megalog astria: (1) the enormous stomach, (2) the lack of any gastric disturbance so far as the patient was concerned, and (3) the ability on the part of the stomach to empty itself as well as the normal stomach. The physician's interest in this stomach might be termed a purely platonic one. The patient was not sick, she had called upon the doctor on account of a cardiac disturbance. There was no way of determining how frequent such cases might be, but they must often be overlooked for the reason that the patient did not draw attention to the stomach. The etiology was not clear. It was probably a congenital abnormality, the patient being born with the enlarged stomach. How such a stomach was able to dispose of its contents without any difficulty was an interesting question.

Dr. William S. Deutsch asked if at the same time any of the other organs were enlarged.

Dr. Lippe thought it quite as commendable of the patient as of the doctor to overlook this condition of the stomach.

Dr. Charles Shattinger wanted to know the lateral boundaries as shown by the percussion figures. The question was whether the long measurement (from the ensiform cartilage down to the symphysis) could possibly have been due to vertical position of the stomach rather than increase of size.

Dr. Horace Soper said that the case was interesting inasmuch as there was often described a condition of dilatation of the stomach in pathological conditions, but this case was rare. It was hard to understand how such a stomach in that position could empty itself as this stomach evidently did. In connection with the physiological enlargement of the stomach there was evidently a compensatory hypertrophy.

Dr. F. J. Taussig, in this connection, mentioned Dr. Myer's method of estimating the size of the stomach by taking an X-ray photograph of the stomach after introducing into the stomach a rubber tube containing a metallic center, and he wanted to know if this was not a more accurate means than the percussion method. He wished to know, too, just how accurate were the percussion results compared with the findings at post mortem,

M

Dr. Rush, in closing, said, in regard to the size of the other organs, that this woman's cardiac hypertrophy had no connection with the enlargement of the stomach. The liver might possibly have been slightly enlarged, but if so, very slightly. There was no en

as

largement of any of the other organs noted. Of course it was impossible to say anything about the size of the intestine. This was not a dilated stomach, it was simply enlarged. He did not like the term physiologic enlargement. "Naturally enlarged" better described these cases, where the stomach was simply large, not dilated or atonic. As to the possibility of this being a case of vertical stomach, the lateral boundaries of the percussion figure excluded that. It was 21 cm. in width, this measurement being taken midway between the ensiform cartilage and the umbilicus. This woman weighed less than 100 pounds. In reply to Dr. Taussig's question Dr. Rush stated that by the use of the elastic tube referred to one could determine the lower border of the stomach, but not its capacity. The boundaries of the stomach could be determined with just as great accuracy by air and water percussion by the means referred to. There was much variation in the reports as to the amount of water the stomach would hold. Ewald stated that 1600 cc., (or from 250 cc. to 1680 cc.) was probably a fair estimate. Others had It given an estimate as high as 5500 cc. would seem about as impossible that the normal stomach would hold so large an amount as it did that any normal stomach would hold but 205 co. One author had given 2500 co. in case of a very large man (height 7 feet) as abnormally large. Recently Dr. Rush had filled the stomach of a patient with water, and found that he could introduce but 1200 co. without discomfort. A dilated stomach with the same boundaries as the one considered this evening held 2500 c.c. of water, though this patient was a man 6 feet in height. The characteristic feature of the dilated stomach is not its size, but its motor power, which is always impaired.

PRESENTATION OF SPECIMENS.

FRANCIS REDER, M. D.

ST. LOUIS.

RESECTION OF RUPTURED BOWEL.

THE first one of these cases required immediate abdominal section. It was a case where the history was totally obscure. This man sustained a compound fracture of the lower left femur about 4 o'clock one afternoon. He was taken to the hospital where his condition became alarming. His pulse steadily increased and his temperature lowered. When I saw him twenty-six hours after the accident, the pulse was 132, temperature 99 degs. He had a pulse of 98, temper

ature of 102 deg. a few hours after the accident. I found the abdomen tympanitic, there was much pain in the right hypochondriao region, his face was searching in expression, there was an anxious look, with pinched features. Upon being asked if anything had struck him upon the abdomen he at first failed to recall any such experience, then said that a clod of earth had struck him on the lower rib and glanced off, that it did not amount to anything. It required an hour and a half to convince those interested in the patient that a serious condition existed in the abdomen and to get their consent to an operation. When section was made, not knowing just what the condition was, or the exact location, I entered at the median line. The rigidity of the abdominal muscles was not relieved by the firm and constant pressure of the hand; no vomiting. I had no difficulty in locating the injury after abdominal section. It was near the ileocecal junction and proved to be a torn mesentery and a ruptured bowel. I resected eighteen inches of the bowel. The abdomen was full of blood. Blood was removed by dry mopping-drain was introduced. This is a gangrenous condition that took place eighteen or twenty hours after the injury. The man lived five days and then died, I presume, of a septic peritonitis. I was surprised after noting the condition of the peritoneum that he did live five days. The tear is along the mesenteric attachment of the ileum.

GALL BLADDER WITH GALL STONE IN CYSTIC DUCT.

The other case is a gall bladder removed from a woman who had been ill ten years. She was very much emaciated, with a complexion like parchment, the skin seeming attached to the bone, there being no fatty tissue. She said she had at times been very sick and was readily exhausted after doing a little work about the house. The liver was in a normal state as to size, but markedly greyish in color. This stone occupied all of the gall bladder and extended into the cystic duct, pressing upon the common duct, it caused permanent jaundice. I kept her in the hospital for general observation.

Her

condition changed rapidly. Her cheeks took on color, she called for food and the bowels began to move without aid. She was brought in on a stretcher and was able to walk out four weeks later.

next day it pained her very much. She had a normal pulse and temperature, and slept fairly well. Examination revealed pus in phalangeal action of this toe. I found sugar in the urine. The operation was done under local anesthesia. She did not feel the insertion of the needle, and though I used but very little cocaine she experienced no pain in the ablation of the toe. A great deal of pus has penetrated into the joint and collected underneath the tissue. I have put her on bichloride of mercury, which I have found beneficial in some cases of diabetes mellitus. The end of the toe is gangrenous. I have seen two deaths as a result of infection following the paring of corns. What the result will be in this case I am not yet able to state. From the amount of sugar in the urine the prognosis is an unfavorable The patient is 70 years old.

one.

DISCUSSION.

Dr. Norvelle Wallace Sharpe did not think any one was in a position to criticise the wisdom of this amputation. He had at this time a diabetic case that was bothering him. A gentleman had called upon him for an opinion upon a trouble with his foot. He had an infected foot. The great toe of the right foot had two ulcerated patches and brawny induration running well up to the ankle joint. Dr. Sharpe knew something of this gentleman's history. About eighteen months before this, he had been told, that "he was threatened with a diabetic gangrene of the foot," and since that time he had had an infected foot with which he had been walking, and upon which no intelligent care had been bestowed. The urine showed considerable sugar, abundance of albumin, hyaline and granular casts. It was remarkable that a man with so marked a type of diabetes had been able to carry an infected foot for that length of time without serious consequences. Dr. Sharpe had advised him to have the foot thoroughly cleaned, as it was a menace to him, and while assuring him that any operative procedure was fraught with danger, his actual peril was greater with the septic foot than with the operation. The toe nail was removed and at the base of it the tissues looked gangrenous. Within forty-eight hours a true gangrene supervened. This was maintained in the dry form. The dry gangrene finally merged into the moist, but it did not spread rapidly. After seven weeks the phalanx terminal had to be removed, and there was a fair quantity of pus. Dr.Sharpe then deemed it necessary to remove the proximal phalanx, (the patient had persistently refused high amputation, saying that below the ankle anything might be done, but even

there that which was only absolutely necessary). Finally, the great toe, the second toe and their metatarsi were removed. The especial point of interest was the infected foot in a marked diabetic of at least eighteen months' standing without important local or general changes. Another point of interest was that this gentleman, though abnormally sensitive, had been anesthetized twice, with perfect result with the scopalamine, morphine and ethyl chloride-ether combination. He came

out from under this anesthesia with a nice full pulse and no nausea.

Dr. Soper, referring to the removal of the infected toe, thought that the surgery was to be commended. He had seen a similar case in which there was pus in the joint and it had gone to the bad for lack of thorough operative procedure.

Dr. Deutsch said that it was not a question any longer as to the results following surgical interference in cases of diabetes mellitus. A continuous gangrene was to be expected, but the doctor's premises in amputating this toe because the sepsis were correct, for the sepsis was more likely to kill the patient than the diabetes. It was always bad surgery to am

putate if conservative surgery and watching the condition would take its place, for amputations in diabetics were followed by poor results.

Dr. W. C. G. Kirchner, speaking of the first specimen presented, said that it illustrated that class of cases often too long neglected. Those having hospital experience saw such cases persistently. They always came to the surgeon at the very last stage. These patients were given morphine and were often practically hopeless cases when first seen by the surgeon. There was no discoloration of the abdominal wall and this led the patient, his friends and the doctor astray. There might be no external indications of trauma of the abdominal wall, yet with rupture of the spleen, liver or kidney. He had recently seen such a case at the hospital. A man entered the hospital with no sign of in

jury to the abdominal wall, yet a ruptured spleen was removed, the bleeding continued, and the next morning it was found that there was an extensive rupture of the liver. That patient died of hemorrhage.

Such

cases should all be explored as soon as possible. The second case is interesting because those large stones would sometimes perforate the gall bladder and enter the intestinal tract. In one case that had come to his attention the stone was of sufficient size to obstruct the bowel and peritonitis followed. Gangrene following slight injury in diabetes

was frequent, and he had seen the entire leg affected progressively.

Dr. M. J. Lippe, referring to the second case, said that the stone had evidently been in the gall bladder a very long time. This woman had complained of a train of symptoms of one kind and another for a very long time, and she had seen a number of doctors and had been allowed to go on to an age when operation was more dangerous than if undertaken earlier in life. Eleven years ago Dr. Lippe had seen a patient who complained of a pain in her stomach. She would have this pain and again get better. Dr. Lippe had concluded after two or three years that this patient must have gall stone disease. For eleven years he had observed this patient, but there was no set of symp. toms that would allow him to make a positive diagnosis of stone in the gall bladder. Some two months ago this patient was taken with severe pain. He could palpate the distended There was also a rise in temgall bladder. When he had exposed the gall perature. bladder he had found it was large as the fist and had gotten out a lot of muco pus, but could find no stone. Down in the cystic duct was a stone as large as the end of his thumb. It was embedded in the duct and

only by considerable pressure was he en

If

abled to milk it back into the gall bladder. He used the Mayo method, and within two weeks the gall bladder ceased draining and the woman made a perfect recovery. there was any set of symptoms by which the diagnosis could be made, these patients would not have to go on suffering for so many years. The diagnosis of stones in the gall bladder was not easy; impaction in the ducts of course is not so difficult.

Dr. William S. Deutsch thought these remarks belittled both medical and surgical men. He was sure that Dr. Rush and Dr. Taussig would bear him out in the statement that these gall bladder cases did give a train of symptoms that would permit a diagnosis of the disease. It was true they might not be able to decide just how many stones there were, or exactly in every case where

they were until the abdomen was opened, but it was certainly possible to diagnose these

cases.

Dr. Lippe replied that if the previous speaker could diagnose stones in the gall bladder so readily he should tell the profession how he does it. Impacted stones with colic or jaundice, which occur years after the formation of stones in the gall bladder is easily diagnosed. Dr. Lippe replied that statistics showed that fully 50 per cent of the people past middle life had gall stones,

yet many of these certainly did not manifest symptoms of the disease, at least not sufficient for a diagnosis. Sahli could not make this diagnosis in many cases, DaCosta could not do it and many other good men were unable to do it. Ten per cent of the people present had stones in the gall bladder and did not know it. The presence of stones was a very difficult matter to diagnosticate.

Dr. Shattinger considered Dr. Lippe's remarks exceedingly to the point. He had said something Dr. Shattinger had often wanted to say himself. For many years on the floor of the medical society, they had been told that they must bring these cases to the operating-table early, and, often had their eyes regaled with bead-strings of gall stones. Many had been the admonitions that the general practitioner should not allow his patients to suffer untold agonies for untold ages, but to get them operated upon. But these gentlemen had failed to tell the general practitioner just how to make the diag. nosis. After a patient had had all sorts of diagnoses made, after all sorts of treatment had been tried for years, and after an immense amount of data had been collected, then, when this patient came to the surgeon and told him the story, when this surgeon had the benefit of everybody's mistakes and was driven by exclusion to make a diagnosis that was something more than a shrewd guess, he operated and pulled out the gall stones and then criticised all his predecessors. It was a fact, as Dr. Lippe had stated, that in very many cases one did not get symptoms clear enough to make the necessity for operation apparent.

Dr. A. E. Taussig came to the defense of the internist and expressed his belief that in a great number of obscure cases the diagnosis could be made. Each case must be considered upon its merits. If it were possible to state a few symptoms by means of which the diagnosis could be made in the great majority of cases, nothing would be easier than the recognition of gall stones. It was necessary to examine the liver, the urine, to know the history of pain, etc., in fact the patient must be examined from the ground up, there must be a careful study of the gastric function; then if the physician could not conceive of any adequate explanation of the symptoms except the existence of gall stones, the diagnosis was sufficiently certain to justify turning the patient over to the surgeon. If the case had been studied with sufficient care, when turned over to the surgeon the gall stones would be found. Of course, many cases gave no symptoms. In the case described, the very fact that a large gall bladder

was felt indicated that there were no stones in the gall bladder, for in such cases the gall bladder was usually shrunken.

Dr. Deutsch stated that his object in making the remarks he had was to bring out a little discussion on the subject. He had noticed that the Eastern societies devoted but little time to the set papers, but they had these discussions, which were most helpful. In regard to Dr. Lippe's remarks, while it was not always possible to diagnose the number and size of the stones, yet it was possible to diagnose trouble in the gall bladder region. The works of Moynihan and Mayo gave a train of the symptoms found in such cases, and Dr. Deutsch believed these men were competent and positive in their statements.

INTESTINAL OBSTRUCTION.-G. P. La Roque, Richmond, Va. (Jour. A. M. A., April 7), gives in rather full detail the diagnostic points and symptoms of simple dynamic ileus and of mechanical obstruction of the bowels in its various forms. He gives a table for differentiating strangulation from occlusion and a study of individual symptoms. The differential diagnosis between mechanical ileus and all forms of acute dynamic ileus, particularly those due to pain, from acute pancreatitis, appendicitis, etc., are noted. The article is instructive in its details.

The

THE FORMATION OF URIC ACID.-L. B. Mendel, New Haven, Conn. (Jour. A. M. A., March 24), discusses the formation of uric acid in the body, reviewing the later physiologic investigations on the subject. probable endogenous and exogenous antecedents are considered, and the probable chemical reactions involved in the formation of uric acid from other purin bodies are given. He calls attention to the peculiar role of enzymes in both the formation and destruction of uric acid. The organs and tissues concerned in these processes and the factors modifying these metabolic changes are all considered and treated of in detail with full references to the leading literature on the subject. There are many admittingly missing links, especially as regards the origin and significance of endogenous uric acid. The questions yet remain to be solved as to the cause of the modifications in physiologic conditions, the variations of the endogenous output, the tolerance of the organism, the chemical regulations of the balance between formation and destruction, the differences in different species as regards purin metabolism, and still many other unmentioned questions yet remain for investigation.

THE annual meeting of the Illinois State Medical Society will be held in Springfield, May 22 to 24, and promises to be one of great interest and profit. The being being

Illinois State

Medical Society. location being

central, will attract a large attendance, and then Springfield has always opened its doors on such occasions, and as a result the meetings held there have been uniformly successful. The preliminary program has not yet been announced, but a full one is assured, as the number of papers allotted to each section were supplied early in March. Since the reorganization of this society some few years ago it has been gradually growing in numbers, until now it is among the foremost in numbers in the United States. The spirit of organization is growing, and largely through the missionary influence of Dr. McCormack, who in his journey through Illinois has preached the spirit of fraternity and the usefulness of medicine to every community, encouraging laymen as well as physicians to see the true light in organization and perfected service.

The Illinois State Medical Society is decidedly in line with this wave of organization, and is more and more becoming of greater service to its members in all that pertains to a united brotherhood and honorable, scientific profession which seeks the opportunity for greater service. F.P.N.

DR. PALMER FINDLEY, of Chicago, will remove to Omaha on May 1st, where he will in future reside. He was recently elected to the chair of gynecology in the College of Medicine of the University of Nebraska.

The Crusade Against Illegal Medicine.

THE crusade against quacks and medical men and midwives doing illegitimate work which was inaugurated by the St. Louis Medical Society some months since has borne fruit. In two lower courts judgments have been gained in the test case in the matter of indecent and obscene advertisers, and the prospect is that this decision will be confirmed by the higher courts to which the case is being taken. A test case against one of the papers carrying such advertisements is at present in the courts, and if the explicit wording of the law stands there can be but one result in face of the facts.

The matter of abortion has been taken up, and as a result of the evidence brought to the State Board of Health the certificates of two midwives and one physician have been revoked.

The St. Louis Medical Society has raised a fund to follow up this good work and cleanse our city of these evils. The undertaking is tremendous and merits the moral and financial assistance of every lover of decency and order. Its success depends on a continuance of endeavor for months, and until the desired end be accomplished. A spasmodic effort with slight result and then relaxation is worse than making an attempt. The campaign must be vigorously pushed, and those active in it should be assisted by the profession and by the public that our cleaning may be thorough and permanently effective.

MUCH is being written in the medical press about the scientific side of medicine, and but

The Fee of the Physician.

little upon the business side. And yet the scicientific side cannot be fully developed unless the business interests of the physician are likewise looked after. There is a disposition at the present time "to outrates" in meeting the presence of more competition than has existed in the history of medicine. In place of this petty commercial spirit, there should be a fair increase in rates. There are many reasons for such an increase. In the first place at best medical skill and attention is probably the most poorly paid of any of the professions. The doctor as compared to the lawyer, for instance, receives paltry fees. This has been so since time immemorial. The education of the physician is probably more expensive than that of the lawyer. The expense of doing business is as a rule more for the doctor than for the lawyer. The nature of the doc