place soon after treatment was discontinued. The treatment in some of these cases was prolonged to nine months with some intermissions. CASE V.-A papermaker, aged twenty-six years, with a negative family history, was admitted to the hospital September 16, and discharged November 11, 1902. His disease was diagnosed sarcoma of the ileum.

At twelve years of age patient's testis was injured by having a board fall on it, causing atrophy of the organ. He has two children living and well. The third died at the age of three weeks. He had la grippe three years ago, and has had the diseases of childhood and typhoid fever, the latter when about seven years of age. He has had no venereal diseases.

Three years ago while going to work one morning he fell on a slippery walk. He struck on his hip and had a watch in his hip pocket. He experienced no pain at the time, but after five or six months the parts became very sore in a circumscribed area. This condition remained about the same until last May, when a lump appeared and grew continually until to within the last three or four weeks. His physician diagnosed his condition rheumatism. In July last, after riding a wheel, he was unable to leave his bed the next day on account of pain, and the leg has ached ever since. He applied such things as camphor oil and turpentine to it. He had pain of a burning character in the lower right leg. He lost about forty pounds in weight.

Examination of the right hip showed a swelling about five inches in diameter extending from the crest of the ileum downward. The skin over the swelling was roughened as a result of blistering. The tumor felt hard, nodular and infiltrating, especially at the periphery. The tumor extended from the anterior border of the ileum back to the sacroiliac joint and down nearly to the lowest portion of the bone, involving the entire bone.

An exploratory needle was inserted into the tumor by Doctor Darling but no cavity was found, and only blood escaped from the wound. It was then treated daily with the Roentgen rays at a distance of four inches for six minutes. It measured five and one-half by eight inches October 3, and was smaller and softer in the region exposed to the r-rays, but at the upper border it was hard, nodular, very sensitive to pressure, and apparently growing very rapidly. The new portion of the tumor was also exposed to the Roentgen rays but no change was effected in it. The only benefit the patient received from the treatment was a temporary relief from pain. Instead of being bedridden he was able. to walk around in the ward. He finally became discouraged and went home, where a so-called surgeon opened the tumor and the patient died of hemorrhage. This patient was given forty-three exposures to the Roentgen rays. There was no increase in weight during the patient's sojourn in the hospital.

The results obtained in the treatment of sarcoma with the Roentgen rays have not been uniformly satisfactory. Some cures have, however, been reported. One of Coley's patients recently suffered a recurrence

in the axilla, groin and behind the colon, and treatment with the r-rays has again been begun. Three cases have been cured in this manner, one by Skinner, of New Haven, one by Pusey, of Chicago, and the third by Fisk, of Brooklyn. Mosely, of Philadelphia, reports one patient with recurrent sarcoma of the temporal region cured, one patient with sarcoma of the pharynx and one of similar disease in the buttock, which died. In some cases the tumor has entirely disappeared, apparently by absorption. In nearly all the cases there has been marked relief from pain during the treatment with the Roentgen rays. Coley reports that in five cases of inoperable sarcoma the tumors entirely disappeared, but there were slight local recurrences in periods varying from three to four months. These recurrences disappeared upon further treatment with the x-rays. In each of these cases the treatment was prolonged for a long time, having been kept up in one case of sarcoma of the femur for eleven months. In nine other cases there has been great improvement but no cure. The remaining thirteen cases either showed no improvement or none worthy of being noted.

CONCLUSIONS.

Every case which is to be treated with the Roentgen rays should be given one exposure for about five minutes at a distance of six or eight inches, and then all further treatment be discontinued for a week or ten days in order to determine whether any idiosyncrasy toward the Roentgen rays exists and to avoid severe burns of the tissues. After that time exposures may be made every second or third day according to the needs of the case. To emphasize the necessity of these precautions reference need only be made to a case reported from the Johns Hopkins Hospital by Doctor Maurice Rubel, wherein death occurred from an extensive r-ray burn of the abdomen produced after two exposures of twenty minutes each, the tube being at a distance of six inches from the abdominal wall and the spark gap three inches. For lupus vulgaris and superficial malignant growths very soft tubes should be used, the spark gap not being over one-quarter to one-half an inch. For deep-seated growths and neoplasms of the internal organs tubes of a slightly higher vacuum may be used with a spark gap of two inches. Sufficient cases have now been reported to show that it is not necessary to excite a dermatitis to effect a cure. Such a reaction is an actual interference with the process of healing and may do great harm to the patient by causing the extension of the malignant growth to the surrounding tissues and the intoxication produced by the absorption of products of the broken-down cells, and the toxins resulting from infection with pyogenic organisms may further increase the general exhaustion and hasten death.

REFERENCES.

(1) Wiener Medical Presse, Number XXI, 1899.

(2) WILLIAMS: "The Roentgen Rays in Medicine and Surgery," page 394.

(3) HOLLAND: Liverpool Medico-Chirurgal Journal, March, 1901, pages 87-92.

(4) SCHIFF: Klinisch-therapeutische Wochenschrift, 1901, Number XXVII, July 7, pages 883-887.

(5) GREENLEAF: Buffalo Medical Journal, October, 1901, pages 189-193.

(6) HYDE, MONTGOMERY and ORMSBY: Journal of the American Medical Association, 1903, Number I.

(7) COLEY: American Medicine, Volume IV, 1902, pages 251-256. (8) RUBEL: Journal of the American Medical Association, November 22, 1902, pages 1321-23.

(9) JOHNSON and MERRILL: American Medicine, August 9, 1902, pages 217-218.

175.

(10) SKINNER: New York Medical Record, December 27, 1902. (11) MOSELY: American Medicine, January 31, 1903, pages 171(12) W. B. COLEY: Medical News, January 31, 1903, pages 193-195.

ORIGINAL ABSTRACTS.

MEDICINE.

BY JAMES RAE ARNEILL, A. B., M. D., ANN ABBOR, MICHIGAN,

INSTRUCTOR IN CLINICAL MEDICINE IN THE UNIVERSITY OF MICHIGAN.

AND

DAVID MURRAY COWIE, M. D., ANN ARBOR, MICHIGAN.

FIRST ASSISTANT IN MEDICINE IN THE UniversiTY OF MICHIGAN.

INTESTINAL INDIGESTION (DYSTRYPSIA).

HEMMETER (Medical News, Number XVI, 1903) states that enteritis may occur with or without diarrhea. If stool is soft, (1) mucus mixed with feces, (2) bile pigments, and (3) bile-stained epithelia and muscle fibres indicate enteritis. If hard, the colon must be washed, and the washings examined for shreds of mucus to exclude colitis. With colitis, enteritis cannot be definitely proven clinically. In constipation with no colitis, the signs of enteritis are abundant muscle fibres, well recognized starch cells and fat in droplets, fatty acid crystals or

soaps.

Diarrhea may be due to absence or abnormality of the stomach juice, and such dyspeptic diarrheas are recognized by test meal analysis and by the presence of unchanged meat, connective tissue, and especially vegetable foods in the feces. Pawlow has shown that hydrochloric acid is the most essential stimulant to pancreatic secretion, and has demonstrated a new ferment, chymaze, which accelerates the action of the pancreatic ferments. Hence, the importance of appetite on gastric secretion applies also to pancreatic secretion. Pawlow has shown that the "psychic" secretion (that is, that produced by the sight or smell of food) of the stomach and the "chemic" secretion (that produced by

the chemical composition of food in the stomach) are distinct, and moreover that the action of the psychic on the food produces a greater chemic, and hence a more efficient total secretion. Also that starch paste alone does not increase the gastric efficiency, but starch paste plus meat gives better gastric juice than meat alone. Also the stomach. responds with different qualities of secretion to lactic, butyric and hydrochloric acids. All this goes to show that abnormal fermentation. in the chyme, due to lessened psychic secretion in the stomach, may cause intestinal indigestion, and be due simply to errors in diet.

Hemmeter mentions that he has discovered a ferment in the saliva which acts on gastric digestion as chymaze does on pancreatic. He calls this ferment "salivary secretion."

Carbohydrate diet may bring about dystrypsia by abnormal acid fermentations, the acids formed causing a hyperperistalsis beginning in the jejunum, and extending on downward. The first stools passed are normal, but the later ones are rich in bile pigment, have slight fecal odor, and are acid in reaction. They have no epithelia and round cells, thus distinguishing them from catarrhal stools. Starch dystrypsia may be diagnosed by the history and by the presence of excess of starch in the stools, shown by Lugol's solution. Meat fibres after weighed diet, especially if nuclei are plainly seen, signify, when present in the stools, insufficiency of the pancreas. Abstention from food, after calomel or castor oil have cleansed the tract, is efficient as treatment. Connective tissue after a meal of raw meat indicates gastric, not intestinal indigestion. Fat or fatty crystals are pathologic, but soaps are not.

Treatment. (1) Bland diet, governed by study of the stools for undigested foods, so that these may be avoided in future. Diet must be purely experimental for each case. (2) Constipation must be experimented upon therapeutically to see whether due to atony or spasm. (3) Neurasthenia is treated with massage, baths and electricity. In addition, the author recommends special remedies for special symptoms, as anorexia, anemia, putrefactive and fermentative diarrheas, et cetera, but emphasizes the point that these remedies are given only to remove the cause after it has been discovered. PRENTISS B. CLEAVES.

HENOCH'S PURPURA.

THIS somewhat rare disease, first described by Henoch in 1874, is characterized by relapses of gastrointestinal crises, purpuric eruptions. of the skin and intestinal mucosa, and hemorrhages from mucous membranes. Macarthur (Edinburgh Medical Journal, January, 1903) reports the case of a robust boy of sixteen. History.-June: Pain in umbilicus. July: Purpuric eruption on legs. August 18: Extensive purpura around elbow-joints, left thigh and knee; lips swollen, gums bleed readily; no fever. August 20: Collapse, intense pain about umbilicus, spasm of left rectus, otherwise abdomen soft; vomiting quantities of bile-stained fluid with altered blood; constipation. Five relapses, no joint symptoms.

D. M. C.

SURGERY.

BY HENRY O. WALKER, M. D., DETROIT, MICHIGAN.

PROFESSOR OF SURGERY AND CLINICAL SURGERY IN THE DETROIT College OF MEDICINE.

AND

CYRENUS GAVITT DARLING, M. D., ANN ARBOR, MICHIGAN.

LECTURER ON SURGERY AND DEMONSTRATOR OF SURGERY IN THE UNIVERSITY OF MICHIGAN.

THE MALIGNANCY OF JOINT TUBERCULOSIS CHARLES F. PAINTER (Boston Medical and Surgical Journal, January 8, 1903). The writer uses the term malignant in the sense of recurrence or return of the disease in the same place after a period of apparent cure and gives clinical evidence to justify the term. The cause of recurrence in twenty-five per cent of the cases is traumatism and the time from three to thirty years. The scar tissue from repair which remains in a diseased joint may be easily broken by direct violence or a strain thus lowering its resistance, setting free bacilli and permitting them to enter surrounding tissues. The patient is always in danger after an apparent cure, and he should be taught how to avoid those accidents which may cause a return of the disease. Age plays an important part in recovery, fewer cases recovering when the disease occurs in advanced life after the tissues have in a measure lost their resistance.

The modern treatment of tuberculous joints calls for more complete and longer fixation when the disease occurs in childhood. Earlier and more radical operative measures, in adults, when the x-ray and the tuberculin test have made the diagnosis certain, thus cutting short the process or lessening the pernicious effect of prolonged local disease upon the general health.

Relapsing cases should receive energetic treatment. He also advises the open-air treatment, especially in septic cases.

HEPATIC DUCT STONES.

C. G. D.

RAYMOND CUSTER TURCK, M. D., of Chicago (Annals of Surgery), after a careful review of the literature, is prepared to state that he finds no case reported of isolated stone in the hepatic duct, and that this condition associated with stone in the common or cystic duct is rare. Mayo, in a report of three hundred twenty-six cases, found but five. Ochsner, in reporting forty-eight cases, does not mention it. Mayo-Robson in three hundred five cases found only four. The author then proceeds to report his own case.

A German woman, aged forty-one years, who presented the usual symptoms of gall-stones, came to operation. The gall-bladder was six inches long and contained two floating stones, one, which blocked the cystic duct, was readily milked into the gall-bladder. Another concretion, which was felt higher up in the gastrohepatic omentum, proved to be a stone in the hepatic duct. The lower end of the stone was about