Second: In cases where cerebral symptoms are clearly due to trauma, as

(a) Where unconsciousness comes on after a period of consciousness.

(b) Where unconsciousness has lasted for more than twelve hours.

(c) Where unilateral convulsions are present without any previous history of convulsions.

As to complications and sequelæ, each must be managed on its own particular merits as it appears, and the subsequent treatment is that of the particular condition present.

Hysteria and neurasthenia or neuro-pyschasthenia of traumatic origin, should be treated the same in a general way as that found from any other cause, as well as all the traumatic psychoses. The same rule holds good when applied to traumatic meningitis and cerebritis.

If the general aspect of the case be grave, however, because of acute compression, no matter what the cause, it is generally safer to open the cranial cavity than to refrain. Yet the surgeon may hesitate because of the possible increase of his mortality per cent, for these cases are frequently unpromising from the beginning, but certainly are most serious, if left alone, and will usually die.

Hospital Versus Home Care of the Sick.

*By H. WINNEtt Orr, M. D., Lincoln.

The aim of medicine is to provide the most immediate relief and the best care for the sick. Recent years have seen many improvements in the methods employed for this purpose. Instruments of precision and refined technique have been rendered necessary in all branches of medicine by the application to diagnosis and treatment of the X-ray, blood pressure apparatus, microscopical and physiological laboratory examinations, the requirements of asepsis and others too numerous to

mention.

A comparatively few of these methods have been so simplified that they can successfully be carried to the bedside of the patient at home. Nearly all, however, can be successfully assembled in even a small hospital. That these facts are recognized is shown by the rapid multiplication of institutions of all kinds and sizes for the care of the sick, not only in the cities,

*Read before the Nebraska State Medical Association, Omaha, May 2, 3 and 4, 1911.

but in the town and villages. The hospital represents the concentration of the best things in modern medicine. Moreover, it represents usually the association and co-operation of physicians who formerly worked alone. Out of this association there develops a better kind of competition and opportunities for comparison of methods which account in large measure for the high tone of the profession today.

Much of the progress that has been made in organization and science can be traced to the hospital and the hospital laboratory. Much of the uplift in medical education can be traced to the failure of the smaller and inadequately equipped schools to measure up to the laboratory and hospital standards of their more successful competitors.

At the present time only some physicians who are still outside of hospitals and a large majority of the laity fail to sympathize with the development of hospitals.

Hospitals represent not only much better but less expensive care for the sick. The hospital nurse, the graduate of a proper training school, is the nurse of today. The day of the practical nurse, so-called, is past. Practically all physicians and many patients now recognize that fact, but much education will still be required before the entire profession and all their patients can be brought to realize that only in an institution can the nurse and the doctor in association give the best service and secure the best results for the patient. The hospital offers not only the advantages of modern equipment and apparatus but the kind of care which comes from systematic organization of workers and methods.

Conclusions as to the results of these methods and of certain lines of treatment can not be reached from their application to a single patient but only where the effects upon different patients under similar conditions can be accumulated and checked up.

The hospital becomes a means of education for patients as well as doctors and nurses. Better ideas as to the conduct of the sick room can be inculcated and made available for future use so that the effect becomes an effect not only upon individuals but upon the family and the community as a whole.

It is safe to assert that the grade of medical service is higher, without regard to any other factors, in any community or in any locality where there is a hospital than where there is none. Any physician who has ever so small a hospital with a nurse or nurses and with such equipment as he is able to gather together, even though his own personal qualifications

may not be so high or even though he himself may not rank as a specialist along any given line, is giving his patients more for their money, as the saying is, than he could possibly give without his hospital.

Whatever may be said in criticism of the present day hospital the writer believes that the above facts will be conceded and that our efforts should be not to discourage but to encourage what might be called the hospital movement. If there are abuses let them be carefully considered and as rapidly as possible properly dealt with. The hospital is based upon a correct idea. It is good for the patients and for the doctors. Let us make hospitals better if we can and by all means let us have more of them.

Pyloric Obstruction Due to Gallstones.

*By F. A. BREWSTER, M. D., Beaver City, Neb.

I have classified this case as Pyloric Obstruction, because the adhesions which resulted from the inflammation excited by the impacted stone included and involved the pylorus, causing it to become completely obstructed. However, it may be more appropriate to class it as suprapapillary duodenal obstruction, since the stone which was the exciting cause of the obstructive adhesions was situated in this region. It has only been within recent years that obstruction of the duodenum has heen described, and the reported cases are quite few; and the majority of text books have little, if anything, to say about it.

History: Mrs. S., age 44, married, previous health good except some indigestion for about two weeks previous to her illness. She had never consulted a physician until July 1st, 1910, when I was called to see her on account of pelvic pain, for which / grain of morphine was given. Upon a vaginal examination a firm mass could be felt, filling the entire right side of the pelvis, pushing the uterus over to the left. She had a chill during the night, which was followed for 24 hours by a temperature of 10212, which gradually subsided and was followed by attacks of nausea and vomiting. The vomiting became more frequent, and was preceded by eructations of gas, and neuralgic pains over the pit of the stomach and left hypochondriac region, which the nurse found were relieved by deep pressure in the pit of the stomach. She became unable to retain any nourishment, and considerable dark-colored, sour fluid was vomited,

*Read before the Republican Valley Medical Association.

which contained hydrochloric acid. I asked for consultation, the result of which was a conclusion that inasmuch as uterine and ovarian neoplasms may cause severe gastric neuroses, and in the absence of any other apparent cause we advised removal of the pelvic growth, which proved to be a multiple fibroid tumor of the uterus. The operation consisted of removal of the uterus, tubes, ovaries and appendix, which was done July 22nd, 1910. There was a hæmatoma in the right broad ligament, which I blamed as the cause of the pain, chill and fever upon my first visit. After the operation the patient was supported by rectal nourishment, and the stomach symptoms closely watched. When the time expired during which the nausea could be explained as the effect of the anesthetic, we watched the stomach symptoms more intently than ever, and while the symptoms were different in character and the vomiting not so frequent as before, yet the vomiting continued at intervals, and the record shows that at this time there was vomiting of a considerable quantity of dark green material. In about a week after the operation she ceased vomiting bile and the dark-colored material as before, and vomited only celar water or such material as was put into the stomach. The test meal showed hydrochloric acid, yet there was conclusive evidence of pyloric obstruction. No enlargement could be felt through the adbominal wall, and there was no cachexia, and not the ordinary disgust for food that cancer patients usually have. She had never been jaundiced, and never had biliary colic. Her vitality was rapidly becoming exhausted, as she had not retained food for five weeks, and had vomited more or less continually.

On Aug. 5th we again decided to open the abdomen to investigate the cause of the pyloric obstruction, and found the pylorus firmly bound down in a mass of adhesions, in the central part of which could be made out an indefinite mass about the size of a small hen's egg. Suspecting that we had a malignant growth to deal with, we hurriedly did a gastroenterostomy and put the patient back to bed, as she was too weak to withstand much shock. She at once began vomiting bile, which escaped into the stomach through the anastomosis, and this continued to occur about every hour all night and part of the next day, when I had her turned on her left side and her head and shoulders elevated, then the bile ceased going into the stomach and she stopped vomiting altogether and began taking light nourishment. Her convalescence was uninterrupted until August 28th, when she was taken with severe abdominal pain and vomiting, with obstruction of the bowels, which continued seven days.

The obstruction occurred in the small intestine, and a lump could be distinctly felt through the abdominal wall. These symptoms subsided and the bowels began moving and she again began taking nourishment, and on September 11th a gallstone nearly 2 inches in length and 11/4 inches in diameter was removed from the rectum under anæsthesia. Since this time she has had perfect health, and has increased greatly in weight.

From this case we learn that we may have a large gallstone make its way from the gall bladder to the lumen of the intestine without causing jaundice and without biliary colic; and that the early symptoms pointing toward cholelithiasis may be so trivial as to be entirely overlooked. Our attention is called to the symptoms of duodenal obstruction, which, when occurring above the ampulla of Vater, can not be differentiated from pyloric obstruction, and so far as I have been able to determine, not a single case has ever been diagnosed during life. About six years ago I sent a patient with symptoms of pyloric obstruction to Dr. C. C. Allison, and a probable diagnosis of cancer was made, although the test of stomach contents excluded it. An incision was made, and a local tubercular peritonitis found, involving the upper portion of the duodenum. Obstructions of the remaining portions of the duodenum, either over the ampulla of Vater or below it, present such definite and characteristic symptoms that a correct diagnosis in these cases can usually be made. If the stenosis is directly over the exit of the bile and pancreatic fluid there will be an obstruction of the biliary tract resulting in jaundice, clay-colored stools and icteric discoloration of the urine. The obstruction to the flow of pancreatic fluid will result in an inability to split up fats. Therefore, an important diagnostic symptom of duodenal stenosis over the ampulla of vater is fæces containing no biliary coloring matter, and which are rich in fatty elements.

The most serious and at the same time the most definite symptoms are found in cases of obstruction of the duodenum below the ampulla of Vater. The typical symptoms are a discharge of bile and pancreatic juice into the stomach, and there is continual vomiting of bile and pancreatic juice, but no fæcal vomiting. There is no meteorism, and the epigastrium is retracted on account of the empty condition of the intestine. The surgical treatment for both supra- and infra-papillary stenosis is gastro-enterostomy. The question may arise with cases of stenosis below the opening of the bile and pancreatic duct whether or not the constant presence of these two secretions in the stomach can result in any injury; and until recently it was