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cles in the affected region. Temperature 98 acid 1.8%. No blood (guaiao-turpentine test), deg., pulse 72, respiration 24. The patient nothing abnormal microscopically. is advised to enter the buspital, but refuses. The patient was now turned over to the

September 9.-The pain in the thorax and medical department and came again under pectoralis is diminished. The patient now my care. complains of pain in the epigastrium, in the The skin was asben, not cachectic. Lungs left hypochondrium and in the left anterior normal to percussion and auscultation, Apex lumbar region. The tenderness in tbe epi. beat in the fifth interspace one inch inside gastrium is increased, and now extends to the the mammary line. No heart murmur, car. left bypochondrium. There is also a tender diao dullness from the left border of the ster. spot below the angle cf the left scapula. The num to within one inch of the mammary line. muscular rigidity renders satisfactory ab. Liver dullness at the sixth rib. Two par. dominal palpation impossible. Temperature tially healed wounds of recent incision of 99 deg. He is again urged to enter the hos- glands in the left axilla, still discharging. pital, or to remain in the hospital a day for Dorsal spine rigid, not irregular. Extreme examination in narcosis, but refuses both. tenderness in the entire epigastrium and in The patient was not seen again at the

the left hypochondrium, point of greatest

tenderness to the left of the median line clinic until March 20, 1906, when he was placed in the surgical ward by Dr. Dixon.

about two inches below the ensiform carti. He had failed greatly, and was now evidently

lage. Marked tenderness to the left of the desperately sick. His gait was unsteady, his

spinal column from the third to the ninth

dorsal vertebra, slight tenderness also to the face baggard, his voice weak, his respirations sballow and panting. He had lost sixteen

right on the same level. Pressure on the left pounds in weight in the last three months.

lower anterior and lateral thoracic wall painHe suffered with a constant, heavy, aching

ful. Attempt at anteflexion of the dorsal pain that extended from the epigastrium and

spine causes pain from the left -scapula sternum through to the back, under the left

through to the epigastrium. Purplish scapula. This pain had been present about

blotches or scars on the legs, white papery one mouth and had grown worse daily. In

scars on the left knee. addition to this there was a severe cutting

Pupillary and patellar reflexes normal, pain in the stomach soon after eating solid

pupils equal.

p food, which was first noticed three months

Urine. -Specific gravity 1020, trace of alpreviously. The pain under the scapula and

bumin, a few hyaline casts, no pus, no sugar. behind the sternum increased with tłe stom.

Blood.-Hemoglobin 85%, red cells 4,850,ach pain. The pains bad destroyed tbe pa.

000, leucocytes 14,400.

Stool.-Free from blood (guaiac-turpen. tient's rest at night, and had frequently been

tine test) and mucous. so serere as to require morphine.

Temperature 100 deg., pulse 80, respira. The appetite bad remained good, but the tion 24. patient had refrained from eating solid food The features of the case that impressed on account of the pain that followed. There themselves most prominently upon the mind was no nausea, and no belohing except of gas, of the observer were the pains as described, which brought relief.' There had been no increased by taking food, the tenderness over vomiting, except once, when the patient had the entire area of the stomach, but greatest taken some medicine said by his physician over a definite point below the ensiform car. to have been intended to cause vomiting. tilage. the tenderness inside of the left soapThe vomitus contained nothing apparently ula, and lastly, fever. This, with the excepto suggest blood. The bowels bad been con- tion of hemorrhage, is as complete a picture stipated, stools never observed to be black. of gastrio ulcer with perigastritis as one The patient complained of an inability to could wish to see. To the perigastritis, I take a deep breath, and deep inspiration attributed the fever, the diffuse tenderness caused pain in the lower left thoracio and in the upper abdomen, the pain on pressure splenic region. There was no cough nor over the lower thoracio wall and the pain on hoarseness. The patient bad always bad a bending the spine. The dyspnea I supposed "strong back” until about one month pre- was due to interference with the excursion of viously.

the diaphragm by the perigastritis. Stomach examination, at the request of Tenderness posteriorly is found in one-third Dr. Dixon.-Stomach fasting empty. Test of ulcer cases. * Usually the tender point is meal of toast bread 35 grams, water 400 cubio small and located to the left of the 10th to the centimeters, removed in one hour. Amount 12th dorsal vertebra, rarely to the right. Occaobtained, 75 cubio centimeters, well digested, sionally, however, there is a more extended no mucous, free hydrocbloric acid 1.6%, total

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

ibe am very hlarly,

fel the paita At the the

tender zone bigher up, in the region of the 4th rather recent, loose adhesions, and the suor 5th dorsal. Tuberoulosis of the spine was perficial vessels of the stomach in the corresthought of as a possible cause of the fever, the ponding region were injected. spinal rigidity and much of the pain of which The heart was displaced to the right, the this patient complained; but that could not apex lying in the median line. The left explain the tenderness in the epigastrium or pleural cavity was filled with blood, parthe pain after food.

tially olotted. The lungs were both adherUlcus ventriculae then with perigastritis ent at the apices, and the lower lobe of the was the diagnosis to which I was driven. Jeft, also along the posterior border. This And thougb he was seen by several other lobe contained considerable blood, and the pbysicians after he came into the medical tissue was soft and friable, especially in the ward, none of whom, however, examined him portion opposite the sixth dorsal vertebra. more than casually, no one considered seri. The entire aroh of the aorta and the thoracic ously any other explanation of the patient's gorta were atheromatous, and projecting condition. He was accordingly put at once from the outer curve of the arch and from upon a strict ulous regime. He was given the outer side of the upper part of the thorabsolute rest in bed, moist hot packs were acic aorta was a group of several small sacplaced on the epigastrium, and hot bottles on oulate aneurisms, the smallest no larger the side and under the shoulder for the re- than a pea. The largest, very thin walled, lief of pain. At the suggestion of Dr. Fisch. about two inches long and irregularly cylinel, the attempt was made to carry out a drical in shape, had ruptured into the left few days of rectal nourishment. But against pleural cavity and into the left lung. The this the patient rebelled absolutely, and he bodies of the fifth and sixth dorsal vertebrae received then by mouth every two hours were eroded irregularly to a depth of one censix ounces of milk, lukewarm. After two timeter. days, strained oatmeal gruel, or an egg The esophagus showed nothing abnormal beaten in inilk, was substituted for the milk externally, and the stomach nothing further at part of the feedings, and the portions than mentioned abore. On opening the stomwero increased from six to eight ounces. acb, the contents were found to consist of In view of possible syphilis, potassium iodide dark groumous material, obiefly blood. There and mercury were administreed after a few was no ulcer. In the esophagus, on a level days trial, and the iodide was rapidly in- with the upper and one of the smaller aneurcreased to sixty grains three times daily. isms was an irregular sballow ulcer about He received no other medication.

two centimeters in diameter, partly covered For about two weeks the patient made a by a recent clot. The ulcer accounted for the remarkable improvement. The nourishment blood in the stomach. was cautiously increased in quantity, more I must reproach myself for not having even semi-solid food was given and was followed thought of aneurism in connection with this by no pain. The pains in the shoulder and case. I regret also that I did not have an side were so diminished that they were en. X-ray examination made. This might have tirely controlled by the hot bags. The pa. rendered evident the erosion of the vertetient slept fairly well, and complained chiefly brae, and possibly revealed the aneurism it. of the confinement and of hunger. Again on self. I thought of the X-ray in connection April 7th, he complained of severe pain un. with a possible disease of the spine, but the der the left shoulder-blade, without other conditions, all saving hemorrhage, pointed unusual symptoms. Trusting that this so clearly to ulous, that this possible means would soon subside as before, I made no of enlightenment dropped from my mind. further examination. The next morning. The aneurism was, of course, the cause of after taking his food as usual, he was sud. the pain and tenderness in the back, the pain denly seized with hemorrhage, and in thirty in the thorax, and doubtless of some of the minutes was dead. The blood was bright pain in the upper abdomen, possibly also of colored, frothy, free from food particles, the dypsnea. The tenderness anteriorly and about one-fourth litre in amount, manifestly the pain after solid food, I think must have from the lungs.

been due to the perigastritis. The perigas. Of the post-mortem findings I will tritis may have been caused by an inflammamention only those that have a direct tory process originated by the aneurisin bearing upon the case. The portion of through pressure, and whicb penetrated the the obest over the lower lobe of the left diapbragm; or it may have been simply a lung was dull on peroussion. The stomach local peritonitis of some other origin. Periwas greatly distended and filled with Auid. tonitis localized in this region is not rare, The fundus was connected with the spleen, and is sometimes very troublesome, and and with the diaphragm posteriorly by causes many symptoms noted in this case.

THE MEDICAL FORINIGHTLY

charge oln, has fali Hospitalrintend.

The ulcer in the esophagus, I think, caused none of the symptoms observed. It was prob. ably due to pressure, and of recent origin, or else quiescent during the greater part of the

Issued Tenth and Twenty-Fifth of Every Month. patient's stay in the hospital. Otherwise blood

THOMAS A. HOPKINS, would have been detected in the stools, which

Managing Editor. were examined repeatedly. The patient was

Editorial Staff : evidently syphilitic.

0. E. LADEMANN, Internal Medicine. My thanks are due to Dr Fischel, by whose JOHN MCHALE DEAN, Surgery. kind permission I report this case.

R. B. H. GRADWOHL. Pathology and Bacteriology.
W. H. VOGT, Obstetrics and Gynecology.
WALDEMAR FISCHER, Ophthalmology.
A. LEVY, Pediatrics.

W. T. HIRSCHI, Therapeutics.
A solution of salioylio acid (1 to 500) is A. F. KOETTER, Otology.

HERMAN STOLTE, Laryngology and Rhinology. useful as a gargle and mouthwash in diph

F. P. NORBURY, Nervous and Mental Diseases. theria.

T. A. HOPKINS, Genito-Urinary Diseases.

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

EDITORIAL Vienpa.

The inauguration of a special clinic on oon. DR. AND MRS. W. G. MOORE are spending tagious diseases at the City Dispensary is a August in lower Canada, they will visit New

recently effected change York and neighboring oities before returning a New

wbich will work to the to St. Louis.

advantage of the com. Departure in

munity. This clinic is Dr. J. L. GREENE, formerly Superintend the Health

to be primarily a tuber. ent of the Nebraska State Hospital for the Department.

culosis clinic, the name Insane at Lincoln, has resigned and will as.

obosen being less spebume charge of the Central Illinois Hospital

cifio since among the class of patients for for Insane at Kankakee.

which it bas been established many would FIGHTING THE MOSQUITO. - Dr. Samuel G. refuse to submit themselves did the name Dixon, Commissioner of Health of Pennsyl. suggest the suspected disease. Dr. L. M. vania. has been for some time exploring the Warfield has been put in oharge of this State for the breeding places of the mos. clinio, and will give the unfortunates the quito, and has now issued orders for the benefit of the best modern methods of exdrainage or oiling of all such collections of

amination and treatment. Chief Dispen. water.

sary Physician Soherck and Dr. Warfield

are enthusiasts over the new venture, and so. ACCORDING to a recent monthly report of licit the co-operation of the profession that the board of health of the Philippine Islands, the many neglected cases of tuberculosis in the number of lepers now living in the archi. the city may be placed under proper supervi. pelago is 3,683. They are scattered through sion. The clinio hours (7 to 10 a.m., 4 to 6 the various provinces. Cebu, which has 675, and 7 to 8 p.m.) are admirably arranged for heads the list, but only one province is the acoommodation of the poorer olasses, for wholly free from the disease.

whose benefit the clinic has been established. PITTSBURGH'S WATER SUPPLY.—The oity

It is hoped presently to establish in conjunogovernment of Pittsburgh is finding it neces

tion with the clinic a day sanatorium, where sary to issue a oiroular warning the people

patients may spend their days, receiving not to use any water in an unboiled state on

proper hygienio, dietetic and therapeutio at. acoount of the impure condition of the water

tention and suoh instruction as will make

their return home for nights harmless to supplied by the city and the various compan. ies. Typhoid fever is on the increase.

themselves and their families.

Another feature of the olinic has been the The University of Giessen completes, in transfer of the antitoxin squad to its super1907, the three-hundredth year of its exist. vision. Hereafter patients needing antitosin enoe, says a contemporary. The University who are unable to pay for the same will reof Leipsio is arranging a celebration for 1909ceive it on application from the attending of its five hundredth anniversary. The Uni. physician; a dispensary physician will ad. versity of Liepsic was founded by secession minister the antitoxin and work in conjunoof several thousand students, December 14, tion with the attending physician, retiring 1409, from the flourishing University at from the case as soon as the antitoxin has Prague.

been effectively used.

[graphic]

de mater; Cros; Docartococasionath suicidas

These are changes which must needs be ap. himself liable to being considered by a later preciated by physicians and those interested generation a piotim of some pbase of insanin charitable effort. It is believed that the ity. It is difficult to reconcile the opinions clinic will be of tremendous advantage to the established in us in our school days with poor, and that, as its scope is broadened, it these later ideas that our heroes have become will become one of the strongest of our mun. mad men in a greater or less degree. It is icipal institutions for the publio good. very easy to see that almost any of our

fellows has some aberation from wbat ap. pears to us as the normal. Eaoh one of

us is peculiar in his own peculiar way. We PRELIMINARY steps were taken at a meeting may suoceed in going to earthly oblivion of State delegates, called by Dr. Jabez N. without baving gained a degree of prom.

Jackson, in Kansas inence that will leave out defects as a mat.

City, on July 16, for ter of history. But he who gains eminence Medical

the organization of a in statecraft, art, science or in any walk Association of

society to be known as leaves for the elaboration of future generathe Southwest. the Medical Association tions all his major and minor personal

of the Southwest, com. traits. prising the states of Missouri, Kansas, Ar. They tell us that Martin Luther had kansas, Oklahoma and Texas. It is the pur. ballucinations; Peter the Great and Napo. pose of its founders to unify the profession leon I. were both epileptios, as was Julius of this section by forming a strong society, Caesar; Raphael was affioted with suicidal similar to the Mississippi Valley Society, in mania; Richelieu on oocasions imagined the Central States and the Missouri Valley himself a horse; Decartes was followed by Society in the Northwest. The first meeting a specter; Cromwell was a hypochondriac will be held in Oklahoma City in October. and bad visions; J. J. Rosseau was a melanDr. F. J. Lutz, of St. Louis, was chosen oholy madman; Swedenborg imagined that temporary chairman, and Dr. F. H. Clark,

he went to heaven on a white borse; Mo.. El Reno, Secretary.

hammed was an epileptio; Dean Swift was partially insane by inheritance; Shelley had

hallucinations; Charles Lamb and bis sister ONE of the best somnifacients yet discovered

were both victims of insanity; Coleridge was is the practice of reading in bed. With a

a morbid maniac; Milton was of morbid pillow of a size to raise

temperament, modern ideas of bell being the shoulders somewhat,

formed by his descriptions of a diseased imReading a light falling, not on

agination. Joan of Aro, in the twentieth in Bed. the face, but on the

century, would never have bad an opportunpage, a book so light as

ity to save France; she would have been conto be supported without fatigue and subjeot

fined that France might be safe. matter which neither necessitates study nor Even our revolutionary statesmen are bejs exciting-an almost dull novel for example ing subjected to a latter day diagnosis, and --will insure sleep within balf an hour their symptoms are classified, and the exact in many cases which resist medicinal meas. degree of their insanity is being firmly estabures to that end. Properly oonducted read. lished. The same is true of earlier American ing in bed is not harmful, but harm comes men of science and art. With modern means from not seeing that all tbe above conditions of diagnosis it is no longer taking a century are met.

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 expeoted SINCE history began it has been held before

in our generation. the youth of all nations that eminence is a We may regret having our idols shattered;

most worthy ambition, we confess to a liking of the belief that the

and that all should seek beroes of the middle ages did what they did The Penalty

to attain it, as they from normal motives and with normal ininds, of Fame.

doubtless should. À but if it must be that they were irresponsible

side of the picture not in a degree, and the victims of ciroumstances, illumined is the penalty of greatness as de. let us know the worst. A fortunate Provi. veloped subsequent to the exit of an actor dence and a mass of plodders who have left who has assumed an important role.

no record for diagnostication, have brought It would seem that he who would earn a pretty good world to the twentieth century, fame and who succeeds in this arbition lays and the same will oontinue.

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DR. JOSEPH D. BRYANT, New York. President-elect American Medical Association. Dr. Bryant is Professor of the Principles and Practice of Surgery, Operative and Clinical Surgery in the University and Bellevue Medical College; Consulting Surgeon to the Hospital for Ruptured and Crippled: Visit. ing Surgeon to Bellevue and St. Vincent Hospitals.; author of Bryant's System of Surgery, eto.

The British Toronto, and proscientific of

THE TORONTO MEETING OF THE BRIT

ISH MEDICAL ASSOCIATION. The preliminary program for the meeting of the British Medical Association, which will

R. A. REEVE, M. D., Toronto. convene in Toronto, August 21st to 25th, President-elect of the British Medical Association. has lately been issued and promises, as we suggested in an earlier issue, a scientific op- 47 Grosvenor street, Toronto; Geoffrey Boyd, portunity to be missed with regret. The offi. B. A., M. B., 167 Bloor street, Toronto; cers of the association are: President, George Adam Brown Kelly, M.D., 26 Blythswood Cooper Franklin, F.R.C.S., of Leicester; Square, Glasgow. president-elect, Dr. Richard Andrews Reeve, Dean of the Faculty of Medicine, Toronto. The Address in Medicine will be delivered by Sir James Barr, M.D., F.R.C.P., F.R.S.E.; President: Sir Thomas Barlow, Bart., K. that in Surgery by Sir Viotor Horsley, M.B., C.V.O., M.D., London. Honorary SecreF.R.C.S., F.R.S., and that in Obstetrics by taries: Robert Dawson Rudolpb, M.D., M. Walter Spencer Anderson Griffith, M. D., R.C.P., 36 Bloor street W., Toronto; John F.R.C.P. There will be thirteen sections, Taylor Fotheringham, B.A., M.B., M.D., as follows:

C.M., 36 Carlton street, Toronto; Robert

Hutchison, M.D., 22 Queen Anne street, ANATOMY.

London, W. The following subjects bave President: Professor Arthur Robinson, M. been seleoted for discussion: Tuesday, Au D., Birmingham. Honorary Secretaries: gust 21st.-On Blood Pressure in Relatio.

MEDICINE.

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