the intramarginal space, with pronounced entropion and distortion of the lashes that I wish to call your particular attention. For it is these cases that cannot be cured by any ordinary treatment. Electrolysis will not cure them; nor the electro-cautery

pose. The operation to shorten and evert the lid as practiced by the novice or inexperienced surgeon usually fails to correct entropion.

Not only do they fail, but frequently they. disfigure the lid and interfere to a certain extent with its normal physiological function. Many patients have come to me with so much of the skin removed that they could not even close the lid; and the cornea was suffering from exposure. In these complicated cases we have to resort to plastic sur. gery. The operation that I have been making lately I have found most satisfactory.

It consists of grafting a strip of skin from the lid into the intramarginal space,

Fig. 1.

puncture; nor the actual cautery incision through the integument, near and parallel to the margin of the lids; nor an elliptical strip of integument taken from the margin of the lid and the space closed. I have been dealing with these cases for the last thirty-five years, both in my private practice and public clinic; and I speak advisedly. These old cases of chronic entropion with trichiasis and districhiasis are among the most troublesome and annoying affections of the eye that the practitioners have to deal with. They are among the most frequent causes of ulceration of the cornea, leucoma and pannus.

The patient has usually had all kinds of treatment: removal of the lashes by the housewife, local treatment by the family physician, and perhaps some surgical treatment by the local oculist, but all to no pur

Fig. 2.

Fig. 3.

thus widening the space and wedging all the lashes away from the eyeball. It matters not which lid is operated on, as the technique of the operation is practically the same for either the superior or the inferior.

I make an incision from near the punctum to the outer canthus, parallel to and about two millimeters from the margin of the lid. I then make a second incision parallel to and about three millimeters from the first incision, making the strip a little wider than the normal intramarginal space. I dissect up the narrow strip freeing it from all areolar tissue, but leaving it attached at either end. With the keratome I then slit the intramarginal space at the conjunctival or mucous line, from the punctum to the outer canthus; going deep into the tarsus, and taking care to embrace all the lashes with the hair bulbs in the superior flap. The hemorrhage having been well checked, I divide the strip of skin in the middle; and then with the keratome, I make near either pedicle an opening into the slot.

Through these small openings I draw the free ends of the skin graft (see figure) and place them in the slot, first taking care to free the graft from all adipose or areolar tissue. If there is much redundancy of skin, and the strips are too long I shorten them to the desired length and join the two ends by a catgut suture. This is the only suture that I use in the grafts. If the hemorrhage has been thoroughly checked

Fig. 4.

and the skin is placed smoothly in the slot, there is no occasion for any further sutures either in the graft or in the slot.

The advantage of this operation over any previous operation is that we have a living pedicle at each end, and the graft is secured in the slot or groove merely by one suture, and that confined entirely to the graft. If the operation is carefully and accurately done it will not only correct entropion, but any trichiasis or districhiasis as well, affecting a permanent cure and in many cases improving the appearance the appearance of the lid. Just before leaving Kansas City to attend this meeting, I made this operation, and in this case I did not divide the strip of skin but separated the entire strip with the lashes, and slipped the entire graft underneath into the slot or groove at the intramarginal space; and so did away with all sutures excepting one at either end to hold the graft in place.

When we wish to dry the flow of the mother's milk, as in case of death of the child, or at weaning time, the application of an ointment containing belladonna will accomplish it in short order with no detrimental effect.

AFTER THE OBSTETRICIAN, THE
GASTROENTEROLOGIST*

J. M. BELL, M. D., St. Joseph, Mo. Enteroptosis following confinement is more common than is supposed. Its symptomatology is vague upon casual inspection, and unless looked for, is not detected. Those who suffer thus are invalids. The diagnosis is passed over as a "bad getting up." I meet perhaps a dozen cases every year who date the trouble from confinement, but this is a very small percentage of the number of cases existing in our city. Every case of stretched and relaxed abdomen is not one of ptosis. Still, loss of abdominal support is one of the factors. There are women with the most pronounced abdominal pouches who have no evidence of ptosis. Enteroptosis, with pregnancy as the etiological factor, is observed in two classes of women. The most common group are those of the enteroptotic habit, an inherited tendency. These women, always, sooner or later suffer with ptosis. It shows itself when any strain is put upon the nervous, circulatory, or muscular systems. they escape the strain of school work or social demands they are fortunate. It prac tically always will develop after gestation. They are those spoken of by the late Pepper as the albuminous children of gelatinous parentage. Hemmeter describes the condition as one of nervous, cardiac vascular asthenia with osseous dystrophies and disproportions. Women of this enteroptotic habit if they escape before confinement, they do not after. The strain put upon the body incident to delivery, and the relaxation which follows it always leave a marked abdominal ptosis. Confinement is blamed abdominal ptosis. for it, any strain, mental or muscular, would have done it, but parturition, being the last straw and the exciting cause, shoulders the blame.

If

In these cases ptosis is inevitable. The obstetrician is not culpable for the condition, but he should be able to detect it and take steps toward reparation. Women of

this class, the enteroptotic, have long necks, drooping shoulders, flabby spine. The epigastric notch is a long spire, the result of prolapsed ribs. The abdomen, long narrow, flabby. The abdominal wall thin,skin silky, as in the neurasthenic type. The nervous system hyperesthetic, the circulatory system relaxed, with imperfect emptying of the abdominal veins. The ligaments, like the general tout ensemble, lacking robustness. With such a physique enteroptosis is inevit

*Read before the St. Joseph-Buchanan-Andrew County Medical Society, November 6, 1913.

able upon the individual assuming the burdens and responsibilities of life. These cases must be informed of their condition, that confinement is merely the exciting cause, and that they will need attention for some months to restore natural tone within the abdomen. The dragging feeling of exhaustion when in upright position, the dyspeptic symptoms, the pressure on the bladder and at times the tendency to uterine prolapse, the constipation, headache and dizziness are not the result of confinement, but rather of a prolapse of the abdominal organs due to their primary lack of robustness. Such cases must remain in bed several weeks, well fed on an easily digested diet. They need abdominal massage every day with faradic electricity, to overcome the relaxation of bed and to strengthen abdominal muscles and ligaments.

They

should have a cold morning sponge bath followed by five minutes rub with a coarse towel. When they do get up some form of an abdominal support must be used for an indefinite period.

It is much easier to repair such damage at once than to allow them to drag around for a year or two, with displacements well marked and perhaps adhered in the prolapsed position, necessitating surgery. For with rest, massage and electricity dilated organs will contract, and elongated peritoneal ligaments will shorten within fair limits.

If, as some one has said, we could get away from our higher education and ultra refining influences of present-day civilization, and give some attention to the physical body for the next hundred years, ptosis of all sorts would disappear, our typical American girl would assume more the proportions and robustness of the German peasant, the life-work of the obstetrician would be a joy and the gastro-enterologist would be out of a job. We are, however, still on the down grade physically. Observe any day at noon when the streets are

filled from the factory and office, the large percentage of women undeveloped, undersized, frail, willowy and pale. Leaning over the sewing machine in the factory the type-writer in the office, or the desk in the business college is creating a type of abdomen among women that tends to deterioration. Even where the enteroptotic habit has been escaped, there is a relaxation of fibre, an absence of robustness in muscle and ligament, a condition of progressive atonicity of tissue which tends more to elongation, lack of resistance and ptosis under ordinary strain. The atonicity of these women render rapid normal return of vigor impossible after parturition. Even after the uterus has contracted to normal limits and general indications suggest leaving bed, an immediate return to household duties results disastrously. The abdominal parietes are flabby, the intra-abdominal pressure is unequal to the task, peritoneal supports are slow in regaining normal vigor and ptosis results.

Thus it happens that various forms and degrees of ptosis come into existence, some so slight as to be hardly appreciable, others pronounced and intolerable, so that further pregnancies are avoided, because of the invalidism remaining from the recent experience.

These cases require the same treatment and care as the enteroptotic. There is this difference. The latter cases can make a perfect recovery and become happy wives and mothers-whereas the enteroptotic type never are perfectly restored, but remain more or less incapacitated, always a little below par. The treatment outlined does restore them to a point where life is tolerable. A very few cases who are able to employ help to do the daily drudgery, recover fair poise.

By way of practical application if a moral be permissible, advise your young men when considering matrimony to fight shy of the enteroptotic.

GASTRIC AND DUODENAL ULCER.*

FRED H. CLARK, M. D., El Reno, Okla.

In presenting this short paper on gastric and duodenal ulcer, the author has no hope, in view of the large amount already written, to be able to add anything new to the literature on this subject; but rather by simply going over the common history of the disease and briefly reciting a limited number of cases from his own experience to be of some help to those present. Neither is it the purpose of the author to follow closely the usual plan of consideration but to confine himself more particularly to the condition of a patient presenting himself at his office, or whom he may be called to attend away from the office.

In choosing this title and considering the two classes of ulcer at one time one is attacking a very large subject and my only reason for doing so is the fact that quite a considerable of the symptomatology of the two conditions is very similar if not altogether analogous; yet there are some points of difference which if kept in mind may aid very materially in making the diagnosis.

Gastric and duodenal ulcer may be roughly considered as a circumscribed loss of tissue on the inner wall of the stomach or duodenum beginning with the mucous membranes and extending in depth through the various layers of the stomach wall.

They may be roughly divided into two general classes, viz., acute and chronic. While other and more delicate classification might be made this will suffice for so brief a paper as this. As to the causes bringing about this condition much has been written by various authors; and as stated before the purpose of the writer will be to consider this subject as a clinical study, so we will first name as the cause of an acute ulcer some hyper-toxicity or poisoning, or some direct trauma, such as a fall, the patient striking with force over the region of the

Read before the Medical Association of the Southwest at Kansas City, Mo., October 8, 1913.

stomach, which may cause the sudden destruction of the tissues; and secondly, as the canse of a chronic ulcer a lowered vitality of the tissues causing them to become weakened so that either they break down or become so softened that they are di gested by the ordinary processes of stomach digestion.

One author in a recent article names 36 specific causes of chronic ulcer. Regarding the sex and age of the patients some little variation in the figures given will be found to exist among all authors, but about 60 per cent is usually given as being the average of female cases with the remaining 40 per cent male. As to the age, cases have been reported in children only 10 years of age; but the age when we may usually ex pect this condition among women is from 20 to 40, and in men from 40 to 50.

Such a wide diversity as this makes the age of no particular value except when considered in connection with other symptoms.

Mention has been made recently of the fact that this condition may be expected more frequently in the spring and fall than at other seasons of the year.

Probably more than 90 per cent of patients suffering with gastric ulcer seek the physician for relief from what they term indigestion. This was true especially in one of the cases I shall cite. This probably is caused by the fact that one of the earliest, if not the earliest symptom of gastric ulcer is a sense of fullness in the stomach after eating. Another symptom often complained of is the desire to partake of food more frequently than usual and more or less of pain when the stomach is entirely empty. One writer has described this condition by saying that many of these patients when presenting themselves for examination will be found to have a cracker in their pocket, so they can have something to eat whenever they begin to feel this discomfort which they describe as a gnawing sensation in the stomach. The writer men.

tioned says, that when that condition is met with one may almost always make a positive diagnosis of gastric ulcer without further examination.

These are the early symptoms of what is usually termed a latent ulcer, and which may go on for years, or which may bring on at any time a crisis which will call for heroic treatment. Hyperchlorhydria is nearly always present in this condition also. The one symptom which should always be looked upon as a serious one, especially in chronic ulcer, is the presence of blood either in the vomit, in the water if lavage is practiced, or in the stools; the latter can oftentimes be found only by careful microscopical examination. W. L. Rodman says that hemorrhage may be found in 50 per cent of all cases of this character if persistently looked for. The limited number of cases coming under my own personal observation would not warrant me in attempting to say what is the usual percentage.

The question of differential diagnosis in this condition is one that may not be easy to make; or rather as to whether this condition may not be accompanied with grave complications which I will note when citing one of the cases at the close of this paper. Because of this one cannot be too painstaking in securing the personal history of his patient and carefully studying it before making his positive diagnosis.

With the positive diagnosis at hand what shall we say of the treatment? I shall only quote what seems, so far as I am able to learn, to be the opinion of the largest number of men, and in which I coincide, that the acute form of either gastric or duodenal ulcer calls for medical treatment, while as a general rule to be laid down every case of chronic ulcer calls for surgical treatment if we would avoid complications which may be briefly summarized as (early) hemorrhage so severe as to be fatal late adhesions which cause great discomfort and more or less danger; the complete closure of the pylorus from cicatrization; an abscess with a fistulous opening and cancer which seems to practically always, or at least in a very large majority of instances, have an ulcer for its starting point.

Surgery, if done early offers excellent results for this condition in the large majority of cases.

In closing, I desire to briefly recite four cases covering the four points mentioned:

1. Acute, Mr. D., aged 50; white; married. Patient had been complaining of more or less difficulty in digesting his food for some little time but no history obtainable suggesting ulcer.

Was called to his residence to see him about 3 a.m. and found him almost pulseless, suffering from a severe hemorrhage from the stomach, having been vomiting blood in large quantities. The case was considered a very desperate one with every probability of a fatal termination; operative procedure at the time was not to be thought of. The patient finally rallied, and as he was very much opposed to operative procedure nothing could be done for him in a surgical way. Careful medicinal treatment was administered with every possible attention to diet, and the patient is alive at the present time, and while he still suffers more or less with his stomach he is well enough to be about and attend to his ordinary duties.

The hemorrhage spoken of occurred about six or seven years ago.

The second and third cases to be mentioned may be considered as belonging to the same class, viz., that in which the preponderance of other symptoms so overshadow the stomach symptoms that they are overlooked.

Mrs. A., age 25; white; married. Came to me complaining of severe attacks of pain in right upper abdominal quadrant, paroxysmal in character, and at the time. she applied to me for relief was considerably jaundiced. A diagnosis of gall-stones was made and operation was advised and accepted. As patient was suffering excruciating pain operation was done with as little delay as possible upon her arriving at the hospital.

Upon opening the abdomen the gall bladder was found to be distended with bile, and down in the cystic duct pressing against the common duct was a stone so impacted that it was with difficulty that it was removed; after removing it drainage was put in and the patient left the table in splendid condition and was conscious and feeling as well as could be expected in a little less than two hours.

About four hours later the writer was hurriedly called to the hospital where the patient was found vomiting large quantities. of coffee ground vomit and in pressing the husband for a more specific history, I found she had formerly had attacks similar to this one, having vomited the same material as now. Though a careful written history of the case had been taken this point had been overlooked by the patient and it proved a fatal error, as in spite of all that could be done to stop the hemorrhage she died about eighteen hours later.

Had the history included that concerning the ulcer it might have received attention