ten minutes; respiration

To the Editor:— In the Dec 6 issue ( 194 :1159, 1965), Dr. Mason provides excellent recommendations on the management of a case in which a piece of 25-gauge, 5/8-inch needle had become lodged in the triceps. May I discuss another technique for localizing foreign bodies in soft tissue, which has proved useful in similar situations. Diagnostic ultrasonic equipment can localize imbedded foreign objects in three planes. A search probe is placed over the general site of the foreign body. The probe transmits a painless, harmless inaudible sound beam into the tissue and receives echoes from any subsurface interface that is not homogeneous with surrounding tissue. Reflected sound is picked up by the probe, amplified, and fed to a display screen. When the foreign-body echo appears on the screen, the examiner knows that the object is directly beneath and in line with the probe. Moreover, since the display is calibrated in

The roentgenographic examination of certain hollow organs of the body, by means of material opaque to the roentgen rays, is now an everyday procedure. The employment of the contrast mediums, barium in the gastro-intestinal tract, bromides and iodides in the urinary tract, has put roentgen-ray diagnosis of these parts of the body on a sound basis. More recently, with the aid of iodized oil, it has been found possible to make radiographic studies of the bronchial tubes, and also of the uterus and fallopian tubes. According to Forestier, Portiet of France, in 1923, was the first one to inject iodized oil into the uterine cavity for the purpose of roentgen-ray study. Probably the first published article relating to the subject was by Ferre, 1 in October, 1925, when he reported six cases of uterine fibroma, diagnosed by the roentgen-ray. Heuser 2 of Argentina was the first to employ this method

To the Editor: —Instead of plugging the ear-piece of the stethoscope with wax or cotton, a three-way valve, such as is used for bladder irrigation, is connected with the tubing leading to the ear-pieces and the chest-piece. This enables the examiner to switch the sound into either ear, or to exclude it altogether without removing the stethoscope from the registrant's ears and without his knowledge of what is being done. Some of the registrants have been coached, and naturally assume, if the apparatus is removed from the ears and then replaced, that it has been changed, and govern their replies accordingly. With this appliance, malingering can be readily detected, especially if it is used with the registrant's back toward the examiner. The small valve tip is connected with the bell, and it may be necessary to wind this with one or two turns of adhesive plaster to make it fit

The control of hemorrhage following the removal of a prostatic adenoma by either the perineal or the suprapubic approach is the anxious concern of every operator. The popularity of the hemostatic bags of either the Hagner or Pilcher model attests their effectiveness. The use of these bags is almost entirely confined to those who remove the prostatic obstruction suprapubically. The bladder is opened by median section, the adenoma removed by blunt dissection. A special sound with a Benique curve and a notched tip is then introduced through the urethra into the bladder and the bag threaded onto the tip of the sound. The rubber may or may not be held to the sound by means of a ligature. The sound is then slowly withdrawn through the urethra, pulling the bag down into the cavity left by the removal of the adenoma. The bag is inflated with fluid or air and

In the winter or spring of 1881 a Norwegian between 60 and 70 years of age, who had been in the habit of using a catheter in consequence of enlarged prostrate gland, was brought to my office, having broken the catheter in the prostatic portion of the urethra. I could not feel the catheter by external manipulation, but by passing a sound into the urethra, I discovered the end of the broken catheter in the position indicated. The catheter was what is known as a gum, or soft catheter, No. 7. Not having seen or known of such an occurrence, I confess I was at a loss as to what course to pursue. There was danger of pushing the fragment into the bladder, and I possessed no instrument constructed to meet such an emergency. It is said “necessity is the mother of invention,” and calling upon my inventive powers, I

This operation resembles the Whitehead inasmuch as in each operation a pile-bearing ring of mucous membrane is removed, but the method employed is so radically different from the Whitehead or any of its modifications that I have preferred not to call it by that name. Eight pairs of curved hemostats and the same number of straight hemostats are required. The rectum is well dilated. Eight deep mattress sutures are placed well beyond the hemorrhoidal mass into sound mucous membrane at points corresponding to 12, 3, 6 and 9 o'clock and half-way between each of these—eight in all. Chromic gut is used. Straight hemostats are attached to ends of sutures left long. Well out on the mucocutaneous junction place corresponding mattress sutures—eight in all—and attach curved hemostats to ends of sutures left long. Hemorrhoids are now between rows of sutures. Cut mucous membrane circularly around the internal row of sutures, avoiding

Accidental perforations of the walls of the uterus by instruments in gynecologic practice and in efforts to produce abortion are probably more frequent than the reports of cases would appear to show. The circumstances under which these accidents occur are generally such as would lead them to be passed over and the results which sometimes follow are often no doubt assigned to other causes. Dr. Brothers of New York has been able to collect sixty-six recorded cases of accidental perforations of the uterus, of which seventeen died and forty-nine recovered. The use of the sound and the curette in gynecologic practice is probably the most frequent cause of this accident in legitimate practice. The facility with which the sound can be used in exploring the interior of the uterus and in repositing a retrodisplaced organ is no doubt responsible for some of these accidents. There are no means by which

There are five ways of curing stricture of the urethra, viz.: bydivulsion, external urethrotomy, internal or dilating urethrotomy, simple dilatation, and electrolysis. The first named is dangerous, inexact, rude and unsurgical, and is now practically relegated to the dark ages in the history of urethral surgery. External urethrotomy is associated with more or less danger, but it is an operation that has to be resorted to in many cases. Dilating urethrotomy has many ardent advocates, and while much can be said in its favor much can be said against it. In this article, however, I propose to speak principally of the method by dilatation and that of electrolysis, calling attention to the plan I have adopted in dilating with my gleet olives. I have been in the habit for some years of using Van Buren's steel sound, and it always impressed me that there was a good deal more pain

Anteflexion of the uterus may not infrequently be regarded as a symptom of an undeveloped condition of the genitalia. The state is, no doubt, in many cases, congenital in its manifestation, or is early superinduced by exposure of the subject to faulty hygienic surroundings. Improper modes of dressing during the years of childhood and before puberty have been ascribed as an important factor entering into its causation, but it is often difficult to appreciate how the normal intra-abdominal pressure can be so modified as to cause, to any great extent, before the vulvovaginal introitus has been affected by the influences of parturient processes, displacement of so small an organ as the uterus, which, for the most part scarcely measures by the sound two and one-half inches in depth. The uterus, including its cervix, sustained in its proper position by the uterosacral ligaments, with the axis of the corpus assuming with

To the Editor: —The interesting case reported in No. 8 ofThe Journalby Dr. McShane, of Carmel, Ind., recalls to mind a case I had a few years since. A lady, aged 24 years, consulted me to ascertain why she could not have children. She had been married six years, was well developed, not masculine; breasts were normal, the pudendum normal, and well covered with hair. I found by digital examination a good-sized vagina, but no cervix uteri; in fact, there was nothing but a smooth, well arched vagina, about 4 inches in depth. I introduced a sound into the bladder, and with my finger in the rectum I could readily feel the sound, showing that there was complete absence of the uterus. Having been a member of the Association for several years, I think it best to let well enough alone and publishThe Journalat Chicago. Oneida

To the Editor:— The extracardiac origin of chest sounds synchronous with heart beat is well established. Most of the reported cases have had supradiaphragmatic pathologic conditions, ie, mediastinal emphysema, pneumothorax, lung interstitial emphysema, pneumopericardium, air embolism, and hiatus hernia.1Recently we examined a patient with an unusual chest sound, which was easily heard several feet away from the patient, in whom the gas bubble in splenic flexure seemed to be the cause. Report of a Case:— The patient was 10 years old, and she had been referred because of a murmur discovered four months previously during the course of an apparently insignificant gastrointestinal tract illness. However, for approximately nine months the patient had been aware of a phenomenon which she described quite simply: "I beep." The parents also had noted the sound and described it as "like a radio signal." It could be heard from a distance, occurred at

While performing a seminal vesiculectomy some time ago, it occurred to me that the operation could be greatly facilitated by the use of a tractor inserted into the bladder, through the urethra, which has the same curve as that of a sound. For this purpose I therefore designed the one shown in the accompanying illustration. It consists of two fenestrated blades attached to shafts, the inner one of which has a cable in the curved portion which allows one of the blades to revolve around the other. There are two handles at the outer end of the shaft which regulate the rotation of the blades after insertion into the bladder through the urethra. When inserted, the handles are rotated from each other to open the blades within the bladder. The gland is thus pulled into the operative field and at the same time the handle of the instrument is out

Recent experience with several cases of stricture of the urethra in which it was possible to pass only the smallest filiform reveals a meager armamentarium for handling such cases. With the exception of the LeFort filiform and steel follower together with the flexible urethral bougie and whalebone there are no instruments for handling cases in which it is impracticable to use the instruments mentioned. The presence of one or more areas of stenosis of the urethra at times precludes the use of a steel sound, so that it is very difficult to dilate the urethra from the size that admits a fliliform to a 16 or 18 French caliber. I have found that a ureteral bougie at times fills a long felt need for such an instrument whereby the urethra could be dilated up to a size sufficient to admit a steel instrument without the possibility of much trauma. In

Direct cystoscopy in men with air distention of the bladder is seldom employed in this country, if one may judge from the infrequent reference to such examinations in the urologic literature. This procedure, with the patient in the knee-chest posture, has been used with such definite advantage in four or five instances that a brief report of these cases seems warranted. Certainly, in the first case operation could hardly have been avoided by any other method. REPORT OF CASES Case 1. —A well developed young man was admitted to the University of Virginia Hospital on his statement that he had a nail in the bladder. About ten days prior to admission the nail had gotten away from him during urethral masturbation, and the resultant vesical irritation finally forced him to seek attention. Palpation along the urethra was negative. A sound elicited a metallic click in the bladder. Indirect cystoscopy revealed

To the Editor:— In this day of computer controlled management of the operative patient and computer interpretation of the electrocardiogram and electroencephalogram, some of the time proven methods of physical diagnosis are easily overlooked. In this communication, a simple modification of the stethoscope is described which under certain circumstances is superior to the standard version for auscultation of the chest. The stethoscope, as originally introduced by Laennec, was a single hollow tube that transmitted sound from a single point to one ear (monophonic, monaural). The only significant modification of this arrangement was to split the tube so that the sound from a single point is delivered to both ears (monophonic, binaural). The differentiation of transmitted vs diffusely originating sounds is frequently difficult with the standard stethoscope. The exact site of origin of cardiac murmurs is sometimes difficult to determine. These problems may be overcome by use of this modified stethoscope.

Normal speech requires breath from the lungs acting on the larynx and the organs of enunciation in the throat and mouth. When the larynx has been removed without cutting off the supply of breath from the lungs to the mouth, the speech is like that of a very faint whisper. When the air-passage is entirely closed between the lungs and mouth, speech ceases entirely. Although the person can make all the movements of enunciation, he has no means of producing any sound. Strangely enough, however, he can be taught to speak quite audibly in a new way. Several such cases have been reported, but I have recently had the opportunity to push the speech development much farther than anywhere reported by employing some of the finer principles of phonetics. The patient came to me three months after his larynx had been removed for carcinoma. The passage from the mouth to

Oct. 30, 1917, a man aged 31, entered the hospital complaining of great pain on urination, with pain over the bladder. The patient had been in this condition for over ten years, gradually getting worse. When he came to the hospital, he could not stand erect on account of the pain. The man was emaciated, and his face and body were covered with pit marks of old smallpox. A sound introduced into the urethra met at the neck of the bladder a solid, immovable body. This could be palpated 2 inches above the pubes. The urine showed an intense cystitis. An incision was made above the pubes almost to the urbilicus and the bladder, which was distended with boric acid solution and opened. A large irregular stone was disclosed which was found to be impacted. Efforts to dislodge it proved fruitless, and finally a hammer and chisel were used to

These spiral urethral dilators are made of steel that takes the finest polish and they are heavily nickel-plated and polished. They are made in sizes 16-24, 18-28, 20-32, 22-36, 24-40, 26-44, 28-44 and 30-46, and are 9¾ inches long. They are numbered so that the first numeral represents the approximate metallic circumference, the French scale being used for numbering sounds. The last numeral represents the approximate diameter of the outside spiral circumference. The 20-32 size has the actual metal as in a number 20 F standard sound, and the outside diameter of the spiral is about the size of a number 32 F sound. Spiral urethral dilators were designed for the purpose of milking and massaging infected follicles and lacunae of the urethra. The surprising ease of introduction into the urethra when strictures were present stimulated me to make

Philadelphia, April 16, 1906. To the Editor: —InThe Journal, April 14, 1906, appears a clinical note on the pulmonic sound in health and disease. There is suggested the undoubted, and often overlooked fact, that an evidently accentuated pulmonic sound in certain normal persons can be rendered normal by exercise, as the result of an equal distribution of the blood volume of the body, so to speak. Dr. Hardy concluded: "If this be true, it would seem that too much stress has been laid on this sign as an early indication of pulmonary tuberculosis, thus giving an opportunity, at least, for misleading conclusions." It is needless to say that a constant and pathologic increase in the intensity of the pulmonic sound is a valuable aid in the diagnosis of early pulmonary lesions, indicating as it does an overtension in the pulmonary circulation, almost, if not always, due to mechanical causes

I wish to report a case of double uterus. I first saw the patient one year ago, when called to determine whether she was pregnant or not. She had been married five years without becoming pregnant, but had not menstruated for five months and now thought she felt motion. She called me in because the tumor seemed to be all on the left side. On making a vaginal examination, I found the vagina divided by a septum, and at the upper end of each side of the vagina a cervix and uterine cavity. As the patient was certainly pregnant, I could not use a sound. She was pregnant on the left side. The finger passed naturally up the right side and was with difficulty passed on the left side. I asked her if she knew that she was different from other women and she said no, but on further questioning

In cases of ascites, when one side of the abdomen is tapped with the finger and the other side is auscultated, two sounds similar in timing to the normal heart sounds have been observed. The first sound is caused by the sound wave being transmitted through the fluid; the second is the result of the fluid wave crossing the abdomen and striking against the auscultated side. These two sounds are heard more clearly in thin, tense abdomens as opposed to flat, soft, flabby ones and are best heard at the level of the fluid and intestine, as demonstrated by an experiment with a closed rubber bag partially filled with air and water. There seems to be no reference to this auscultatory sign in cases of ascites in any of the standard textbooks on physical diagnosis. It is stated by several of the German writers that, when fluid is injected into

The forcible feeding of the insane through the nose with the stomach tube is frequently a most tedious operation, and in many instances becomes an impossibility, and resort is finally had to the use of the mouth-gag, so as to allow of the introduction of the tube through the mouth. As the passing of the tube through the nose, in most cases, is greatly to be preferred, the following is offered as a simple and efficient method whereby the tube may, in nearly if not quite all cases, be quickly and easily passed through the nasal cavity and into the pharynx. The instrument used is very similar in appearance to a small-sized urethral sound. It should be about six inches in length over all, and not more than one-eighth of an inch in diameter from the handle to the extremity, the curvature beginning about an inch and one-quarter from the

My purpose in this writing is to individualize this one and only ausculatory sign as the criterion of pulmonary health, its absence as the positive proof of either functional or organic disease, also suggestions as to the most successful method of restoration and its application to the treatment of pulmonary tuberculosis. In the auscultation of the normally acting healthy chest, two sounds are heard on inspiration, totally different in production, location and character. The first is the bronchial sound, caused by the friction of the inrushing tidal air, through the convective system of tubes, and is, in varying quality and pitch, always present in health and disease. It is first in regard to the time of its production in the inspiratory act, and, during the first eight to twelve years of life, is the only sound heard in health, the pulmonary system being as yet incomplete. The tidal air does

To the Editor:— The presence of an arteriovenous communication is usually obvious on physical examination. When the continuous murmur and palpable thrill of such a communication are noted, the diagnosis is easily made. The localization of the fistula, however, is often a more difficult task. When a bruit and thrill are present in the neck, the differential diagnosis includes local arterial disorders as well as central or cardiac disorders that may transmit sound and energy distally to the cervical vessels. Probably as a result of their rather uncommon occurrence, congenital fistulas of the vertebral system are not considered in the differential diagnosis of such disorders. We report an example of a congenital arteriovenous fistula of the vertebral system which was initially thought to be a patent ductus arteriosus. Report of a Case:— A 23-year-old white man was admitted to the hospital for diagnostic studies in May 1968. The patient was

To the Editor: —Hippocrates employed immediate auscultation. Laennec conceived the idea that mediate auscultation is practicable, and first used a roll of paper between his ear and the patient's chest. Later he constructed the monaural stethoscope, which is still the favorite instrument of many clinicians in Europe. From the days of Laennec (1816) up to the present, for the last ninety-seven years, the instrument has been called the stethoscope. The word is of Greek origin. It is compounded of [unk], breast, chest, and [unk] inspect, see. The word "stethophone" would be compounded of stethos and the suffix phone, which means sound or voice. In the days preceding the ophthalmoscope, the auriscope, cystoscope, gastroscope, bronchoscope or the phoneidoscope, and in the days preceding the telephone, graphophone, dictaphone and microphone, the word stethoscope need not perhaps have been criticized; but in the present day I believe it is just as well that

This needle holder was designed for three reasons: Many small curved needles are broken by needleholders with a catch and with wide jaws. The snap of a catch sometimes startles a patient. In introducing needles in delicate operations it is sometimes awkward to manipulate a catch. The handle is 83 mm. long; the jaws are 8 mm. long and 2 mm. wide. The lever arm that manipulates the blades is 55 mm. long, which permits the needle to be held firmly with slight pressure. At the end of the arm that activates the jaws is a rounded and roughened finger piece which encircles three fourths of the handle, permitting the needle holder to be rotated in the fingers, still maintaining even pressure on the needle. The needle holder was first designed for introducing small curved needles in cataract work, in which the sound of an opening needle holder might frighten the

Macon, Ga., Jan. 4, 1899. To the Editor: —I send you the following sketch of a case which I believe to be unique: In July of last year there was brought to me for treatment a young white man, and the following history given: Born in Georgia, 18 years of age, he had never had any serious sickness, and gave no history of any of the eruptive fevers, but was born deaf. On careful examination I found him in a generally good physical condition, all organs except the ears performing their proper functions. Bone conduction of sound was acute and a rudiment of hearing by aerial conduction sufficient to catch only the highest pitch of the human voice thrown directly into the left ear. The tympanic membranes were tightly distended and the turbinated bones enlarged. Since he could not hear he could not speak. He exhibited a great desire for

April 12, 1924, a negro man, aged 58, was admitted from the outpatient department of the General Hospital suffering with severe cramps in the lower abdomen. He was much emaciated, and there were no physical findings except a few râles in the chest, and right epididymo-orchitis. Three tacks were found in a specimen of urine, and the nurse disclaimed all responsibility, saying that the urinal was clean. This being reported to the roentgenologist, a picture was taken of the bladder area at the time the patient was sent to the fluoroscope room. The roentgenologist, Dr. Rhinehart, made a diagnosis of foreign bodies in the region of the bladder. An 18 French sound was passed, and a grating click was felt when the instrument entered into the bladder. Rectal examination revealed no masses in the rectum, but grating was felt anterior to the rectal wall with the palpating finger in the