THE MEDICAL TREATMENT OF DUODENAL AND GASTRIC ULCERS. A. Lambert, New York City (Journal A. M. A., September 15), states that when medical treatment is considered desirable in gastric or duodenal ulcer, the first essential is complete rest for the body and stomach, which implies rest in bed and rectal feeding, followed by milk diet. The length of time necessary for the patient to remain in bed varies from a week or two to several weeks, according to the severity of the case, and the rectal feeding should continue from three or four to ten days correspondingly. Gastric feeding should be given before the rectum becomes intolerant, and as the amount given this way is increased that by the rectum should be decreased. Peptonized milk at long intervals should be the first food, and at the end of the week the patient should be getting a quart in 24 hours, with rectal feeding discontinued. It should then be gradually increased up to two quarts a day and it is safe to begin to reduce the peptonization and to use cooked cereal gruel as part of the diluent. At the end of the fourth week the patient may be taking raw milk and in the fifth and sixth weeks can gradually return to a light unirritating natural diet. During the bed fast period the patient should receive daily alcohol spongings and baths and light massage, avoiding the abdomen. Some unirritating iron preparation may be given if necessary. To insure against relapses the patient should be instructed to use an unirritating diet and mode of life, avoiding over-exertion, alcohol, highlyspiced foods and anything that will irritate the stomach. Large doses of bismuth subnitrate are recommended before meals. The Lenhartz protein diet is mentioned and described. Special mention is made of two methods of drug treatment; the Fleiner bismuth cure and Cohnheim's olive oil treatment. The objections to them are use of the tube, which the author, however, thinks is not always essential and can be used safely with due precautions. In cases with hemorrhage, however, it is decidedly contraindicated. The use of astringents is mentioned-also the use of alkalies. The serious complications of ulcer are perforation and hemorrhage and the former is always a matter for surgical treatment, and the latter, if severe, the patient should not look on the surgeon as the last resort. While the results of medical treatment are not altogether favorable, Lambert thinks that if we could separate the acute cases in young individuals, we would have a high percentage of actual cures. As regards hemorrhages, he thinks medical treatment offers more chances than surgery, but accepts Leube's indications for surgical interference. "1. Repeated, little, unceasing hemorrhages, sapping the vitality of the patient, absolutely indicate early surgical interference, and all the more so if stasis is also present. 2. A simple profuse hemorrhage is not a surgical indication. But if it is repeated, an operation is relatively, not absolutely, indicated. An operation is only indicated if the pulse and general condition of the patient justify it." Lambert thinks that in skilled hands the mortality of gastric surgery for ulcer is today about the same as in medical treatment without surgery. Physicians can not adopt enthusiastically a surgical point of view until the best operation and its technic is more generally agreed on, and we have more statistics of final results. At present, he believes, at least, in careful preliminary medical treatment. THE PRESENT STATUS OF BRAIN SURGERY. M. A. Starr New York (Journal A. M. A., September 22), considers that sufficient time has elapsed to enable us to estimate the value of brain surgery for the relief of tumors, epilepsy and abscess with considerable accuracy. It is only in localized Jacksonian epilepsy (about 2 per cent. of all cases) that operation is indicated and in only about 20 per cent of these is it successful. Trephining for epilepsy, therefore, is of very limited application and is only to be recommended in a few selected cases which present the necessary guide to both physician and surgeon. In abscess of the brain, early operation as soon as the condition is diagnosed is imperative, and in cases of skull fracture or concussion followed within two or three weeks by symptoms suggestive of abscess, even if there are no localizing symptoms, trephining is imperative. There are many regions of the brain, injuries of which are associated with no localiz ing signs. In abscess due to chronic otitis, operation is demanded as soon as the diagnosis is made. While statistics show the percentage of recoveries after operation for cerebral abscess at present is only about 60 per cent, there is every reason to believe that it will be much greater when early diagnosis and immediate operation is the rule. In brain tumor with positive localizing symptoms, operative interference may be warranted, but in the far greater number, without localizing symptoms, operation promises nothing. Postmortem statistics indicate that about 10 per cent of brain tumors are open to surgical treatment, and that the best results may be expected when the growth is located near the Rolandic or Sylvian fissures, and the highest mortality when it is in the cerebellum. The proposition to afford relief in inaccessible tumors by making a considerable opening in the skull to relieve pressure, may be of value in some cases. Starr mentions one of his own observation in which this procedure was of benefit and two others in which it failed. In cases of extradural hemorrhage from traumatism, with symptoms of intracranial pressure, slow pulse, steady rise in blood pressure, deepening coma, Cheyne-Stokes respiration, and increasing hemiplegia, all appearing within six hours of the injury, trephining is sufficiently clearly indicated. The hemorrhage is usually from the middle meningeal artery, hence a large trephine opening or a large, bony flap should be made in the area just above the ear. In apoplexy Cushing has applied successfully, in hospital cases, the test of the condition of the blood tension in determining the need of surgical intervention to save life. When the blood pressure rises steadily to 250 mm., measured by the Riva-Rocci or the Janeway apparatus, in a case of apoplexy, and when coincidently with this there is a slow pulse falling to 50 a minute it may be said that the case will be fatal unless pressure is relieved by a considerable opening in the skull, without regard to the finding or removal of the clot. The best place for this is over the motor area of the side opposite the paralysis, as the clot may be there. Cushing's cases show that this operation may sometimes save life in an otherwise hopeless condition. Cushing has also treated surgically with success new-born infants who after a difficult labor, have suffered an extradural or intradural hemorrhage. Such infants usually die, or if they survive are defective, hemiplegic, idiotic, etc., and any measure for their relief is justifiable. It is easy in these cases to relieve intracranial pressure by opening the sutures of the parietal bone with scissors, and his success warrants urging obstetricians to consider this operation in the case of asphyxiated infants of the class described above. Obstetricians see these cases, and if they are convinced that delays are dangerous the percentage, Starr says, of idiocy and hemiplegic epilepsy will certainly be reduced. The last class of cases of cerebral hemorrhage suitable for trephining is that in which hemiplegia or hemianopsia develops slowly after an injury, and does not come to its height for three or four days. In these there is probably a surface hemorrhage from a vein in the pia mater and lumbar puncture will probably reveal blood in the cerebrospinal fluid. The symptoms may progress and threaten life, or come to a standstill, leaving the patient permanently incapacitated. In either case surgery is indicated. Starr refers here to a case of this kind in which a clot was removed from the lower third of the Rolandic fissure with good results, and remarks that many other similar cases, equally successful, could be cited. In conclusion he refers to the methods that have been recommended and employed to cure microcephalic idiocy by relieving pressure on the brain and permitting its expansion. Experience has shown the uselessness of such surgery, and it is no longer recommended. Dr. Wilcox, in a paper on Cystoscopy read before the Columbus Academy of Medicine, said that the cystoscope, with both the direct and indirect lens system and water dilatation, is an instrument of great precision and most valuable aid in the diagnosis of genitourinary diseases. With it the bladder can be inspected, the prostate outlined, the ureteric orifices viewed, the kidneys catheterized and the pelvis lavaged. Foreign bodies in the bladder can be located, and the best method for their removal determined. Stones can be seen when they can not be "struck" with the searcher. Incrusted ulcers sounded and verified by its use. Beginning hernia, fistulous tracts, primary tuberculosis, neoplasms, and the several varieties of cystitis can be seen through the cystoscope. Several cases were reported in which the cystoscope had been of indispensable value in diagnosis and treatment. Dr. Wilcox's paper will be published in a subsequent issue of our Journal. A MONTHLY Magazine of Medicine AND SURGERY. EDITORS. JAMES U. BARNHILL, A. M., Ph. D., M. D., 248 E. State Street. ASSOCIATES. D. N. KINSMAN, M. D. J. E. BROWN, M. D. V. A. DODD, M. D. H.H, SNIVELY, M. D. Communications relating to the editorial department should be addressed to Dr. J. U. Barnhill, 248 East State Street; those relating to business management should be addressed to Dr. W. J. Means, 715 North High Street. Per annum, in advance, subscription price, including postage.. Bound volumes. 15 cents. $1 00 2.00 Single copies... Original articles, scientific and clinical, memoranda, correspondence and news items are cordially solicited from the profession. NOVEMBER, 1906 MEETING OF THE OHIO ASSOCIATION OF MEDICAL COLLEGE TEACHERS. The second annual meeting of the Ohio Association of Medical College Teachers will be held in Columbus, December 26th. Dr. Starling Loving, of this city, president; Dr. J. C. Oliver, of Cincinnati, vice-president; Dr. F. C. Waite, of Cleveland, secretary. To this association are eligible (1) for active membership, all teachers of professorial grade (professors, associate professors and assistant professors) in the medical colleges of Ohio, and also the members of the State Board of Medical Examiners; (2) for associate membership, all presidents and all teachers of professorial grade of chemistry, biology, zoology and physiology in the colleges of the Ohio College Association. The object of the association, as stated in the provisional constitution, is to promote the interests of medical education, and especially to increase the efficiency and uniformity of the teaching of premedical and medical students. It also aims to secure co-operation between the medical schools and other educational institutions and to secure harmonious rela |