the fibrous exudation has begun, the consequence is the lung can not so readily expand to fill the vacancy with the serum.

DR. WALTER COURTNEY-I was to discuss Dr. Hunter's paper, but I did not hear Dr. Burch's paper at all. Dr. Hunter wrote to me asking me to make up data from our records in regard to this work in our hospital. When we have an accumulation of serous fluid in the chest, just as soon as there is enough of it we tap, and I do not recall a case where we had any reason to regret it. Where the amount is moderate or large we tap at the earliest possible moment. Sometimes we let it go two or three days, not too early. In many instances one tapping is sufficient, in others we do it twice and sometimes oftener. That is our practice.

DR. C. F. MCCOMB-I have very little to say on this subject, except that I am a strong advocate of early aspiration in effusion. I believe the proper time to operate if we can get at it, or as nearly as we can get at it, is when the pleura ceases to exude the serum. If we can get at it at that point we will have better results from the operation I think than we will if we go at it haphazard. In my experience, the usual time to get the best results from aspiration in pleuritic effusion is from two or three days after the onset of pleurisy, provided there is not a rapid effusion poured out long before that time sufficient to dangerously compress the lung or the heart, but if the patient is uncomfortable and there is a disagreeable dyspnea I should not wait at all. Even at a late date, after a number of weeks, where there has been a tremendous effusion, the lung compressed, the heart pushed way over to the right side, I think it is remarkable how often we get a satisfactory and rapid recovery from the use of the aspirator. I remember one of the first cases of pleurisy I ever tapped years ago when I drew a gallon and a pint of fluid at one tapping. It was in the case of a man probably fiftyeight years of age, a blacksmith, and aside from some troublesome adhesion he made a satisfactory recovery and is alive and well to-day. I cite that case simply because it had progressed so far before my attention was called to it, and there was such an abundance of fluid flowing out. There was another case a short time ago that was especially interesting to me, a case of pleuritic effusion. I had the patient taken to a hospital and tapped him and drew off three pints of fluid. That was all that came with the aspirator, and the result was not entirely satisfactory. The heart did not assume its natural position, and I thought there were other causes there that prevented my getting a satisfactory result. I found the cavity was filling up, and ten days afterward I tapped him again with the same result, about three pints of fluid. The case went on and did not progress satisfactorily, and about a week or ten days afterward I tapped him a third time in the same position, perhaps between the seventh and eighth ribs, the same place where I had tapped him before, without any result. I did not get any sign of fluid at all. I then went further up, between the third and fourth ribs, and found a separate cavity. I immediately withdrew the fluid

you can.

from that upper cavity, the heart recovered its normal condition, the patient made an uneventful recovery and is well and healthy to-day. I believe pleurisy with effusion is not a disease for medication. I decidedly believe in early tapping, allaying the pain as best I am sorry I could not get a detailed statement of cases in the Duluth Hospital, but I know that in the hospitals of Duluth for the last fifteen years the majority of cases of pleuritic effusion have been treated by practically early tapping, and in a very large majority of cases the treatment has been successful, and in those cases that were lost it was simply owing to the presence of some other affection at the time of operation. I am a strong advocate of early tapping.

DR. E. J. Cox-The doctors have related their successful cases. 1 would like to relate a case quite similar to that mentioned by the last speaker, but it proved to be unsuccessful.

The patient had

pleurisy, and after waiting two weeks I suggested tapping. I waited five days longer and introduced the needle, but failed to get any fluid. I then went higher up and drew out the succeeding day about eight ounces of pus and I introduced a drainage tube. I then again applied the aspirator and drew out about one and one-half ́ounces of pus, and the patient collapsed instantly.

DR. C. G. SLAGLE-The paper discussed very thoroughly getting rid of the effusion, but there has not been anything said about prevention. Excuse me if I appear a little dogmatic. I believe if the first treatment is properly carried out that generally you will not have occasion to operate. (I will not give Dr. McLaren a chance to sit down on me like he did at Mankato.) His treatment with cold and the use of an antiphlogistine is a good remedy in some cases. I have not in my practice, which has been inconsiderable, had the experience with so much pleuritic effusion as demanded operation as the cases we hear about. I want to speak of treatment, and I want to say first that the first treatment of pleuritis is the important one. That is the time to do the work to get results. I want to speak of one or two remedies which I have found effective. One is the syrup of hydriotic acid. I think if you will give syrup of hydriotic acid you will experience good results. Another remedy is guaiacol, but delicate stomachs go back on it and can not use it. There is a new preparation called triacol that will not disturb the stomach, and so far I have had good results with syrup of hydriotic acid and triacol, but the most important feature in pleuritis is the first treatment.

THE RELATIONSHIP BETWEEN DISEASES OF THE NOSE AND THROAT AND GENERAL

DISEASES.

WITH INTRODUCTORY REMARKS ON THE FACULTY OF PERCEPTION AS IT CONCERNS THE PHYSICIAN.

JACOB E. SCHADLE, M.D., ST. PAUL.

To be able to correctly and readily interpret the signs of disease as they present themselves to our powers of discrimination, is a rare gift..

Intuition and perception constitute important factors in the mentality of the physician, and he who possesses to an unusual degree these qualities of character is certainly fortunate and in a measure destined to succeed. On the other hand, all things being equal, one who is but moderately endowed by them, can often acquire by cultivation the power of critical observation and attain to a similar extent an enviable standard of excellence in the practice of medicine. The doctor should be one of the best of observers and scrutinizers. He should have an acute perception of the physiognomy of disease and a ready recognition of all that is concerned in its minutest details, the general make-up of the patient and his environment. On this depends to a reasonable degree the success of the physician.

As a study of the relationship of morbid processes usually is based on a differential conception of the symptoms present, the faculty of observation and analysis necessarily forms an essential and advantageous purpose in the diagnosis and therapy of disease. A high order of perception is requisite in the comparative study of any subject, and especially is this true in matters pertaining to the healing art.

As to specialties in the practice of medicine, a mental grasp of the associated phases of special disorders as related to general diseases, is an important qualification.

The physician of special medicine too frequently loses sight of the importance of erecting early for himself a stable foundation, comprehensive in its scope, for practical as well as theoretical purposes. He often forgets that "our to-days and yesterdays are the blocks with which we build," and wanders along the lines of his special work unobservantly and mechanically until eventually he finds himself "ditched" and unable to extricate himself from the "rut" into which he has fallen. Such an one sometimes wakes up to discover when too late that medicine is a progressive science and that he has been "left" in the rear of the procession. No specialist is fully or even respectably equipped for his work unless he first has had a practical experience as a general practitioner for a period of years. Without the knowledge that such an experience brings to one, the tendency is for the specialist to cause nearly all the ills man is heir to, to come under the domain of his line of work. We would not say that such an one is dishonest, but we have ground for saying that he is an exponent of illogical ideas and incompetent training, reflecting discredit on the specialty which he represents.

In the evolution of disease, cause and effect play an important rôle. They form the basic principle which governs every morbid action whether it be of extrinsic or intrinsic origin. Cause and effect may act independently or in a reciprocal relation with each other with regard to their specific significance. Those physicians are most successful in the management of diseased states who study their cases most carefully, and search for indications which each case offers.

Not only is the faculty of observation valuable in the recognition of the symptoms of pathologic states, but it is requisite in the estimation of the physiologic and therapeutic action of the remedies applied.

A relation of the following fable, with which perhaps you are all familiar, forcibly illustrates the importance of observation and also how gifted he is who possesses it to a marked degree:

A Dervish was journeying alone in a desert when two

merchants suddenly met him. "Holy man, we have lost a camel," said the merchants. "Was he not blind in his right eye, and lame in his left leg?" asked the Dervish. "He was," replied the merchants. "And was he not loaded with honey on one side, and with meat on the other?" "Most certainly he was, and as you have seen him so lately and marked him so particularly you can in all probability conduct us to him." "My friends," said the Dervish, "I have never seen your camel, nor heard of him, except from you." "A pretty story," said the merchants, "but where are the jewels which formed a part of his burden?" "I have never seen your camel nor your jewels," replied the Dervish.

On this they seized him and forthwith hurried him before the Calif; but, on the strictest search, nothing could be found upon him, nor could any evidence whatever be adduced to convict him either of falsehood or theft. They were about to proceed against him as a sorcerer by bastinadoing him when the Dervish with great calmness thus addressed the court:

"I have been much amused with your surprise, and own that there has been some ground for your suspicions; but I have lived long and alone, and I can find ample scope for observation even in a desert. I knew that I had crossed the track of a camel that had strayed from its owner, and not been stolen, because I saw no mark of any human footstep on the same route. I knew that the animal was blind of an eye because it had cropped the herbage only on one side of its path; and that it was lame in one leg from the faint impression which that particular foot had produced upon the sand; I concluded he had lost a tooth, because where he had grazed, a small tuft of herbage had been left uninjured in the center of the bite. As to that which formed the burden of the beast, the busy ants informed me that it was meat on the one side; and the clustering flies, that it was honey on the other."— (Cotton-Fothergill.)

As an illustration of ready perception and positive conclusions formed as to cause and effect, the following experience is an example of a case in point.

It was once related to me by a patient of Dr. Weir Mitchell