cles in the affected region. Temperature 98 deg., pulse 72, respiration 24. The patient is advised to enter the bospital, but refuses.

September 9.-The pain in the thorax and pectoralis is diminished. The patient now complains of pain in the epigastrium, in the left hypochondrium and in the left anterior lumbar region. The tenderness in the epigastrium is increased, and now extends to the left hypochondrium. There is also a tender spot below the angle cf the left scapula. The muscular rigidity renders satisfactory abdominal palpation impossible. Temperature 99 deg.

He is again urged to enter the hospital, or to remain in the hospital a day for examination in narcosis, but refuses both.

The patient was not seen again at the clinic until March 20, 1906, when he was placed in the surgical ward by Dr. Dixon. He had failed greatly, and was now evidently desperately sick. His gait was unsteady, his face haggard, his voice weak, his respirations shallow and panting. He had lost sixteen

pounds in weight in the last three months. He suffered with a constant, heavy, aching pain that extended from the epigastrium and sternum through to the back, under the left scapula. This pain had been present about one mouth and had grown worse daily. In addition to this there was a severe cutting pain in the stomach soon after eating solid food, which was first noticed three months previously. The pain under the scapula and

behind the sternum increased with the stomach pain. The pains had destroyed the patient's rest at night, and had frequently been so severe as to require morphine.

The appetite had remained good, but the patient had refrained from eating solid food on account of the pain that followed. There

was no nausea, and no belching except of gas, which brought relief. There had been no vomiting, except once, when the patient had taken some medicine said by his physician to have been intended to cause vomiting. The vomitus contained nothing apparently to suggest blood. The bowels had been constipated, stools never observed to be black. The patient complained of an inability to take a deep breath, and deep inspiration caused pain in the lower left thoracic and splenic region. There was no cough nor hoarseness. The patient had always had a "strong back" until about one month previously.

Stomach examination, at the request of Dr. Dixon.-Stomach fasting empty. Test meal of toast bread 35 grams, water 400 cubic centimeters, removed in one hour. Amount obtained, 75 cubic centimeters, well digested, no mucous, free hydrochloric acid 1.6%, total

acid 1.8%. No blood (guaiac-turpentine test), nothing abnormal microscopically.

The patient was now turned over to the medical department and came again under

my care.

The skin was ashen, not cachectic. Lungs normal to percussion and auscultation. Apex beat in the fifth interspace one inch inside the mammary line. No heart murmur, cardiac dullness from the left border of the sternum to within one inch of the mammary line. Liver dullness at the sixth rib. Two partially healed wounds of recent incision of glands in the left axilla, still discharging. Dorsal spine rigid, not irregular. Extreme tenderness in the entire epigastrium and in the left hypochondrium, point of greatest tenderness to the left of the median line about two inches below the ensiform carti

lage. Marked tenderness to the left of the spinal column from the third to the ninth dorsal vertebra, slight tenderness also to the right on the same level. Pressure on the left lower anterior and lateral thoracic wall painful.

Attempt at anteflexion of the dorsal spine causes pain from the left scapula through to the epigastrium. Purplish blotches or scars on the legs, white papery scars on the left knee.

Pupillary and patellar reflexes normal, pupils equal.

Urine.-Specific gravity 1020, trace of albumin, a few hyaline casts, no pus, no sugar. Blood.-Hemoglobin 85%, red cells 4,850,000, leucocytes 14,400.

Stool. Free from blood (guaiac-turpentine test) and mucous.

Temperature 100 deg., pulse 80, respiration 24.

The features of the case that impressed themselves most prominently upon the mind of the observer were the pains as described, increased by taking food, the tenderness over the entire area of the stomach, but greatest over a definite point below the ensiform cartilage, the tenderness inside of the left scapula, and lastly, fever. This, with the exception of hemorrhage, is as complete a picture of gastric ulcer with perigastritis as one could wish to see. To the perigastritis, I attributed the fever, the diffuse tenderness in the upper abdomen, the pain on pressure over the lower thoracic wall and the pain on bending the spine. The dyspnea I supposed was due to interference with the excursion of the diaphragm by the perigastritis.

Tenderness posteriorly is found in one-third of ulcer cases. Usually the tender point is small and located to the left of the 10th to the 12th dorsal vertebra, rarely to the right. Occasionally, however, there is a more extended

Boas, Magenkrankheiten. Pel. Handb. d. prakt. Med.

tender zone higher up, in the region of the 4th or 5th dorsal. Tuberculosis of the spine was thought of as a possible cause of the fever, the spinal rigidity and much of the pain of which this patient complained; but that could not explain the tenderness in the epigastrium or the pain after food.

Ulcus ventriculae then with perigastritis was the diagnosis to which I was driven. And though he was seen by several other physicians after he came into the medical ward, none of whom, however, examined him more than casually, no one considered seriously any other explanation of the patient's condition. He was accordingly put at once upon a strict ulous regime. He was given absolute rest in bed, moist hot packs were placed on the epigastrium, and hot bottles on the side and under the shoulder for the relief of pain. At the suggestion of Dr. Fischel, the attempt was made to carry out a few days of rectal nourishment. But against this the patient rebelled absolutely, and he received then by mouth every two hours six ounces of milk, lukewarm. After two days, strained oatmeal gruel, or an egg beaten in milk, was substituted for the milk at part of the feedings, and the portions were increased from six to eight ounces. In view of possible syphilis, potassium iodide and mercury were administreed after a few days trial, and the iodide was rapidly increased to sixty grains three times daily. He received no other medication.

For about two weeks the patient made a remarkable improvement. The nourishment was cautiously increased in quantity, more semi-solid food was given and was followed by no pain. The pains in the shoulder and side were so diminished that they were entirely controlled by the hot bags. The patient slept fairly well, and complained chiefly of the confinement and of hunger. Again on April 7th, he complained of severe pain under the left shoulder-blade, without other unusual symptoms. Trusting that this would soon subside as before, I made no further examination. The next morning, after taking his food as usual, he was suddenly seized with hemorrhage, and in thirty minutes was dead. The blood was bright colored, frothy, free from food particles, about one-fourth litre in amount, manifestly from the lungs.

Of the post-mortem findings I will mention only those that have a direct bearing upon the case. The portion of the chest over the lower lobe of the left lung was dull on percussion. The stomach was greatly distended and filled with fluid. The fundus was connected with the spleen, and with the diaphragm posteriorly by

rather recent, loose adhesions, and the superficial vessels of the stomach in the corresponding region were injected.

The heart was displaced to the right, the apex lying in the median line. The left pleural cavity was filled with blood, partially clotted. The lungs were both adherent at the apices, and the lower lobe of the left, also along the posterior border. This lobe contained considerable blood, and the tissue was soft and friable, especially in the portion opposite the sixth dorsal vertebra. The entire arch of the aorta and the thoracic aorta were atheromatous, and projecting from the outer curve of the arch and from the outer side of the upper part of the thoracic aorta was a group of several small sacculate aneurisms, the smallest no larger

than a pea. The largest, very thin walled, about two inches long and irregularly cylindrical in shape, had ruptured into the left pleural cavity and into the left lung. The bodies of the fifth and sixth dorsal vertebrae were eroded irregularly to a depth of one centimeter.

The esophagus showed nothing abnormal externally, and the stomach nothing further than mentioned above. On opening the stomach, the contents were found to consist of dark groumous material, chiefly blood. There was no ulcer. In the esophagus, on a level with the upper and one of the smaller aneurisms was an irregular shallow ulcer about two centimeters in diameter, partly covered by a recent clot. The ulcer accounted for the blood in the stomach.

I must reproach myself for not having even thought of aneurism in connection with this case. I regret also that I did not have an X-ray examination made. This might have rendered evident the erosion of the vertebrae, and possibly revealed the aneurism itself. I thought of the X-ray in connection with a possible disease of the spine, but the conditions, all saving hemorrhage, pointed so clearly to ulcus, that this possible means of enlightenment dropped from my mind.

The aneurism was, of course, the cause of the pain and tenderness in the back, the pain in the thorax, and doubtless of some of the pain in the upper abdomen, possibly also of the dypsnea. The tenderness anteriorly and the pain after solid food, I think must have been due to the perigastritis. The perigastritis may have been caused by an inflammatory process originated by the aneurisın through pressure, and which penetrated the diaphragm; or it may have been simply a local peritonitis of some other origin. Peritonitis localized in this region is not rare, and is sometimes very troublesome, and causes many symptoms noted in this case.

The ulcer in the esophagus, I think, caused

ably due to pressure, and of recent origin, or else quiescent during the greater part of the patient's stay in the hospital. Otherwise blood would have been detected in the stools, which were examined repeatedly. The patient was evidently syphilitic.

My thanks are due to Dr Fischel, by whose kind permission I report this case.

A solution of salicylic acid (1 to 500) is useful as a gargle and mouth wash in diphtheria.

DR. LEO CAPLAN is spending the summer in Europe, he will spend some weeks with former friends in the Laryngologic clinics of Vienna.

DR. AND MRS. W. G. MOORE are spending August in lower Canada, they will visit New York and neighboring cities before returning to St. Louis.

DR. J. L. GREENE, formerly Superintendent of the Nebraska State Hospital for the Insane at Lincoln, has resigned and will assume charge of the Central Illinois Hospital

for Insane at Kankakee.

FIGHTING THE MOSQUITO.-Dr. Samuel G. Dixon, Commissioner of Health of Pennsylvania, has been for some time exploring the State for the breeding places of the mosquito, and has now issued orders for the drainage or oiling of all such collections of water.

ACCORDING to a recent monthly report of the board of health of the Philippine Islands, the number of lepers now living in the archipelago is 3,683. They are scattered through the various provinces. Cebu, which has 675, heads the list, but only one province is wholly free from the disease.

PITTSBURGH'S WATER SUPPLY.-The city government of Pittsburgh is finding it necessary to issue a circular warning the people not to use any water in an unboiled state on account of the impure condition of the water supplied by the city and the various companies. Typhoid fever is on the increase.

THE University of Giessen completes, in 1907, the three-hundredth year of its existence, says a contemporary. The University of Leipsic is arranging a celebration for 1909 of its five hundredth anniversary. The University of Liepsic was founded by secession of several thousand students, December 14, 1409, from the flourishing University at Prague.

THE inauguration of a special clinic on contagious diseases at the City Dispensary is a

A New Departure in the Health Department.

recently effected change which will work to the advantage of the community. This clinic is to be primarily a tuberculosis clinic, the name chosen being less specific since among the class of patients for which it has been established many would refuse to submit themselves did the name suggest the suspected disease. Dr. L. M. Warfield has been put in charge of this clinic, and will give the unfortunates the benefit of the best modern methods of examination and treatment. Chief Dispensary Physician Soherck and Dr. Warfield are enthusiasts over the new venture, and solicit the co-operation of the profession that the many neglected cases of tuberculosis in the city may be placed under proper supervi sion. The clinic hours (7 to 10 a.m., 4 to 6 and 7 to 8 p.m.) are admirably arranged for the accommodation of the poorer classes, for whose benefit the clinic has been established. It is hoped presently to establish in conjunction with the clinic a day sanatorium, where patients may spend their days, receiving proper hygienic, dietetic and therapeutic attention and such instruction as will make their return home for nights harmless to themselves and their families.

Another feature of the clinic has been the transfer of the antitoxin squad to its supervision. Hereafter patients needing antitoxin who are unable to pay for the same will receive it on application from the attending physician; a dispensary physician will administer the antitoxin and work in conjunotion with the attending physician, retiring from the case as soon as the antitoxin has been effectively used.

These are changes which must needs be appreciated by physicians and those interested in charitable effort. It is believed that the clinic will be of tremendous advantage to the poor, and that, as its scope is broadened, it will become one of the strongest of our municipal institutions for the public good.

Medical
Association of

the Southwest.

PRELIMINARY steps were taken at a meeting of State delegates, called by Dr. Jabez N. Jackson, in Kansas City, on July 16, for the organization of a society to be known as the Medical Association of the Southwest, comprising the states of Missouri, Kansas, Arkansas, Oklahoma and Texas. It is the purpose of its founders to unify the profession of this section by forming a strong society, similar to the Mississippi Valley Society, in the Central States and the Missouri Valley Society in the Northwest. The first meeting will be held in Oklahoma City in October. Dr. F. J. Lutz, of St. Louis, was chosen temporary chairman, and Dr. F. H. Clark, El Reno, Secretary.

Reading in Bed.

ONE of the best somnifacients yet discovered is the practice of reading in bed. With a pillow of a size to raise the shoulders somewhat, a light falling, not on the face, but on the page, a book so light as to be supported without fatigue and subject matter which neither necessitates study nor is exciting an almost dull novel for example -will insure sleep within half an hour in many cases which resist medicinal measures to that end. Properly conducted read. ing in bed is not harmful, but harm comes from not seeing that all the above conditions are met.

himself liable to being considered by a later generation a victim of some phase of insanity. It is difficult to reconcile the opinions established in us in our school days with these later ideas that our heroes have become mad men in a greater or less degree. It is very easy to see that almost any of our fellows has some aberation from what appears to us as the normal. Each one of us is peculiar in his own peculiar way. We may succeed in going to earthly oblivion without having gained a degree of prominence that will leave out defects as a matter of history. But he who gains eminence in statecraft, art, science or in any walk leaves for the elaboration of future generations all his major and minor personal traits.

They tell us that Martin Luther had hallucinations; Peter the Great and Napoleon I. were both epileptics, as was Julius Caesar; Raphael was afflicted with suicidal mania; Richelieu on occasions imagined himself a horse; Decartes was followed by a specter; Cromwell was a hypochondriac and had visions; J. J. Rosseau was a melancholy madman; Swedenborg imagined that he went to heaven on a white horse; Mohammed was an epileptic; Dean Swift was partially insane by inheritance; Shelley had hallucinations; Charles Lamb and his sister were both victims of insanity; Coleridge was a morbid maniac; Milton was of morbid temperament, modern ideas of hell being formed by his descriptions of a diseased imagination. Joan of Arc, in the twentieth century, would never have had an opportunity to save France; she would have been confined that France might be safe.

Even our revolutionary statesmen are being subjected to a latter day diagnosis, and their symptoms are classified, and the exact degree of their insanity is being firmly established. The same is true of earlier American men of science and art. With modern means of diagnosis it is no longer taking a century to make a diagnosis, and we may live to see the fact determined while the unfortunate is yet alive, though this is hardly to be expected in our generation.

We may regret having our idols shattered; we confess to a liking of the belief that the heroes of the middle ages did what they did from normal motives and with normal minds, but if it must be that they were irresponsible in a degree, and the victims of circumstances, let us know the worst. A fortunate Providence and a mass of plodders who have left no record for diagnostication, have brought a pretty good world to the twentieth century, and the same will continue.

THE TORONTO MEETING OF THE BRITISH MEDICAL ASSOCIATION.

The preliminary program for the meeting of the British Medical Association, which will convene in Toronto, August 21st to 25th, has lately been issued and promises, as we suggested in an earlier issue, a scientific opportunity to be missed with regret. The officers of the association are: President, George Cooper Franklin, F.R.C.S., of Leicester; president-elect, Dr. Richard Andrews Reeve, Dean of the Faculty cf Medicine, Toronto. The Address in Medicine will be delivered by Sir James Barr, M.D., F. R.C.P., F.R.S. E.; that in Surgery by Sir Victor Horsley, M. B., F.R.C.S., F.R.S.; and that in Obstetrics by Walter Spencer Anderson Griffith, M. D., F.R.C.P. There will be thirteen sections, as follows:

ANATOMY.

President: Professor Arthur Robinson, M. D., Birmingham. Honorary Secretaries: