the physician is not accurate, observing and painstaking, the nurse will not be. Some nurses are mentally totally unfitted for scientific observation and never can become close and reliable observers. The same may be said of many physicians.

Temperature. In all cases in which bilateral axillary temperature are not required, and in which the patient is sane, conscious and free from delirium, the mouth is the preferable place in which to place the thermometer. Whether the temperature is registered in the mouth or axilla, these places must not be allowed to cool before placing the thermometer in place.

It is important to register the temperature in each axilla in certain unilateral brain cases, especially in cases of apoplexy. It is very difficult to make accurate bilateral axillary temperature records, and no nurse is fitted to take charge of this work until she has had special training for it under a competent observer.

A very frequent, a very slow, an intermittent or irregular pulse usually has grave significance in organic disease of the brain.

Respiration is modified in various ways by organic disease of the brain. About eighteen months ago I was requested to see a case in consultation. The patient, a woman, married, about 35 years old, had been thought to be a sufferer from paroxysms of hysteria for several weeks before I saw her. She presented a remarkable array of symptoms of this disease. She had a slight elevation of temperature above the normal, but this was variable. I was unable at first to point to a single symptom and say that it positively indicated organic disease of the brain. A few days later I observed that while awake her respirations were nearly normal in frequency, but while she was asleep they were increased considerably above the normal. I felt that I had one positive symptom of organic disease of the brain, and on this I made a diagnosis of organic disease, involving the respiratory Before death occurred nearly two months later, she presented all kinds of irregular symptoms. Often she would laugh and talk with her relatives and led them to believe that she was going to recover, but respiration during sleep or unconsciousness became nearly twice as frequent as it was while she was awake. For weeks before she died the respiration often numbered 120 to 144 per minute, when asleep, and only 60 or 70 while she was awake. The autopsy revealed a tubercular meningitis, and a periarteritis involving the smaller vessels of the pons in the region of the respiratory centers.

centers.

"The property of and must not be taken from

THE HAHNEMANN HOSPITAL COLLEGE

The principal abnormal forms of respiration that I have found most important to study in disease of the brain are, the remittent, sighing, two forms of abdominal, stertorous, intermittent, "ascending and descending" or "up and down" and the Cheyne-Stokes. Those who are interested in this subject I must refer to the paper as it will appear in full in our Transactions, or in the New York Medical Journal, as I cannot devote much space to these various forms of respiration in a brief abstract. Two or three of them deserve a few words here.

Sighing respiration has been observed from time immemorial, both by physicians and laymen, but so far as I am aware no importance has been attributed to it in the study of disease of the brain. Of late I have observed it in nearly every case of tubercular meningitis that I have seen at the first manifestations of the disease, and have had an opportunity to study. It is one of the early symptoms, and usually precedes remittent and intermittent respiration, but does not exist long without having intermittent respiration added. I have said of it, "When it is found in organic disease of the brain, it certainly adds gravity to the prognosis. It seems to indicate that the ordinary involuntary respirations are not sufficient for nature's purposes, and extra efforts are needed from time to time to supply more oxygen to the blood. If it occurs, it is an early symptom, and, like remittent respiration, denotes some disturbance in the respiratory centers." I wish to add here that sighing respiration occurs in connection with all kinds of functional disturbances, and that it apparently has no special significance, except when found associated with other suspicious symptoms of organic brain disease. Its early occurrence in disease affecting the posterior fossa of the brain gives to it its chief importance as a diagnostic sign in certain diseases of the brain.

"Ascending and descending" or "up and down" respiration, next to the Cheyne-Stokes' type, gives the greatest gravity to the prognosis in organic disease of the brain. There is no remission or intermission, no undue pause between any of the respiratory acts. The patient takes a full breath, and each succeeding respiration becomes less and less until the chest or abdomen scarcely seems to move, but almost immediately, without any lengthening of the normal pause, there follows a respiration a little fuller than the faintest, which was the last of the descending. Each subsequent respiration increases in size until a full respiration is reached, when again, without an abnormal pause,

the respiration begins to descend. Thus the "ascending and descending" respiration may continue for hours before the Cheyne-Stokes' type develops.

I described, but did not name this form of respiration in a paper presented to the College of Physicians, Philadelphia, in 1883, entitled "Report of Three Cases of Abscess of the Brain." Without attempting a further abstract of this paper, I will submit the following conclusions:

I. That by a careful study of the temperature, pulse and respiration much valuable information that will aid us in the diagnosis and prognosis in certain diseases of the brain, can be obtained.

2. Much care must be exercised and considerable time and patience are required on the part of the physician in obtaining reliable records.

3. Nurses are totally incompetent for such detailed work, unless they have been especially drilled for it.

4. A change in the character of the respiration, rather than in its frequency, is sometimes one of the first positive symptoms of organic intra-cranial disease, especially of tubercular meningitis.

5. A respiration that is more frequent while the patient is asleep or unconscious than it is during the waking or conscious moments is very strong evidence of organic disease of the brain, so situated as to interfere with the respiratory centers.

6. Apoplexy, due to hemorrhage, is attended with greater disturbance of the temperature of the body, soon after the occurrence of the stroke, than is the case when the apoplexy is due to thrombus or embolus. The temperature disturbances in apoplexy, due to hemorrhage, especially attended with hemiplegia, are a slight fall of the axillary heat within an hour after the occurrence of the hemorrhage, the fall being a little greater on the paralyzed side; after reaction has occurred (8 to 12 hours on the average) a slight rise of temperature, a little greater on the paralyzed than on the opposite side; an elevation of temperature from half to 2° or 3° above normal for the next few days, temperature remaining a little higher on the paralyzed than on the unaffected side for a week or more (in cases of complete hemiplegia); later, temperature slightly lower on paralyzed side if trophic disturbances occur.

7. In apoplexy, from thrombus or embolus, there is scarcely an apreciable disturbance of temperature before the end

of the second day, except in the severer cases. In these cases it is slight. In the majority of cases of apoplexy from thrombi or emboli, there is no marked variation of temperature from the normal at any time, so that disturbance of the temperature the first day points very strongly to hemorrhage as the cause.

8. Considerable or only slight disturbance of temperature, beginning from the second to the fourth day, is significant of thrombus or embolus and indicates extensive softening, and an unfavorable prognosis.

9. If the temperature on the paralyzed side remains higher than on the opposite side, several weeks after the occurrence of the apoplexy from any cause, it indicates that softening or inflammation of the brain is going on, and lends great gravity to the prognosis.

IO. It is premature to attempt to arrive at any definite conclusions from a study of the temperature, pulse and respiration in traumatism of the brain. This class of cases, on account of their great importance, deserves a more detailed study of all their symptoms. It is probable, if cases of traumatism of the brain were classified and grouped according to the severity of the injuries and the character of the symptoms, that a careful comparison of the temperature, pulse and respiration would lead to important conclusions.

In regard to the traumatic class of cases it seems that we are justified in making the following tentative statements:

a. That all cases of injuries to the head in which the temperature does not reach normal a few hours after the receipt of the traumata will likely prove rapidly fatal. The higher the temperature the greater the probability is that contusion or laceration of the brain and membrances is playing a more important factor in the case than is intracranial hemorrhage. The greater the variation of the temperature from normal, either above or below, the worse the prognosis.

b. A rapid, weak and intermittent or irregular pulse denotes great danger. A pulse that is at first slow, but soon after becomes quite rapid, indicates that brain power is being overwhelmed by the intracranial lesion and justifies a bad prognosis.

C. An exceedingly slow (8 to 10 per minute) and intermittent respiration indicates a lesion at the base in the posterior fossa. The slower and the more pronounced the intermissions. of the respiration the greater is the danger of sudden death. A respiration, at first nearly normal in frequency, but soon after becomes quite rapid, indicates a rapidly fatal case.

PERSISTENT OR CYCLIC ALBUMINURIA WITHOUT CLINICAL SYMPTOMS.*

By G. E. TYLER, M.D.,

Professor of Medicine, Gross Medical College,

Denver, Colorado,

That albuminuria of renal origin sometimes exists, though no clinical symptoms whatever are discoverable upon the most searching examination and without the presence of casts or other evidence of disease of the kidney, is well established. As a result a separate class has become necessary.

To this form of albuminuria various names have been given, as cyclic albuminuria, intermittent albuminuria, postural albuminuria, functional albuminuria, physiologic albuminuria, albuminuria of adolescence, albuminuria in the apparently healthy,

etc.

The characteristics of the conditon are that albumin, usually in small quantities, may be found in the urine for months or years without other evidence of deranged physical condition. It is rare that casts are found, and when present they are scarce and of the hyaline variety. In quite a proportion of cases calcium oxalate crystals are present.

The subjects are most frequently young persons just past puberty, though no age is exempt. Those of neurotic temperament and with poor digestive systems seem especially liable to attack. Heredity has some influence, the disease having been found in three generations of the same family. A gouty family history is of sufficient frequency to indicate some influence. In certain persons a cold bath will cause a trace of albumin to appear in the urine. In others, severe mental strain, excessive emotion or violent physical exercise produces the same effect. There are persons who are the subjects of albuminuria after the ingestion of several raw eggs.

Those cases which really merit the name of cyclic albuminuria have as a distinguishing feature, the fact that albumin is present during a part of each twenty-four hours and absent the remainder of the time. Ordinarily the morning urine is free, but within two or three hours after rising albumin appears and

* Read before Colorado State Medical Society, Denver, Colo., as a part of Symposium on Diseases of the Kidney, June 19, 1901.