say that in over six thousand abdominal sections, I have seen not over six, although on this point I am unable to speak absolutely, as I have not had time to look over my cases to determine the exact number. This would make it less than one-tenth of one per cent. of all cases that come for operation of abdominal section."

Landau was the first to look upon floating liver as quite common. Glenard in one year, 1887, found in 1300 patients 51 cases or 3.9 per cent. Strikingly similar to the result of Glenard's experience is that of Dr. Max Einhorn, who in the first five months of 1899 noted in the examination of 804 patients 30 cases of floating liver, or 3.7 per cent. Dr. W. J. Mayo says that in his experience floating liver is not uncom

mon.

As regards sex, by far the greater number of cases is found in women. In Graham's 68 cases, 55 were females and 13 males; Einhorn's 30 cases show 21 females and 9 males, and in Carsten's 98 cases about 75 per cent. were women.

ETIOLOGY. The etiology of hepatoptosis is obscure. The theory of Landau will probably account for the condition in more cases than any other. According to this writer the two necessary factors are stretching of the liver ligaments and enlargement of the capacity of the abdominal cavity. This increase in the abdominal capacity may be due to rapidly progressive emaciation (whereby the fat padding the viscera is absorbed and intra-abdominal pressure is decreased), and the removal of large abdominal tumors. The corset is thought to play a minor rôle in etiology. Several cases have been reported in singers. Repeated pregnancy seems to be a predisposing cause in a certain number of cases. Many cases are directly traceable to trauma. Indeed, Carstens, of Detroit, holds that "the cause of movable liver is always an injury, severe fall, heavy lifting, or, in a few cases, the development of a malignant growth in the liver. Leube and Rosencranz report cases, the result of ascites, and the writer's case described below was accompanied by ascites, but whether as a cause or an effect would be a nice discrimination.

PATHOLOGY. The traction upon its vessels of so heavy a viscus as the liver usually produces some passive congestion

and consequent enlargement. Floating kidney was a complication in 10 of Einhorn's 21 cases in women, and was bilateral in three cases. This accurate observer has also taught us that in all cases of cardioptosis there exists a more or less wellmarked degree of hepatoptosis. Richard Douglas states that gallstones as concomitant pathological conditions have been. found in two cases; Jonas, of Omaha, reports another; and J. W. Hayes, of Eureka Springs, Ark., recently did a cholecystotomy on such a case, removing two large gallstones. Treves finds floating liver commonly associated with gallstones. Hemorrhoids are not uncommon complications.

SYMPTOMS. The symptoms are, according to Douglas, due to pressure, traction and the mere movement of so large a body within the abdominal cavity, which latter would give rise to reflex nervous symptoms common to wandering spleen, movable kidney and pedunculated tumors. Sometimes there. is entire absence of symptoms, as in Kreider's case of a man. who went away well pleased when assured that his disease. was not malignant.

Einhorn classifies all cases according to symptoms into five groups: 1, cases unaccompanied by symptoms; 2, dyspeptic cases; 3, cases of hepatalgia; 4, cases of hepatic colic; 5, asthmatic cases. In a personal communication to me he states. that the cases presenting no symptoms comprise, roughly speaking, about one-third of the cases of hepatoptosis. Pain in the region of the liver and referred to the shoulder is common. Icterus is infrequent. The diagnosis rests on physical signs and not on the symptoms; nor is it necessary to detail at length the former. Suffice it to say that if the physical methods of examination, relying especially on percussion, show the absence of the liver from its normal location and its presence in an abnormal one, the diagnosis of floating liver forces itself upon the examiner.

The diagnosis in some cases is difficult, being most frequently confounded with kidney lesions, and especially nephroptosis. W. J. Mayo writes me that a number of cases have been sent to him under the impression that it was movable kidney.

As to prognosis Einhorn declares that "appropriate treatment of this affection is crowned with the most brilliant suc

cess in the majority of cases," but Douglas asserts that "patients with extreme displacements succumb to marasmus, the result of prolonged functional disturbances, or to intercurrent diseases to which they are markedly predisposed."

TREATMENT. The various methods of treatment may be grouped into three classes: 1, the use of a supporting abdominal bandage with proper hygienic measures; 2, the operation of laparectomy; 3, hepatopexy. Einhorn, in advocating a nonoperative plan, says: "I am completely in favor of medicinal treatment, that is, mechanical and dietetic, and am opposed to operative procedures." He recommends the abdominal binder and a full diet.

Laparectomy, as practiced by Dépage, consists of excising portions of the abdominal wall both transversely and vertically to overcome its laxity. Though the International Text-Book of Surgery speaks of this as "probably the best operation," its practice seems to be confined to Dépage.

Hepatopexy in one or another of its several modifications. is the only rational operative treatment. This operation is said to have been done for the first time by Marchant in 1891, though Bilroth stitched a "floating lobe" to the abdominal wall in 1884. The method of Jonas, of Omaha, is to anchor the liver by suturing the gall bladder to the abdominal wall. Carstens scrapes thoroughly the anterior surface of the liver and the corresponding portion of the anterior abdominal wall so that adhesions might form. These denuded surfaces are held in apposition by suturing the coronary ligament in the upper angle of the incision. This is probably the ideal operation in cases where a collateral circulation would be a desideratum. Mayo's operation is to utilize both the gall bladder and the suspensory ligament as supports.

The rule of Douglas should govern the decision to operate. This writer says: "Those cases not made comfortable by a well-fitting bandage and that give rise to distressing symptoms may find relief in the operation of hepatopexy."

The following case is interesting:

Mrs. V. came to me from a neighboring town on September 9, 1903. She is 30 years old, married, has two children 8 and 2 years old and has not menstruated since the birth of

her last child. In October, 1902, she noticed her abdomen began to enlarge and felt pain in both sides under the ribs and suffered with backache. The enlargement and symptoms steadily increased. In July, 1903, she was taken with fever, which lasted about two months. She had pains in the sides as before and rigors, but neither pain in the shoulder, jaundice nor sweats, and was treated by her physician for "slow fever." She gave no history of gallstone colic. When I saw her for the first time she was emaciated and cachectic with abdomen enormously distended, pain on deep pressure and flatness on percussion all over the abdomen. Vaginal examination showed uterus movable, slightly retroverted and prolapsed and the perineum lacerated. This laceration occurred at birth of first child, eight years ago. The pulse, temperature and heart sounds were normal. The examination of the urine was negative with the exception of an abundance of biliary coloring matter. On September 10 I tapped her and drew five quarts of dark-colored ascitic fluid. On examining the abdomen after the tapping a large tumor was found, most prominent at the umbilicus with the patient in recumbent posture; when she sat up the tumor dropped to the pelvic brim, in which position it resembled a uterine fibroid. It was freely movable and flat on percussion. Vaginal examination showed that it had no connection with the uterus. The spleen was not enlarged nor were the kidneys palpable. All over the normal site of the liver marked tympany was elicited. The diagnosis of floating liver was made, which was confirmed by Dr. A. A. McClendon, of Marianna, who saw the case with me. The liver was replaced as well as possible, and a closely-fitted lace abdominal binder was applied. Eighteen hours after the tapping the patient was taken with violent headache and vomiting and fever which lasted two days, ranging from 100 to 102°F., subsiding spontaneously. Fifteen days after the tapping the patient left for home with abdomen free from ascites, appetite and strength good, bowels regular and liver held in good position by the abdominal bandage. All the symptoms being thus alleviated, hepatopexy is not thought to be indicated as yet.

[NOTE. The author advises us by letter that this case was recently operated on by him by the method of hepatopexy, with success at time of writing.]-ED.

BACTERIOLOGY OF PLEURISY.*

N. S. FERRY, M.D.

MEMPHIS.

Demonstrator of Pathology, Memphis Hospital Medical College..

PLEURISY is a parasitic disease. This may seem a rather broad and dogmatic statement, but I think we can show that nearly 99 per cent. of all forms of pleurisy are of a parasitic origin, and that the remaining cases, which constitute the 1 per cent., may be caused by some parasite, either so small as not to be recognized by the highest power lenses, or of such a composition or structure as to have eluded all known methods of cultivation and staining.

Pleurisies may be classified in several ways. They may be classified according to their mode of onset, whether primary or secondary. They may be classified anatomically and divided into pleurisy with adhesions, or pleurisy with effusions, or they may be classified according to the run of the disease, whether acute or chronic. For convenience sake I shall classify them from an etiological standpoint.

Before we take up the various causes of pleurisy, let us consider for a moment the channels of infection by microorganisms. First, we have those cases of pleurisy following direct traumatism to the pleural cavity, as stab wounds, gunshot wounds,

etc.

Second, by direct extension of the infection from some neighboring or contiguous tissue, as from pneumonia or the rupture of some abscess into the pleural cavity.

Third, by the blood stream called blood metastasis. Fourth, by the lymphatics, called lymphatic metastasis. Up to within a short time cold was considered the cause, and sole cause, of pleurisy, "but modern views of serous inflammation," as Osler says, "scarcely recognize cold as anything more than a predisposing agent, which prevents the action of various microorganisms." The same may be said of pneumonia, which, under the name of "lung fever," was thought to be an extension of the cold in the nasal passages through the bronchi to the lungs.

In order to demonstrate that exposure to cold, or sudden * Read before Memphis and Shelby County Medical Society, Jan. 19, 1904.