complication in chlorotic subjects. In this class of cases iron in full doses constitutes our sheet-anchor, and nothing in my experience answers better than a prolonged course of Bland's pills.

Nor must we forget that these neurotic symptoms frequently result from irritation of the spine, so much so, that I make it a rule in all cases of doubt to examine the spinal region, even when the patient makes no complaint of backache, to ascertain whether there is any spot which is tender on pressure; and I have been surprised to find how often there is tenderness in the dorsal region which had never before been suspected. Such tenderness is all the more likely to be present if the gastric are ac• companied by other symptoms, such as hard barking cough, or localised pain beneath the left breast. When the mischief lies in the spine it is needless to attack the stomach, but leeches, and counter-irritations by means of fly-blisters over the tender parts, along with rest, tonics, and careful attention to the general health, constitute our sovereign remedies. As an illustration of this, let me recall the case of a weakly young woman who was under my care in June, 1879, and who came complaining of persistent vomiting of several months' duration. The vomiting was easy and painless, and there was no preceding nausea nor any sensation of pain while the food lay in the stomach; it was accompanied by hard, dry cough. The vomited matters consisted of undigested food, mixed with green streaks and patches, and blood was never observed to be present. The regurgitation of the blood went on getting worse, occurring after every kind of food and at gradually decreasing intervals after meals, sometimes even taking place during the act of eating. All kinds of stomach remedies, including the application of a fly-blister to the epigastrium, had been tried ineffectually, and when I saw her she was not only in a state of the greatest debility but more emaciated than almost any patient I have ever seen. On examination of the spine, distinct tenderness was discovered for a distance of about two or three inches at the junction of the middle lower dorsal regions. A fly-blister was applied over the tender part, and after it rose the vomiting entirely ceased, except on one occasion, after taking some purgative medicine. From that day onwards she never looked behind her, and made a rapid and excellent recovery.

Again, as is well known, irritability of the stomach, in a very tractable form, may set in during the first half of pregnancy. It may sometimes be removed by careful attention to diet and regimen, and by the administration of gastric sedatives, such as those already mentioned, or by the use of the oxalate of cerium, a favorite remedy of the late Sir Jas.

Simpson. But, as has been clearly stated by Dr. Graily Hewitt, it is in many cases the result of interference with the normal expansion and growth of the gravid uterus-there being two factors, both of which may be conjoined in a given case, capable of producing his-viz., (1) incarceration with flexion or version; and (1) hardness and rigidity of the os and cervix, the first being much the more important of the two. The second factor is likely to be removed, and with it the vomiting, by Dr. Copeman's plan of dilating the internal os; while the first is obviated by raising the uterus from its displaced position, and if this can be done, the vomiting almost invariably ceases.

In the last resort we must relieve the condition by the induction of premature labor, which should be done before the strength of the patient is reduced to too low an ebb.

Of the treatment of that hydra-headed monster, dyspepsia, time will only permit of my giving one or two illustrations. Let us take the case of a full blooded man of sedentary habits, who indulges in the pleasures of the table, and whose bowels are habitually costive. He has bad teeth or eats his food very quickly; he dines in town, making for the nearest restaurant and snatching a hasty meal of very miscellaneous and often badly cooked food. He has frequently headaches, or a feeling of "swimming in the head," which may be the immediate cause of his seeking advice. We find that his tongue is habitually coated, that his appetite is defective, that he has a craving for food, and after a meal he has "a load at his stomach," or complains of a feeling of distension, from which he finds relief by loosening his clothing. At times, to, he may suffer from uneasiness in the hepatic region or in the shoulder, and his liver may even be slightly tender on pressure.

I have taken as an illustration a typical case such as we often meet with in business circles, and which cannot readily be mistaken, but minor forms of the same condition are very apt to be overlooked, especially if our advice is sought for some ailment indirectly produced or aggravated by the dyspepsia, such as asthma, or eczema, or gravel.

In such cases the bowels must be carefully regulated, and occasional doses of antibilious medicine-than which nothing is better than calomel-are indicated, or a course of Friedrichshalle or Hunyadi Janos, or of the mineral waters of Harrogate, Homburg, or Marienbad.

This treatment is, however, only of temporary service, unless at the same time, we remove the causes by making complete change in the diet and regimen.

Our patient must be instructed to take plenty of exercise in the

open air, to pay a visit to his dentist if need be, to have his meals with regularity, to eat slowly, and in great moderation, to chew his food thoroughly, even soft food being well mixed with the saliva before it is swollowed-in a word, he must be instructed to do as much as possible in the way of division and digestion of his food in the mouth, so as to throw less work upon the lower portion of the digestive apparatus.

He should dine off two or three dishes, and should, for the most part, avoid many articles of diet in every day use, such as tea, coffee, spices, and stimulants, oatmeal, cheese, pastry, soups, containing vegetables (such as hotch-potch), potatoes, raw vegetables (such as salads), and unripe fruits, fresh bread-stuffs of every kind taking toast, puffed bread, rusks, or plain biscuits instead-sweet things, unless of the simplest (such as rice pudding or stewed apples). Butchers' meat should be partaken of in small quantity, veal and pork being eschewed-raw meat is much harder of digestion than cooked, boiled than roast, old than young, and fat than lean.

A very different form of dyspepsia is one which, from a clinical point of view, may be described as weak digestion (one variety of which is the so-called atonic dyspepsia), and which is apt to be acquired by long-continued abuse of the organ of digestion, although it may occur independently of such causes, being, so to speak, natural to the individ

ual.

The more such persons are in the open air the better, although care must be taken, in the case of those who are weakly, that exercise is short of fatigue, and intervals of complete relaxation from work and worry, with change of air and scene, are frequently beneficial, while a course of mineral waters at one or other of the more noted spas-such as Homburg, Carlsbad, or Spa-which must be selected in accordance with the surroundings of each case, may prove of much service.

The diet must be regulated with the greatest care, the food being nourishing, but light and easy of digestion. The meals should be frequent but small, fluids being taken only at the end of each, and in many cases, with the principle ones, a dessertspoonful of whiskey in potash water may be prescribed with advantage.

Tonics are frequently beneficial—especially vegetable bitters, strychnia, and arsenic-in combination with acids or alkalies, but they must be skillfully selected, for their action in different persons is very capricious and uncertain. It is in this class of cases par excellence that arti ficial aids to digestion are indicated, which consist chiefly in the use of pepsine in some shape or other, or of acids. A fresh extract of the

former may be readily made according to v. Wittich's method, with glycerine as follows. The mucus membrane of a fresh pig's stomach is minced, thoroughly washed, and treated with strong alcohol, which does not affect the pepsine, but lixiviates the salts and precipitates a portion of albumen-500 ccm. of glycerine are then added; in 24 hours the extract is filtered and ready for use, the dose being zi or more. For those who are practicing in country districts, or where expense is an object, this preparation is specially worthy of trial. For my own part I am in the habit of prescribing Benger's liquor pepticus; but there are other preparations, such as Liebreich's pepsin-essenz, which may perhaps be preferred by some.

In the majority of cases, however, it is in the hydrochloric acid of the gastric juice, and not the pepsine, which is deficient, and which is therefore much more frequently required, the dose being eight to ten minims of the diluted acid in a glass of water after each meal. The old established practice of giving acid mixtures in cases of fever-during which the activity of the gastric juice is impaired-is partly due to this circumstance. It may never be forgotten that hydrochloric acid may be indicated, even when the gastric juice is very acid-as the result, for example, of acetic or butyric acid fermentation; for it takes a much greater degree of acidity to affect healthy digestion with them than with hydrochloric acid, the normal acid of the gastric juice. In order to ascertain whether it is the pepsine or the hydrochloric acid of the gastric juice which is defective, Prof. Leube, adopts the following plan in some cases

"I let the patient take about 25 grammes of Carlsbad salt on an empty stomach so as to cause anything which may remain in it to pass downwards then about noon some plain cold roast veal with or without bread. In from one to two hours afterwards I take out a portion of the contents of the stomach with the stomach sound, and convince myself concerning its smell and reaction, as well as how far the process of solution has advanced in the pieces of roast meat. I next put into three bottles equal quantities (about 50 cubic centimeters) of the filtered contents of the stomach, and hand in each of them a bundle of boiled fibrin of about equal volume. Into one of these bottles I put nothing further, into the second two drops of hydrochloric acid and into the third two drops of a neutral solution of pepsine. All three bottles are then placed in a large vessel of water, the temp. of which is kept at 95°-104° F. The digestion which takes place in the last two bottles will show whether one or other of the additions effects a more rapid solution of the fibrin than occurs in the first bottle, or whether they remain without import."

There are two or three other aids to digestion from which I have occasionally derived benefit-such as lactopeptine and ingluvin while Benger's liquor pancreaticus (which should be given in doses of zi in a glass of water two or three hours after food-i. e., when it is leaving the stomach), is specially indicated in cases of failure to absorb fats; but, on the whole, we are more likely to do good to our patients suffering from weak digestion by the administration of hydrochloric acid, or of liquor pepticus than of the above-mentioned preparations.

While there may be doubt as to the propriety of drawing off the contents of the stomach with the view of ascertaining whether the gastric juice is deficient in acid or in pepsine, there can be no question of the necessity of washing it out in cases of dilatation. For this purpose various solutions may be used-such as Vichy water, or lukewarm water containing ten grains of pure carbolic acid, or ten minims of creasote, or a drachm of hyposulphite of soda to the pint. But in addition to the daily use of the stomach tube, the diet must be carefully regulated so as to keep the organ as empty as possible consistent with fair nutrition of the system. The food should, therefore, be concentrated, given in small quantity and at short intervals; and it may be supplemented, if necesSary, by the use of nutrient enemata. In order further to favor contraction of the distended viscus, an abdominal support may be worn, or faradisation restored to (one of the sponges being applied over the epigastric region), and tonics, especially strychnia and nux vomica, are indicated.

It remains for me to refer to the question of operative interference in cases of obstruction at the pyloric orifice of the stomach, such as results from fibroid or cancerous disease, or from the cicatrization of ulcers -a subject which has been carefully considered by Dr. L. Rydygier in Volkmann's Sammlung Klinischer Vortrage, to whom I am largely indebted for the following facts: Merrem was the first (in 1810)—and later Gussenbauber and v. Winiwarter-to prove that resection of the pylorus was quite a feasable operation in the case of the lower animals. But for all that it seems never to have been attempted in the human subject until 1879, when Pean of Paris, at the urgent request of a patient, cut out a carcinomatous pylorus. Death, however, ensued five days thereafter. On the third occasion upon which the attempt was made, on account of a similar condition, in 1881, the operator being Billroth, the patient made a good recovery, but died five months afterwards, owing to a relapse. Altogether, from April, 1879, till May, 1882, the operation seems to have been performed twenty-three times. Of these operations only five were successful.