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Let us briefly enumerate the cases. We have temporary stenosis from inflammatory swelling in acute gastritis; this is usually easily determined from the symptoms and the transitory character and need not concern us at this time.

A foreign body may become lodged in the pylorus. The latter will normally allow a silver dollar to pass (Cohnheim). ColCollections of hair and gall-stones, as well as polypus of the stomach have also caused obstruction. An ulcer with thickened walls often causes stenosis; in some of these cases a tumor is distinctly palpable. Small ulcers, by inducing spasm of the pylorus, may also cause stenosis, likewise a cicatrix of a healed ulcer. The latter contracts, gradually narrowing the orifice and often years pass before symptoms indicate the condition. A tumor external to the stomach and adhesions may compress, and thus narrow or occlude the pylorus. Also, in gastroptosis, acute kinking of the stomach and the duodenum may also cause stenosis. These are the causes in the benign cases, and the malignant ones are, with rare exceptions, carcinoma. Ulcer, or the cicatrix following and carcinoma are the causes in almost all cases.

Now, how are we to diagnose stenosis? This depends on the establishment of two conditions, stagnation and gastrecasia. By stagnation we mean that the stomach does not empty itself in seven or eight hours. Much has been written about atony as a cause of stagnation, and I am not prepared to say it does not do so in rare cases, but I do say that when you find stagnation, in almost all cases, you have a stenosis of the pylorus. If, therefore, you find in the stomach in the morning, food which was taken the evening before, you are practically certain that there is an obstruction at the pylorus.

If, in addition to this, you find the stomach dilated, the diagnosis of stenosis is complete. Let me here direct your attention to a few points too often overlooked. If you find the greater curvature below the umbilicus, it does not follow that you have dilatation; it may mean that the normal position of the stomach is more nearly vertical. This is true in those who have the "habitus enteroptoticus" first pointed out by Stillen. This he used to designate those individuals who had an acute costal angle, and the distance from the umbilicus to the ensiform cartilage was greater than from the middle line to the anterior axillary line, and also a floating tenth rib. Such individuals are usually under-nourished, and are prone to displacement of viscera, including stomach, liver, kidney and uterus, and they, as a rule, suffer from functional diseases. On the other hand, those who have the normal habitus, viz., a

broad costal angle, the distance from the umbilicus to the ensiform is less than the distance from the middle line to the anterior auxillary line, seldom suffer with functional diseases, but are the victims of organic disease. If, therefore, you find the greater ourvature below the umbilicus, and the patient presents the "habitus enteroptoticus," the probability is that gastresctasia does not exist. In fact, we cannot say a patient has dilatation until we demonstrate that stagnation exists. The stomach is like the heart, when there is obstruction to the outflow, the muscular wall hypertrophies and furnishes the necessary force to empty the organ, and when the obstruction becomes so great that the power of the muscle is insufficient, the organ dilates. The stomach, like the heart, dilates when muscular insufficiency exists. So long, then, as the stomach is able to overcome the obstruction, neither gastrectasia or stagnation are found, even if the pylorus is narrowed.

In these cases if the passage of food through the pylorus is markedly compromised, the quantity of urine decreases, and when the total quantity for twenty-four hours falls below 500 co. (one pint), and this is not increased by proper diet, it is an indication that operative interference offers the only hope of relief (Cohnheim).

When we have established the existence of pyloric stenosis we must determine whether the lesion causing it is benign or malignant. This is done in part by the history, but more surely by the examination of the secretions. Benign cases are of longer duration, do not so markedly affect the general health, and while great emaciation may exist, there is no cachexia. The benign cases also usually give history of ulcer, or some acute inflammatory disease or of some lesion outside of the stomach. The malignant cases are attended by more rapid emaciation, cachexia, pain, vomiting of blood and mucus, and the development of tumor. The secretions, however, give us very reliable information, and while not pathognomonic, is nearly so.

If stenosis exists and there is an excess of hydrochloric acid, free and combined, the case is benign; if it is diminished or absent, it is malignant. A carcinomatous ulcer at the pylorus is an exception to this rule, and I have seen two cases in which the excess of hydrochloric acid persisted to the end, but these are comparatively rare exceptions. Still more rare is a benign obstruction developing in a patient who has chronic acid gastritis with atrophy of glands, in which the hydrochloric acid is diminished. These exceptions should not divert you from the fact that the rule given above is true in probably 98 to 99 per cent of all cases.

Let me briefly report a case to illustrate the mode of procedure:

The patient in question was a lady, 55 years of age; she was married and had two children; family history was good and her own health had been excellent, excepting at her fifteenth year she had some trouble with her stomach, which was attended with daily pain and occasional vomiting. This continued about one year, after which she fully recovered and had no illness of any character until the present trouble. Three years ago she noticed that she would occasionally become bloated and there was rumbling in the bowels, and fourteen months ago she began to vomit. The vomiting would recur daily, sometimes once and occasionally two or three times. daily, usually four or five hours after meals, and the quantity ejected was generally large. About this time she began to use lavage which was continued for one year, giving her temporary relief. The vomitus often contained food taken the day before, and the quantity sometimes was as much as a gallon. She had never vomited blood, and never had any severe pain; her bowels were generally constipated. Her normal weight was 206 pounds, and at the time she applied for treatment she weighed just 100 pounds. On physical examination I note first that she had a normal habitus, the abdominal wall was flaccid and through it, the dilated stomach and the peristaltic wave could be distinctly seen, the greater curvature was four fingerbreaths below the umbilicus.

The contents of the stomach was 120 ounces and was removed eight hours after taking food. In this the free acid was 50, and the total acidity 120. I then washed out her stomach thoroughly, and that evening had her eat a few raisins; the next morning gave her a test breakfast (two oz. of bread with four-fifths pint of water) and an hour after, removed the specimen for examination. The raisins were found and the stomach contents yielded a free acidity of 40, total acidity of 90 and the rennin test was 50 per cent above normal. At that time she declined any operative interference, and I put her on a stenosis diet, that is, a diet in which the articles are soft and fluid; under this diet she gained in flesh and strength for a short time, but soon grew worse, lost weight, and finally decided to submit to an operation.

In this case you will note that in the first place she had stagnation, for we found the articles from the day before. She had gastrectasia, which was easily discerned by inspection and palpation. We know also there was insufficiency because of the stagnation and know, too, from the fact that the total acidity was above normal, that the disease was

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THERE are four important things to do. There may be others. 1. Eliminate. 2. Regulate diet. 3. Rest, in plenty of fresh air and sunlight. 4. Administer hematics.

The bowels must be kept open. Constipation with its accompanying autotoxemia predisposes to anemia, and if it continues, makes the condition worse.

A saline laxative should be given every morning. Aloin or some pill containing it is often of great value. A good combination is: Aloin gr. 1-25, strychnine sulphate gr. 1500, atropine sulphate gr. 1-2500, oloeresin capsicum gr. 1-500; emetine gr. 1-500, with a trace of bile. From three to six of these may be given three times a day. They will tone up the bowels and serve to overcome chronic constipation.

The diet should be light, nutritious and capable of easy digestion. Milk is an excellent food, but falls short in that it contains too little iron, and large quantities must be taken to satisfy the patient. Animal food, soups and broths, are indicated in small quantities often repeated. Farinaceous food alone will not suffice. The blood must be built up by an increase in the formation of blood corpuscles. To secure this the diet must be fairly rich in nitrogen.

It should be gradually made more stimulating, and a little burgundy, port, or maderia wine may be profitably given.

Rest in bed in a well-ventilated and welllighted room, or on a couch out of doors, must be insisted upon for a while. It should be remembered that in chlorosis the cardiac muscle underoes fatty changes, and if the heart-wall is to recover itself and perform its function normally afterwards it must have as much rest as possible during the treatment.

As the patient improves, change of place and scenery, with out-of-door exercise, which inspire the psychical impulses and give a new direction to the thoughts, are all very useful.

Blaud's

Iron in some form is necessary. mass freshly prepared is usually preferred. Give one pill three times a day, after each meal, the first week of treatment; during the second week two pills three times daily, and during the third week three pills three times daily. The dose may be diminished, but the patient should have some salt of iron for three months at least. Not uncommonly, the anemia will assume an obdurate persistency, and defy your best laid schemes.

Under these circumstances the patient should go to a chaly beate spring. The amount of dilution is a matter of the greatest moment in attempting to bring the system under the influence of chalybeates in many cases. Iron is more effective when taken with large draughts of water. Under certain conditions, water is a hematic. Not only does water wash away the accumulated waste matter, but in doing so it paves the way for the growth of new material.

The cheerful society and habits of others. at chalybeate springs form a great incentive to invalids, who are inclined to be despondent, to exert themselves, and so aid in their

recovery.

These facts alone often make the difference between failure at home and success at a spring.

The arsenate of iron, 1-6 gr. three times a day, increased if necessary, is a powerful remedy in chlorosis.

Strychnine, quassin, or some other equally good bitter tonic, may be given before meals if the appetite is poor.

Hydriatic measures, such as cold sponging over the spine, and inside and outside the thighs; general graduated cold baths with brisk rubbing, cold abdominal douche, and general massage, will be found of great benefit.

Cold water properly applied is one of the most valuable curative measures in chlorosis.

Quite often it will be found that the iron simply passes through the bowels and is ejected, or else it accumulates in the liver, in both cases failing to be utilized and assimilated into a living part of the vitalized organism. In this case it has been found that the addition of nuclein solution to the prescription, in doses not exceeding a drachm daily, preferably administered by being dropped on the tongue, apparently causes the fixation of the iron in the blood and tissues; and the gain will far exceed that accruing from the use of either iron or nuclein alone.

JUGLANS is a good vermifuge and it is claimed that it has destroyed tape-worms.

NEW MEDICAL COLLEGE ORGANIZED. The College of Physicians and Surgeons of Little Rock has been incorporated by Drs. Joseph P. Runyan, William P. Illing, David C. Walt, Arthur E. Sweatland, Charles C. Stephenson, Joseph P. Sheppard, Beauregard W. Flinn, Charles R. Shinault, S. Paul Vaughter, Edwin Meek, Thomas E. Hodge, George M. D. Cantrell, William B. Hughes, W. B. Smith, Emmet N. Davis, Clinton P. Meriwether, Daniel R. Hardeman and Rezin W. Lindsey, with a capital stock of $100,000, of which $55,000 has been subscribed, to conduct a school for the teaching of medicine and surgery in all their branches; of pharmacy and dentistry; a training school for nurses, and to maintain and operate a sanitarium and hospital. The officers chosen are as follows: Dr. Charles R. Shinault, president; Dr. George M. D. Cantrell, vice-president; Dr. William P. Illing, secretary and treasurer, and Drs. Charles R Shinault, William P. Illing, David C. Walt, Arthur E. Sweatland and Edward Meek, directors. The board of directors, at a meeting, July 14, elected Dr. Jospeh P. Runyan, dean, and Dr. William P. Illing, secretary of the college.

The directors also elected the following members of the faculty: Dr. Arthur E. Sweatland, professor of anatomy; Dr. Thomas E. Hodges, associate professor of anatomy and lecturer on osteology; Dr. S. Paul Vaughter, associate professor and demonstrator of anatomy; Dr. Beauregard W. Flinn, professor of physiology; Dr. Emmet N. Davis, professor of chemistry; Dr. Rezin W. Lindsey, professor of clinical medicine; Dr. George M.D. Cantrell, professor of physical diangosis and diseases of the chest; Dr. David C. Walt, professor of the theory and practice of medicine; Dr. Clinton P. Meriwether, professor of materia medica and therapeutics; Dr. Edwin Meek, professor of obstetrics; Dr. Daniel R. Hardeman, professor of diseases of children; Dr. William P. Illing, professor of mental and nervous diseases; Dr. C. Travis Drennen, professor of syphilology and dermatology; Dr. Charles C. Stephenson, professor of disease of the eye, ear, nose and throat; Dr. Joseph P. Sheppard, professor of genitourinary diseases; professor of pathology, to be supplied; Dr. Joseph P. Runyan, professor of surgery; Dr. Charles R. Shinault, professor of gynecology; W. B. Smith, professor of medical jurisprudence and M. E. Dunaway, professor of English and literature. The adjunct professors and clinical assistants will be supplied later.

ENONYMIN is claimed to be an excellent remedy for prostration with irritation of nerve centers,

and to the numerous entertainments offered

THE MEDICAL FORTNIGHTLY by the Provincial organization.

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As a

to be present. The Association convened on the morning of the 21st, the general sessions being held in Convocation Hall and the thirteen sections meeting in the neighboring buildings of Toronto University. meeting-place the University left nothing to be desired, the buildings are splendidly arranged for the purpose and the Campus, or Queen's Park as it is called, made the surroundings charming in the extreme. Unfortunately the days of the meeting were so extremely warm that life was a burden for those who had gone North with an expectation of finding a very different temperature; the beat to a degree affected the enthusiasm of the gathering, but there being no other adverse condition no material lack of interest was manifest, and meeting was ultimately a tremendous success.

The organization of this Association attracted considerable interest among the American visitors, the committees and subcommittees, with their various ramifications seemed complicated, and to some extent confusing, but the machinery worked with such smoothness as indicated absolute understanding in every department, a matter which does not always so noticeably exist in our own larger gatherings. Visitors from America were accorded all privileges of members for the time, wearing the member's button and being welcome at all meetings

A matter of not a little interest was the wearing of Academic regalia by the officers, speakers and invited guests at the general sessions. The impressiveness of ceremonial at these sessions is a thing unusual in America and might be advantageously copied by us.

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The principal addresses of the meeting were the Address in Medicine by Sir James Barr, M.D., F.R.C.S., F. R.S.M., who spoke on "The Circulation Viewed from the Peripheral Standpoint;" the Address in Surgery by Sir Victor Horsley, M.B., F. R.C.S., F. R. S., on "The Technique of Operations on the Central Nervous System;" and the Address in Obstetrics by Walter Spencer Anderson Griffith, M.D., F.R.C.S., on "The Teaching of Obstetrics. Each of these addresses was

a masterpiece, that of Sir Victor Horsley was especially remarkable, and we regret that every reader of the FORTNIGHTLY could not have heard it. Unfortunately it is of a character that we may not reproduce it. The work of the thirteen sections was uniformly excellent, the presence in each section of various celebrities from various corners of the British domain contributed materially to the interest for Canadians and Americans present. It was a great privilege to listen to such men as Drs. Norman Walker, J. Dundas Grant, Sir Thos. Barlow, Sir Wm. Broadbent, Osler, Adami, Murdoch Cameron, Sir Hector Clare Cameron, and others too numerous to mention. To us it was a little disappointing that so generous a place on the program was allowed the American profession, flattering though the fact is, for we desired the British to have the floor as much of the time as was possible. Among the papers read, by Americans were three by men from St. Louis, Drs. Jas. Moores Ball, Geo. Homan and H. W. Loeb doing the honors for our city in this.

Aside from the scientific entertainment of the occasion the members of the Association feasted and feted from their arrival to their departure. Various excursions were arranged, to Niagara, to the Thousand Islands, to Muskoka, and to many other points, and members of the Association generally availed themselves of so much as their time would allow. Those Americans who were a little apprehensive that our going was at a bad time, as the Canadian profession would have its hands. full with the entertainment of its guests from across the ocean, and would have little time for near neighbors, were given a demonstration of what genuine Canadian hospitality means, and none of us returned with any doubt of what Canada can do when she intends doing it.

The total registration up to noon, August 24, was 1,986, of whom 650 were from the United States. Of these 1,390 were registered as members and 596 as visitors.

Of those registered as members, 1,078 were from the Dominion of Canada, 145 from England. 48 from Scotland, 19 from Ireland, 4 from Wales, 17 from the British colonies, 3 from Continental Europe, and 54 from the United States, chiefly from the following states: New York, 9; Illinois, 7; Massachusetts, 5; Michigan, 4, Missouri, 1, etc.

Of the 596 visitors, 8 registered from Europe, 26 from Canada, and the remainder, 562 from the United States.

The following physicians from Missouri attended the meeting: Drs. W. B. Dorsett, W. E. Fischel, Roland Hill, Geo. Homan, Jas. Moores Ball, Howard Carter, Jno. M. Dean, Thos. A. Hopkins, Chas. H. Hughes, J. Ellis Jennings, H. W. Loeb, Frank J. Lutz, Mary H. McLean, K. C. Millican, E. W. Spooner, A. H. Meisenbach, A. J. Steele, St. Louis; O. L. McKillip, C. A. Ritter, Kansas City; Chas. Wood Fassett, St. Joseph.

The Lid.

IT is now some months since the Governor inaugurated the enforcement of the law requiring that saloons be closed on Sundays, no community has felt the effect of this more than St. Louis, for here the requirement has been enforced and continuously effective longer than at any other point. It would seem that the benefit or detriment of the law must by this time be generally recognized, though there is really no concerted sentiment on the subject. Our coroner tells us that there has been a material decrease in homicide; from the dispensaries we learn of a largely deoreased number of stabbings, shootings, etc., and from the police department comes a definite statement that arrests are fewer from the offences of intoxication, fighting, beatings and the interference with the rights of others in ways which call for police interference; the citizens of St. Louis appreciate the unquestionable fact that we have a more orderly city than we had when we were "wide open.' 1." Whether there will be demonstrated better health conditions later, which may be a result, it is still too early to predict, but it would appear possible. On the other side, we have our ideas of inherent liberty of action, and our dislike for anything which may even in a slight degree interfere with the catering to our individual appetites, and we do not like to be held responsible for the errors of others, or to be deprived of something be

cause another lacks our balance and commits excesses. Impartially weighing the evidence leaves no doubt that the lid is a good thing and should continue. The lid has spread from Missouri to all sections of the continent and is, in some places, more strictly on than here, clcsing saloons in the evening, covering other lines of business in its Sunday requirement and in places working a real hardship, but in spite of this we believe that the lid works to the advantage of the vast majority of our people. In this connection it was a matter of not a little interest that men of such scientific position as Sir Victor Horsley and Professor Woodhead, of Cambridge, have lately declared before the British Association that alcohol is worthless, or nearly so, as a medicine, and that milk and soda is a better tonic for the sick, and in this they were upheld by many of our foremost physician as well as a number from abroad, when this can happen the man who make "medicine" an excuse for his daily dram had better be looking for another excuse, for he is losing his backing. We are not quite ready to accept Sir Victor's belief as final, but we can agree that mighty little that is good comes from it except when it is used as a medicine.

Speaking of lids, the association journal tells us that France is to have the real thing in this line:

"A bill has been before the French parliament for fifteen years and has finally been passed which imposes Sunday rest. Compulsory closing of shops on Sunday is now required, and cessation of week-day work is imperative on all employes or workmen in a manufacturing or commercial establishment or its dependencies, whatever its nature, public or private, lay or clerical, even if it has a character of professional instruction or benevolence There are numerous exceptions provided for. Whenever it is evident that the Sunday rest for all the personnel of an establishment would be prejudical to the public or would compromise the normal function ing of the establishment, the day of rest can be given on some other day than on the Sunday or divided among several days, or the personnel of the establishment may take turns in the Sunday rest. A special permit is necessary to have a right to these exceptional privileges of remaining open all or part of Sunday, except in the case of hospitals, dispensaries, drug stores and saloons. The Semaine Medicale laments this special favor granted to saloons, stating that there is one saloon in France for every fifteen adult males, and their closing on Sunday would be a national blessing.

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