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amined and found it was blood. I then made the diagnosis either ulcer or erosions of the stomach. About two days afterwards there was a very copious hemorrhage of black blood, and the stools for several days afterwards contained these black, tarry masses indicating hemorrhage of the stomach. There could be now no doubt that I had now to deal with ulcer of the stomach. That is to say, the neuro sis had passed into an organic disease, which I take it was produced in this way: There was during the attacks, as I remarked, in tense cramping of the stomach, this anti-peristaltic movement, and the walls of the stomach at such times would feel as hard as a rock; by this spastic condition of the stomach, I believe, others agreeing with me-that an anemia may be produced in the mucous mem-setting in of these appearances and also to the brane of the stomach, and this anemia may be followed by gangrene; then gastric juices digest the gangrenous spot and the ulcer is

ter that, and about three weeks ago, there was another sudden collapse. Again the facies Hippocratica, moderate amount of fever, quick pulse and general debility. This set in after he had been trying to lie on the right side for some time. Then the pain and the following symptoms: On the right side, the lower margin of the ribs stood about an inch higher than the left. On the chest there were three zones of percussion; in the upper portion, there was pulmonary sound; in the middle portion, there was tympanitic sound; and in a small area, the liver sound could be produced. On the left side there was complete paralysis of the respiratory muscles, and only in the upper third was there any respiratory movement perceptible. Owing to the sudden

established.

The patient made a good recovery from the copious hemorrhage. He went East, and although much emaciated, he gained 30 pounds within a short time. After an indiscretion in his diet, he was again taken with a copious hemorrhage. At the time he felt great pain in the region of the ulcer and of the right lang. The attending physician thought that there was hepatitis and pleuritis. He was brought home in a dying condition, almost. Tarry masses still passed from the bowel, but the hemorrhage from the stomach had ceased. He was put on that diet that had been so excellent before-butter-milk. He drank it when he was thirsty; drank it when he was hungry. About one week after he arrived, remaining immovable in bed up to that time and receiving per rectum, opium in conjunction with beef peptonoids, in changing his position he experienced excruciating pain, and there followed all the symptoms of collapse. Three hours afterwards peritonitis had set in. There was pain on pressure in the left iliac region, which afterwards spread over the abdomen. There was tympanites and the pulse was 150, with the facies Hippocratica. He rallied and recovered up to a certain point. The diagnosis had been made then, peritonitis due to perforation of the ulcus rotundum. It has been said that from a peritonitis from perforation no one could recover; I account for the temporary recovery from the fact that at the time he had taken only whey. A very A very small quantity of this went into the cavity, and only a slight amount of inflammatory reaction took place as a consequence. Further more the existence of the peritonitis was verified by the post-mortem. Two weeks af

fact that there was metallic tinkling when he was shaken, the following diagnosis was made: Perforation of the diaphragm, owing to a fistula leading from the ulcer, perhaps through the liver, throngh the diaphragm, and giving either hydro pneumo-thorax, or pyo peumo-thorax. It was not advisable to set him up and only once did I have a chance to auscult the posterior portion of the lung, and there was tubular breathing. Only in the third was there natural respiratory murmur. Pulse varied from 140 to 150; temperature never came down to normal; evening exacerbations ran to 103° sometimes. The stomach was then put absolutely at rest; he was nourished by the beef-peptonoids and large clysters were administered. Even after he took no nourishment by the mouth there was excessive generation of gas. While in this condition he had cramp of the pharyx; he raised membranes thick as my finger, and it was to be supposed that the same condition extended to the stomach. It can be only due to the digestion of this detritus that the immense distention was made. It was removed by warm water, but would be immediately reproduced.

After being in this condition for twelve. days, without any nutriment going into the stomach, another attempt was made to feed by the stomach. The formation of flatus was less than when nothing was taken by the stomach. He seemed to be getting along pretty well, when suddenly general anasarca occurred. On the right side there was an oblong tumor, extending to the iliac region, due to the pus which accumulated in the cavity of the pleura.

Every time the position of the patient was changed, which was necessary on account of a bed-sore, he grew worse, and the fever and pain increased. He kept up his hope and

confidence to the last. This is one of the characteristics of persons who die from perforation of the stomach; they remain conscious up to the last moment. It was evident that it was ulcer of the stomach, and not cancer, for the following reasons: I had examined the stomach's secretion, and found hydrochloric acid to an excessive amount, and we know that in the vast majority of cases of cancer there is no hydrochloric acid present. Furthermore, there was absent the characteristic cancerous cachexia; and, finally, a sign absent, which I never missed in cancer of the stomach, viz., swelling of the supra-clavicular glands on the left side. The post mortem verified the diagnosis except in one point: when the sternum was removed with the portions of the ribs attached, there escaped a fetid gas when I made an incision into the pleura. I looked into the cavity and thought that it was pneumo-thorax, but instead of that there was a large pouch which had been formed between the convex side of the liver and the diaphragm, and the diaphragm had been pushed up to within a few inches of the clavicle. The stomach, at the place of perforation, had been agglutinated to the right lobe of the liver. There had been perihepatitis, and in fact all the serous membranes were inflamed. The pouch, being constantly supplied from the gas of the stomach, through the fistulous opening in the connective tissue, was greatly distended. The convexity was not convex any more, but was concave. The pleural cavity was found to be filled, partly with serum, partly with pus. Where the serum came from, I could not say, but the lung was in a state of extreme compression, and was edematous and had been reduced to one-third its size. There was evidence of peritonitis, although very few adhe. sions had formed. The pylorus was in a state at once of stenosis and insufficiency, and I could scarcely pass a small finger through the opening. In the immediate neighborhood of the pylorus was the ulcer, and it was evident that the ulcer had been healed once, because you could see the folds which had been formed by the contracting connective tissue. But in consequence of this contraction, there was narrowing of the pylorus, and since the walls were rigid it was stenotic and insuffi cient, and the contents of the stomach passed directly into the duodeoum, and the latter was inflamed in consequence. It was on that account that the flatulence would pass immediately into the small intestine, and so it could be seen why the small bowel swelled up directly after eating each time.

DR. A. H. MEISENBACH.-On account of

compression of the lung, was there dyspnea?

DR. BREMER.-Yes. I account for the pain in the left groin in this way: Some of the whey had escaped into the opening, and owing to the fact that he was lying on the left side, the fluid went into the left groin.

DR. H. C. DALTON.-I have here a specimen of apoplexy of the ovary. The woman, a multipara, came to the hospital on the 8th inst., and died on the 11th. We could get no previous history. She had violent peritonitis when she entered, suffered much pain, pulse weak and frequent. The ovary is about the size of a small egg. Graily Hewitt says that collections of blood may be formed in the substance of the ovary probably seated, as a rule, in a large Graafian follicle and constituting a sort of hematic cyst. This cyst may become ruptured, and blood extravasated into the peritoneal cavity. The formation of these hematic cysts in the first instance is involved in an obscurity, but he thinks it is explained by a Graafian vesicle not bursting as it should do in the Fallopian tube but that the hemorrhage takes place into the peritoneal cavity giving rise to the peritonitis. Thomas quotes Kiwisch, as saying that these collections of blood sometimes reach the size of a child's head. Thomas says that the great danger from the accident is peritonitis arising either from implication of the peritoneal fold which makes the broad ligament, or from rupture of the cortical portion of the ovary, and occurrence of hematocele.

We see these cases so rarely, that I thought it would it be of interest to the Society.

DR. J. K. BAUDUY.-I have a case to report, and I am glad to see Dr. Bremer here, as I wish to take public issue with him concerning points in connection with it. There was brought me 18 months ago, a young boy 13 years of age. About a year prior to that time, he had sustained a serious fall in which the cranium was more or less injured, and a swelling resulted. There was more or less destruction of osseous tissue, and as well as I could make out, the osseous structure seemed to be entirely destroyed over a surface as large as an orange, and I could detect what appeared to be membranes, but no pulsation. The boy had been subject to attacks of epilepsy. Pressure over the seat of this injury would produce a distinct attack of vertiginous epilepsy. There was no doubt about its vertiginous epileptic character. Quite a number of medical gentlemen examined him with me, and agreed with me as to the nature of it. The symptoms of the attack consisted in the indubitable loss of consciousness, eyes fixed, pupils dilated, local

spasm of one facial muscle. After the attack passed off he would develop a somnolent condition. But complicating this case-to which feature I wish to call Dr. Bremer's at tention there existed marked narrowing of the foreskin, with retention of smegma, giving a very unpleasant odor, and there was an irritated, angry look to the parts. Likewise, at will I could in this case, produce attacks of epilepsy by any manipulation of the prepuce, and this accords with what I have said before in this regard. I rarely fail to assure the mothers of children brought to me for epilepsy, that a cure will result from a circumcision when I find irritation of the prepuce. So I have been in the habit of recommending circumcision even where there was simply a redundancy, and I have seen it performed with undoubted advantage. I know that Dr. Bremer is much opposed to gynecological treatment of the insane. I believe with him that it is overdone to a great extent, and too frequently resorted to with vast injury to the patient. But in this case, the question was,is not this the result of reflex irritation? Just as cases of reflex insanity which are kept benefited by exception by gynecological treatment. It does not seem to me to be so difficult to understand, if we take into consideration the theory of Jaccoud, of the intracranial prolongations of the spinal cord.

DR. BREMER: I accept the invitation of my friend Dr. Bauduy, to state my views on the subject. Those gentlemen who heard my paper on "Gynecological Treatment in Psychological Neuroses," must have come to the conclusion, that, I did not speak against gynecologists as such, but only of gynecological treatment, which is not done by specialists but by general practitioners. I know that there is such a thing as insanity, produced by diseased conditions of the generative organs. I have seen two cases of melancholia, which got well under gynecological treatment. But I insist on this fact, that there is scarcely a patient admitted to the asylums, that has not had gynecological treatment, and I protest against this indiscriminate treatment. It debases our women, and examining a young girl who has not born children frequently amounts to defloration. I am far from beating down gynecology, so those charges are unfounded.

Now as to that case of epilepsy, I believe every word the doctor said in reference to it: only I don't agree with his interpretation. That epilepsy can be produced reflexly, there is no doubt, but the reflex theory is greatly overestimated. In reality, all these subjects are predisposed; they suffer from spasms dur

ing the first or second dentition, their family is neurotic. How many cases are there in in which no epilepsy is present? It takes the predisposed individual to develop true reflex epilepsy. How many ovaries have been removed without benefit from patients in whom pressure in that region would produce the fits? In Berlin a woman was told that she was to be operated upon, and the ovaries taken out. A superficial incision was made, a sham operation was performed, and she got well of the hystero-epilepsy. In certain predisposed cases, where there is redundant prepuce, I have no doubt that the epilepsy would be benefited. But if one cause of peripheral irritation is removed, it may be brought about again by peripheral irritation at another point.

DR. BAUDUY: I wish to set myself right with Dr. Bremer. I am free to admit that I misunderstood his views. I thought they were more radical than they are. But I will take issue with him about the necessity of a predisposition; in the case I spoke of there was no predisposition, there was simply a petit mal. There are many masked forms of epilepsy, and I believe that the spread of epileptiform disease is much more ubiquitous than we are inclined to think. For instance loss of urine in many cases might come under that head, and then, I think that many slight irritations will produce them, as gonorrhea, or leucorrhea.

DR. BREMER: How do you know they are epileptic? The diagnosis can only be made after there is an attack of grand mal.

DR. BAUDUY: I judged that it was epileptic because there was loss of consciousness. Although there are forms of epilepsy in which there is no loss of consciousness, still that is so rare that that may be taken almost as a sine qua non. I fully agree with the doctor in reference to the immorality of gynecological treatment in these cases.

BOOK REVIEWS.

A new

Gray's Anatomy. Descriptive and Surgical. American from the Eleventh English Edition, Thoroughly Revised and Re-Edited with Additions. By William W. Keen, M. D. Lea Brothers & Co., Phila delphia.

This most perfect of text-books appears in its eleventh revised edition, and both anatomically and typographi cally, supplies everything that could be asked. For years it has been used, above all others, as the text-book of ev

ery medical college in the United States, and its merits fully warrant the demand for it. In this edition a new feature has been introduced, at the expense of great pains and time, which consists in the different coloring of

the arteries, veins and nerves in the plates, thus avoiding

the confusion in the minds of the student as to which is an artery and which is a vein. The attachments of the muscles to the bones are also defined by red lines, thus rendering them even more distinct than in previous editions. New plates have been introduced, which still further serve to render the text clear, and, in fact, the entire work has been subjected to a complete revision which reflects great credit upon Dr. Keen. Until the tenth edition made its appearance, that part of the work devoted to a description of the peritoneum was exceedingly defi. cient in lucidity of explanation, and left nearly everything to be worked out or imagined by the student. With that edition (tenth), however, that portion of the work was completely re-written, and so explicitly and clearly, that the complicated peritoneum was largely shorn of its terrors for medical students. The plates are beautifully clear, and distinctly show the conditions of the various parts of the body in the recent state. Too great praise cannot be bestowed upon this elegant work, and Lea Brothers & Co. have most amply sustained their reputation for publishing nothing which is not of the very best.

THE

MEDICAL NEWS VISITING LIST FOR 1888. Lea Brothers & Co., Philadelphia.

This ever convenient publication makes its appearance for the forthcoming year thoroughly revised, and so constructed as to make it indispensable to every physician who makes use of a visiting-list. It is so arranged as to be adapted to any system of professional accounts, being issued in the form of a weekly edition, dated, for thirty patients; monthly, undated, for 120 patients, and perpetual, undated. New features have been introduced for the convenience of diagnosis, treatment, etc., and the work as a whole readily commends itself to the busy practitioner, saving him its cost many times over in the year, through economy of time.

NOTES AND ITEMS.

-Dr. J. G. Morton reports a case in which a fistula in ano opened by one extremity into the bowel, and by the other upon the posterior aspect of the thigh, below its middle, a distance from the upper opening of at least twelve or fourteen inches.

-Working Both Ways.-A mind-eurer, consulted by a patient, said: Believe you are cured, and all will be well. One dollar, please. Well, just believe you are paid, said the patient, and you are paid, and walked out.

-Professor Tumas believes that the absence of vomiting, which is observed in ruminants, rodents, and some other classes of animals, is due to the absence in them of a vomiting center, or to the very rudimentary condition in which it exists. In a rabbit on which he tried in every way to induce vomiting, no signs of gastric movement of that nature could be detected.

-To Gussenbauer is given the credit of having devised an artificial larynx, by means of which speech is possible after extirpation of the larynx. It possesses a metallic reed, which is placed in the air-current, producing by its vibrations a sound which is converted into articulate speech by the organs above, such as the lips and tongue.

-An ingenious trick to admit of the pursuit of the morphine habit undetected, was devised by a young girl attending a fashionable school. In the room used for hospital purposes she kept a stylographic pen, to outward ap

pearance, but which was in reality a syringe for hypodermic injections. The solution of Magendie was kept by its side, the bottle being painted black, thus simulating a bottle of ink.

-The "Pscynpscynaughty" Lancet-Clinic, in referring to a paper read by a St. Louis gentleman before the medical congress, spells the name of our city L-e-w-i-s. The spelling of the name of its own obscure city is likewise unknown to us, but we did the best we could, and hope to be corrected if any little error has crept into the orthog raphy.

-An express car in Germany was set on fire by the ig nition of woolen material by nitric acid, with which the car was loaded. It is said that nearly all the new explosives, such as roburite, melanite, etc., owe their action to this effect of nitric acid upon hair, wool, etc.

-Even to hemorrhoids can an esthetic aspect be given by choice of words. Dr. Yount, in speaking of them, says: "No disease can come on so insidiously, and spring forth without a moment's warning, a veritable fountain of pain, sending forth showers of agony, mingled with misty vaporings of suffering mortals."

-Dr. T. More Madden says that in appropriate cases turpentine is perhaps the best stimulant in puerperal fever, and one which, from its action on the skin and kidneys, materially helps in the elimination of the materies morbi from the system in such cases.

-It might be well for the Western Medical Reporter to have its proof-reader look over the St. Louis Medical Society reports published by it. We did not count the er rors which appeared in them, but they were something less than a hundred.

-Norman Lockyer, the profound thinker and eminent scientist, known best to physicians through his work in connection with spectrum analysis, has recently propounded what has been accepted by all London scientists as a magnificent hypothesis. From his spectroscopic experiments he concludes that, "all self luminous bodies in the celestial spaces are composed of meteorites, or masses of meteoric vapor, produced by heat which is brought about by condensation of meteor swarms, due to gravity." This hypothesis, if correct, will, of course, en* tirely revolutionize all astronomical bases.

-Since the advent of cold weather, the number of arti cles bearing on sexual intercourse has so largely increased, as to make one feel that the change of season has had a happy influence on the erotic tendencies of writers.

-Mr. Garraway proposes to set up a medical journal devoted to recording the defects and disappointments of medical men, excluding all cases which end in cure or recovery. He proposes to name it, "The Dead Failure, Limited." As doctors are not given to admitting their errors, the number of contributors, we think, will be small.

-Salicylate of bismuth, in the powdered form, usually in eighty centigram doses, three times daily, has been used in cases of chronic diarrhea and intestinal catarrh, which had resisted all other methods of treatment, and with very pronounced success. The efficiency of the drug would seem to depend upon its disinfecting action upon the contents of the intestines.

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without having taken the necessary pains to correctly inform themselves as to the facts in the matter. As the author says: rancid (decomposing) butter or that which is combined with various rich combinations of food is often charged with being the offending cause, when the truth is, it is only equal with the other combined ingredients in its evil influence. It is therefore gratifying to hear so

I. AN INTRODUCTION TO THE STUDY OF the Influence of DIET IN THE TREATMENT AND PRODUCTION OF SKIN DISEASES. II. IMPETIGO CONTAGIOSA.-N. Y. Med. eminent a dermatologist as Prof. White say: Jour. "It may be stated without exception that un

III. ABORTIVE TREATMENT OF FURUNCLES. cooked butter is perfectly harmless as an ar

AN INTRODUCTION TO THE STUDY OF THE INFLUENCE OF DIET IN THE TREATMENT AND PRODUCTION OF SKIN DISEASES.

A very interesting and instructive paper on the above subject was read by Prof. James C. White before the American Dermatological Society, in which he took occasion to plant himself firmly in opposition to some popular as well as professional fallacies upon this subject.

Perhaps no belief is more general than that butter and other fats are the causes of many skin diseases, or rather when they are present, that these substances exert a very injurious influence upon their course. No clinical observation is oftener brought to the attention of the dermatologist, than that of a pale strumous boy or girl having acne, with enlarged glands-who tell us that they have quit eating butter and meat long ago, and the disease has grown worse instead of better. The very food desirable for such patients has been erroneously considered as the cause and abandoned therefore. And it may be added here that a very large proportion of the pro fession have carried those ideas-(conceived in childhood) into their professional lives

ticle of food so far as the skin is concerned." He says of oatmeal, that it is commonly believed to be "heating" and is often abstained from by persons under the fear of provoking skin eruptions. "Is there any foundation for this belief? I know none." He had for years sought for the ground on which this prejudice was based among his patients who held it, and was unable to find the least rationale for it. Dr. White had often taken it from and added it to the diet of patients suffering from the diseases it was supposed to influence without having observed the least effect from it. He takes up the well known prejudice against buckwheat flour, and disposes of it in a similar way, showing that the evil influences heretofore attributed to it are due to the methods by which they are prepared being cooked with fats and eaten with large quantities of saccharine matter, molasses, sugar, etc. "These may be taken as examples of the popular prejudices, which generally prevail concerning certain articles of food. Others might be added concerning many common articles of diet in our own as well as other countriesalike groundless and inexplicable. Yet this vox populi rests upon just as real data as any evidence which exists to sustain these other beliefs. For many of them our profession is

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