Chart No. 2, which is of a case occuring two years ago, shows even more graphically the effect of the serum. The curve covers only three days in which 70 c.c. of the serum was used. As the temperature was here taken every hour, it can be seen that the effect of the serum occurred immediately after the injection.

In these cases there is nothing noteworthy in the pulse records. They follow the temperature almost uniformly.

AN OBSTINATE CASE OF URETHRITIS IN THE SERVICE OF DR. FRANKLIN R. WRIGHT Mr. A began treatment for urethral irritation last April. He had never had a noticeable discharge, but the urine was very cloudy. He was treated for five months by a practicing physician who claims to have had frequent examinations for gonococci made by a competent bacteriologist, always with negative results. At the end. of five weeks the patient was discharged as cured, and he presented himself to another physician in precisely his original condition. This second physician treated him long enough to realize the obstinate nature of the disease, and brought him to me. He likewise had examined for gonococci with no result. Smears were again made, but no organisms were found. The urine was then brought to the clinical laboratory of St. Barnabas and examined in the following way by the resident pathologist: Two culture-media were prepared as follows: (1) Plates made by adding two parts of melted agar, cooled to 45° C., to one part of sterile fluid removed from an ovarian cyst; (2) Tube slants of Loeffler's blood serum were smeared with the cyst fluid by a platinum loop. Two centrifuge tubes were filled with urine drawn from the bottom of the bottle by means of a pipette, and the specimens centrifuged for three hours. The urine was then drawn from the tubes, and some of the sediment placed in small spots here and there by a platinum loop on the plate medium. At the end of 24 hours the plate was nearly covered with germ growth, and but one or two suspicious colonies found. These colonies were small, irregular, and somewhat transparent. Smears made from these showed a biscuit-shaped diplococcus, negative to Gram.

Subcultures were made on the slants previously described. Cultures were also made on a slant medium from a proved case of gonorrhea.

Observations made on the known and unknown cultures at 24, 48, 56 hours, showed typical colonies of the gonococcus in both cases. Smears made from these showed the typical diplococcus biscuit - shaped microorganisms which were negative to Gram. On the second day, however, atypical forms began to appear. Although Koch's third postulate was not attempted a diagnosis of gonococcus was made.

TREATMENT.-For the first week rest was enjoined. Then instillations of argyrol retained for ten minutes were used, and the urine cleared up entirely. Silver nitrate was next employed, and the urine at once became cloudy again, and persisted so until the silver was discarded. Argyrol as high as 25 per cent was used alternating with the silver. Under the argyrol the urine is clear, but shreds are present, whereas if the silver is used for two or three days without rest the urine clouds immediately. A few shreds still remain.

A CASE OF STRANGULATED HERNIA IN A THREE MONTHS' OLD IN

FANT

IN THE SERVICE OF DR. D. C. CowLES

On December 1st Baby P, aged three weeks and three days, commenced to vomit and apparently to suffer intense pain.

On examination a mass was found in the left inguinal region, a typical hernia, which could not be reduced. The baby was sent to St. Barnabas Hospital, and Dr. Rochford called in consultation. It was decided to operate at once. The hernial sac contained omentum and intestine. It was reduced with much difficulty, and great trouble was experienced in replacing the intestines owing to the great distension by gas. The operation required almost an hour. baby recovered satisfactorily from the anesthetic and seemed in excellent condition until at the end of 16 hours, when vomiting commenced. The odor of the vomitus became fecal, and the patient died about 20 hours after operation.

The

CITY HOSPITAL

HIGH TEMPERATURES DUE TO THE
DRAINAGE OF CEREBROSPINAL
'FLUID IN A CASE OF FRAC-
TURE OF SKULL

IN THE SERVICE OF DR. J. CLARK STEWART The patient, Cullen B―, aged 42, was kicked by a horse fifteen years ago, fracturing his skull in the right frontoparietal region. No very accurate history can be obtained of his early condition, as his mental state is not good. Seven years ago he was operated upon by some surgeon in Fargo, and depressed bone was removed. He was better for a time, but soon relapsed into his present condition.

Examination shows a fairly well nourished man of medium size with a marked depression in the right frontal region. There is also a partial paralysis of the arm and leg on the left side, most marked in the arm; and he has frequent attacks of Jacksonian epilepsy, affecting the hand and forearm on the left side. His mental condition is peculiar: he seems rational, but his memory, except for a few important facts of his history, is bad.

Operation, November 5, 1904.

A horseshoe flap was made with its base in the forehead, and running up about five inches toward the vertex. This was densely adherent over the seat of fracture, and had to be dissected carefully free. A deep depression was found, of oval shape about one inch in width by one and a quarter inches in length, whose base was filled by a thin plate of bone. A trephine opening was made at the edge of this depression, and the bone found to be over one-half inch thick. The opening was then enlarged by Rongeur gouge and mallet until normal bone was reached, the resulting gap being about four inches vertically by three at the greatest diameter. The removed bone was very much thickened, a some places being three-quarters of an inch thick. Hemorrhage was very profuse, especially toward the middle line where some large vessels communicating with the longitudinal sinuses

were incised. After the bone had been removed, it was found that the previous operator had removed an oval piece of the dura mater one inch by three-quarters in size, so that the removed bone plate had been directly in contact with exposed pia mater. A blunt instrument was passed backward between the pia and dura, and found no adhesions. The exposed brain was soft and apparently diseased, but no exploration was made for fear of causing a hernia cerebri. The skin incision was sutured, and the cavity between the skin and brain loosely packed with iodoform gauze, a second piece being used to check the profuse hemorrhage from the bone along the central part of the wound.

Patient reacted well after the operation, although he had lost a great deal of blood. His temperature the next day was 101°; pulse 100, dropping to normal on the 7th and running up again to 102 on the 9th. On November 12th his temperature again began to rise after having been approximately normal for some days, and as the interne had some doubt whether all the packing was removed, the wound was explored, and a piece of iodoform gauze was removed. This was followed by free escape of clear fluid, which, on cultures being made, gave no evidence of infection. The wound was drained with rubber tissue, and sterile dressing put on. The next few days were marked by profuse escape of fluid from the skull, accompanied by temperatures running up to 105°, and marked delirium. without much pulse disturbance. On the 17th the temperature reached 105°, and the same on the 18th and 19th. On the 20th the drain was removed, and the wound was allowed to heal, which promptly checked the flow of fluid, and also reduced the temperature, so that by the 23d it was normal, and remained normal and subnormal until his discharge December 14th.

His mental symptoms continued, though it was difficult to judge of the exact mental condition on account of certain queer ways which he developed, but by December 1st he seemed to be approximately normal in every way, his mind was clearer, his paralysis seemed better, though still present, and his Jacksonian epilepsy had entirely. disappeared.

GASTRIC CONTENTS ANALYSIS IN ULCER OF THE STOMACH

In the American Jour. of Med. Sciences for December, 1904, Howard, in his study of 82 cases of gastric and duodenal ulcer, gives some valuable figures relating to the gastric findings.

Gastric contents analyses were made in 52 patients.

Of these 27.5 per cent showed hyperacidity; 42.5 per cent subacidity, while 30 per cent had at total acidity between 40 and 60 per cent.

Free HC was present in 82 per cent, and absent in 18 per cent of the cases.

In 17.6 per cent there was hyperchlorhydria; in 26.4 per cent a normal quantity of HCl, and hypochlorhydria in 26.4 per cent.

As Howard remarks, these figures are rather contrary to the generally accepted statement that hyperchlorhydria is present in 75-80 per cent of the cases of ulcer of the stomach. Lactic acid was tested for in 43 cases. In 6 of these it was present, doubtful in 3 and negative in 34. In the 9 cases where lactic acid was present, dilatation of the stomach existed in 4 cases.

Howard Expresses the belief that the presence of lactic acid in these cases of gastric ulcer is due to the stagnation of the gastric contents, and a consequent fermentation.

The Oppler Boas bacillus was found in four

cases.

Howard offers some interesting figures bearing upon the question of carcinoma of the stomach engrafted upon ulcer. Of the 83 cases only 4 gave evidence of this transformation. Of these he admits that the first and second cases are doubtful, while the third and fourth are probably true instances of carcinoma engrafted upon ulcer of the stomach. Admitting that all four cases were genuine instances of cancer superimposed on ulcer, only 4.8 per cent of the total number could be so classified.

Such studies as these, reported by Howard, serve to establish the value in diagnosis of stomach contents examinations better than an endless amount of theoretical discussion. Some writers have gone so far as to say that these examina

tions are useless, and often misleading; others have taken the other extreme, and maintained that every disease of the stomach can be correctly interpreted if only the clinician studies carefully the stomach contents.

These are extreme views, and both are untenable. The clinical picture of many cases of ulcer and cancer of the stomach is perfectly plain, and requires no study of the gastric contents to establish the diagnosis. On the other hand, every obscure case of stomach disease in which any question arises as to the nature of the trouble should be subjected to a thorough examination of the stomach contents.. The result of this ex

case.

amination will not, in many cases, establish the diagnosis when taken by itself, but when studied in conjunction with the clinical history of the case and the physical examination, will often clear up the diagnosis in an otherwise doubtful We feel sure that many errors in interpreting gastric findings are made because the clinician draws his conclusions from the examination of the stomach contents after only one testmeal. If the patient has never taken a stomachtube before, he is in a nervous state of apprehension over the prospects of what he imagines is a trying ordeal, and the normal gastric secretion is certainly altered thereby. We have observed this repeatedly in many different patients. At the first examination no free HCl would be found, while in subsequent analyses a normal or even increased amount would be present. This we have found true also for lactic acid.

"OCCULT" BLOOD IN THE STOOLS IN GASTRIC DIS

EASE

In 1901 Boas, in the Deutsches Med. Wochenschrift, No. 20, published his first investigations upon the presence of small amounts of blood not detectible macroscopically, or microscopically, in the feces, and described a delicate, practical test for clinical use. The technique of the test is as follows: Put the patient on a meat-free diet for five or six days; make the stools soft by giving a mild laxative, such as Carlsbad salts; take

two or three grains of feces, and mix with 20 c. c. of water. Extract with 20 c. c. of ether to remove the fats. This mixture is now extracted with one-third of its volume of acetic acid, and thoroughly shaken. Then add 10 c. c. of ether, and shake again thoroughly. The ether will now rise to the top of the fluid mixture. To 2 c. c. of the ethereal extract add 10 drops of a fresh solution of tinct. of guaiac (resin of guaiac I; abs. alcohol 25), and add 10-20 drops of an old ozonized oil of turpentine (pure turpentine which has been exposed to the air for 8 weeks). If blood is present an intense blue color will appear in the mixture. The utensils used must be clean and dry, and the ethereal extract must not touch the skin during the handling process. A green or greenish-blue color is not characteristic of the test. Steele (Progressive Medicine, Dec. 1, 1904) gives a splendid résumé of the work done upon this test of Boas, and states that he believes it to be one of the most important additions to clinical diagnosis that has appeared during the past year. He summarizes our present knowledge as follows:

1. Occult blood in the feces or stomach contents is of the same significance as macroscopic hemorrhage, and of the same value in diagnosis. 2. Occult blood is constantly found in cancer of the gastro-intestinal tract.

3. It is present intermittently in ulcer.

4. It is occasionally present in organic and spastic pyloric stenosis.

5. It is absent in acid, anacid, and subacid gastritis, hyperacidity, hypersecretion, and neuroses.

It seems to the writer that only a large number of observations can really determine the value of this test of Boas. If the test is so extremely delicate as its author maintains that it is, even small amounts of blood swallowed from bleeding gums or hemorrhages from the nose, bleeding hemorrhoids, etc., would give the test, and one would always be in doubt when to rely upon the findings.

Then, again, not all cases of carcinoma of the stomach are accompanied by ulceration and hemorrhage. This is true especially of scirrhus, and in this form of carcinoma the reaction would probably sometimes be absent. In benign stenosis of the pylorus and in spastic stagnation of

SURGICAL REFLECTIONS ON THE DIAGNOSIS OF CANCER OF THE STOMACH

A. G. Gerster appeals to general practitioners to take earlier action in cases in which the suspicion of gastric carcinoma seems justified. While it is true that the technique of the excision of gastric cancer has been developed to such a degree that the mortality in the hands of some operators, such as Mayo, has been reduced to about eighteen per cent, in the direction of early diagnosis much less progress has been made. We are furthermore confronted by the dilemma that if we wait until the diagnosis is reasonably certain, especially if we delay till a palpable tumor exists, it is too late to expect cure from operation. A reliable diagnosis of cancer of the stomach in the incipient stage, in which it is susceptible of successful operative treatment, is with our present knowledge a sheer impossibility, and therefore in the case in question we must make up our minds to submit the patient to the risk of an operation before the diagnosis is firmly established. The author concludes that when in a clearly progressive case of an intractable disorder of the stomach the local and general symptoms, conscientiously collected and weighed, strongly justify the suspicion of cancer, diagnostic laparotomy should be considered not only admissible, but obligatory.-Medical Record, October 29, 1904.

A SERIES OF FOREIGN BODIES IN THE
VERMIFORM APPENDIX MET
WITH IN 1.600 NECROP-
SIES

L. J. Mitchell gives a list of true foreign bodies found in the appendix during his service as coroner's physician. One or more grape seeds were present in eight cases, one or more shot in three cases, and fragments of bone in two cases. Other objects were a portion of a shingle nail, a globule of solder, a piece of nutshell, a portion of the vertebral column of a small fish, and fragments, apparently, of ash or stone. None of the appendices containing these bodies showed any signs of inflammation either past or present.— Medical Record, December 10, 1904.

EPILEPTICS WITH EYE-STRAIN

Dr. Ambrose L. Ranney publishes anew, in the New York and Philadelphia Medical Journal, his observations and cure of epilepsy by relieving eye-strain.

This subject has excited spasmodic discussion for years, and has been the center of controversy between a few optimistic oculists and a few pessimistic neurologists.

Some years ago when Dr. Stevens, of New York, proclaimed the cure of epilepsy by glasses and tenotomies a committee of physicians of the New York Medical Society selected twenty epileptics for treatment. For some reason the experiment was not a success, and the methods of Stevens were condemned as visionary. Later, Dr. Ranney became an ardent advocate of the method, and his reports have appeared from time to time, but have not excited the comment that accompanied the Stevens controversy. Dr. Ranney has spent many years in attempting to cure epilepsy, and his report of six cures by the use of glasses and graduated tenotomies has been published so often that there seems to be no reason to doubt the accuracy of his statements. The present article impresses the fact upon the reader that cures are accomplished only by the most skillful treatment and leads one to infer that there is but one person who is sufficiently skilled for this purpose. That eye-strain, even of mod

of nervous symptoms no rational being will deny; and that occasional convulsions may be caused by eye-strain cannot be disputed. The writer, however, makes a sweeping statement and shows his mental error where he claims that private sanitariums yield large revenues from patients who are suffering from eye conditions that have. never been intelligently or carefully investigated. He practically accuses the medical profession, and oculists in particular, of gross incompetency.

Dr. Ranney says it is usually advisable to fully correct the refraction of epileptic patients by properly prescribed glasses, and after a time to correct the maladjustment of ocular muscles by graduated tenotomies. All of this has been threshed over again and again, and skillful men have labored to cure nervous errors by correcting eye errors, but few have the success that has fallen to Dr. Ranney. If a very small percentage of the cases of epilepsy can be cured by the methods suggested, why do we hear of so few successful cases? successful cases? Is it because other oculists are not keen enough to detect minor errors of refraction, or is it due to the fact that epileptics occasionally have remissions lasting from one to twenty years? Are those true cases of epilepsy, or are they epileptiform attacks due to reflex disturbances? Every physician who treats epilepsy has an occasional case that has apparently recovered, and it is fair to assume the recovery is not often due to treatment directed to the eyes.

There may be more to Dr. Ranney's theory than we care to admit, yet his article is not convincing or conclusive, nor does it establish a working hypothesis upon which to base a definite conclusion.

POLITICS, MEDICAL AND OTHER

FORMS

With the new year comes the new governor, housed in a new capital building, and new appointments to be considered. Let us hope the appointments may be as worthy as those already made.

The Board of Medical Examiners is to be rounded out with two new men, and His Excellency, John A. Johnson, will doubtless make a