erally produced by two things; intestinal putrefaction and splanchnic irritation. My clinical work is almost wholly in a negro hospital in Augusta, and we see there those individuals who have been subjected throughout their lives to what we have been accustomed to think of as causes of this condition-syphilis, alcohol and hard work. We see every imaginable type of these conditions there, and yet I do not see as many cases of arteriosclerosis there as I do in private practice.

As to treatment, I believe we have abandoned the idea that every human being is born wrapped up in an invisible, delicate network of fibrous tissue, which slowly contracting, year after year, squeezes the life out of him unless something else gets him first. We believe now that the advent of death may be put off for a great many years by proper hygienic and dietetic measures. The control of intestinal fermentation, the removal of the possibility of splanchnic irritation by undigested and unremoved fecal matter are of the greatest importance.

So far as the effect of drugs themselves is concerned upon the diseased arteries. I do not believe that an artery that has once undergone serious degeneration is ever going to be restored to a physiological condition. We may arrest the process, but that is all.

Just a word more in support of Dr. McHatton's remark about venesection: We are overlooking a chance to do a great deal of good when we overlook the opportunities for venesection when they occur, as in cases of arteriosclerosis, diabetic coma, pneumonia and certain forms of heart disease. It doesn't pay always to be too sorry for our grandfathers in this matter of bloodletting. They believed it to be a good thing, but because every one did not read the indications properly it fell into disuse, and we have allowed this excellent therapeutic agent to lie in oblivion.

Dr. C. R. Andrews, Atlanta: I think that Dr. Lattimore struck the keynote as to the cause of this condition when he said the proteid intake should be regulated; it is a question of improper metabolism. In the work on joint inflammations with putrefactive intestinal trouble we found high arterial tension in all of them. They were put on fermented milk diet, and after a short time this tension was relieved. I agree heartily with what has been said as to this condition arising from digestive disturbances.

Dr. E. G. Ballenger, Atlanta: This subject has been of considerable interest to me, particularly with reference to the diagnosis of chronic interstitial nephritis, and I have certainly enjoyed this interesting paper and instructive discussion.

I would like to ask Dr. Lattimore what form of apparatus he uses in determining the blood pressure?

Dr. J. E. Paullin, Atlanta: I do not think the physical examination of any patient is complete until the blood pressure has been determined, and by that I do not mean the systolic pressure alone; it is just as important to determine the dyastolic pressure, for I am becoming convinced of the fact that perhaps the first sign of arteriosclerosis, or, at any rate, of high arterial tension, is an increase in the dyastolic pressure, and, as a consequence, decrease in the pulse pressure. Very frequently in these patients the pulse pressure is less than normal. Of course to make accurate determinations it is always necessary to have instruments of precision, and the one most frequently used is the ordinary mercury manometer, and in this condition one may easily with one instrument get a blood pressure of 200 m.m., while with another instrument constructed in a more precise manner pressure of

only 120-30 m.m. The difference is due to the band with which the artery is compressed. There are so many factors which influence the measuring of blood pressure that it seems sometimes a bit discouraging. For instance, in, measuring the blood pressure of a patient with a very fat arm it will be more than that of a man with the same blood pressure but whose arm is not so fat. All these things must be taken into consideration, but if we note the difference between dyastolic and systolic pressure a great deal may be learned.

Dr. Ralston Lattimore, Savannah (closing): Dr. Slack speaks of the Wier Mitchell treatment, and says he does not overfeed his patients, but gives them all they will take. I understand by that that he feeds them very liberally. I believe that in the Wier Mitchell treatment as much of the improvement comes from the rest as from the diet. I know of nothing better than rest and a milk diet. As to the diets of various kinds, I think the essential point is to give a diet that agrees with the patient-usually milk; if milk in the natural state disagrees with them, give it in some form that will agree with them.

Dr. Murphey speaks of splanchnic irritation; that brings out the point that we are coming to believe more and more every day that the so-called cases of heart failure do not really exist; that in these cases we have death occurring because of lack of vasomotor tone; practically a bleeding to death within the abdominal veins, because when these cases come to autopsy we find the heart practically empty and congestion of blood in the abdominal veins.

It has been asked what form of apparatus I use for determining the blood pressure; I have been using the Stanton instrument, which is a good one, not easily broken, and I believe fairly accurate.

A CAUSE OF SCROTAL HEMATOCELE.

BY WHATLEY W. BATTEY, JR., M.D., AUGUSTA.

The tunica vaginalis testis is the location of fluid accumulation produced by itself, the lining membrane possessing that property, or by injury of the testicle there being a gradual outpouring into its cavity, further gonorrheal inflammation of epididymis syphilis and new growths act likewise. This hydrocele fluid may become discolored, being in part due to its age, becoming dark yellow or brown. The gradual accumulation of this fluid does not produce symptoms alarming to patient until he actually has pain and marked discomfort. When such a condition presents itself he then seeks relief, not always to the physician who is competent to make a diagnosis and suggest appropriate treatment, but to the druggist who at a glance makes a diagnosis of hernia; gives him a suspensory or applies a truss, and leaves the sufferer in as deplorable a condition as before, increasing the liability to complications. Imagine a patient with a small hydrocele and varicocele harnessed up in a truss; the direct effect being not only uncomfortable, but adding "fuel to the flame," so to speak, by the pressure of truss against spermatic cord as it emerges from external ring, thus interfering with venous return circulation, and constantly favoring increased varicosities. The pressure produced within tunica vaginalis testis is equal on all sides and as compression of brain is produced, according to some authorities by a rupture of small twigs of blood vessels due to cerebral fluids being set in motion, so will fluid collections in scrotum

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A CATISE OF SCROTAL HEMATOCELE under influence of traumatism act upon contents of scrotum, producing a rupture of circulatory apparatus, provided that varicosities exist, or a simple exudation of serum as the direct effect of impaction, constituting the condition known as hematocele. Among other causes may be enumerated the gradual thickening of tunica vaginalis, and lastly repeated punctures of hydrocele.

SYMPTOMS.

The chief symptoms are pain, swelling of scrotum, blood extravasation.

DIAGNOSIS.

This is not always easy. The history of the case will give important diagnostic data. This condition may be confounded with hydrocele and hernia. The important diagnostic points in favor of each are as follows:

Hydrocele.-Gradual increase in size. Translucency, presence of fluctuation. Pyriform in appearance. Closure of external ring. Absence of impulse upon coughing. Non-reducibility. Absence of inflammation or pain.

Hernia.-Doughy feel of scrotum. Impulse upon coughing at external ring. Enlargement of external ring. Possibility of reduction. Presence of marked discomfort. Occasional tympany in other than epiplocele.

Hematocele.-Presence of ecchymosis. History of traumatism. Absence of indications of strangulation. History of the previous existing hydrocele.

To show how important a factor traumatism is in the production of this trouble, I can best do so by reporting a case in point.

Mr. G., a carpenter, age forty-eight, noticed two years ago a swelling of right side of scrotum. This was accompanied by dragging sensation in testicle, partially incapacitating him from work. He applied for aid at a drug store,