sponding to the tumor posteriorly elicited an expansile pulsation which was quite pronounced, giving the impression that the aneurism was slowly giving way anteriorly also. In addition a distinct bruit was present, very distinct in front, not so clear posteriorly, and a loud bruit could also be made out in the vessels of the left side of the neck. The pain has been almost constant since then, more marked some days than others, but never absent. On the night of January 12th the patient experienced some discomfort in the precordial region and on examination the next day evidence of pericardial effusion could be elicited. His temperature has been entirely normal or subnormal (98° to 98.6° F.) since observation, with the exception of the past week when he ran a temperature ranging from 99° to 101° F., which dropped to normal January 12th. He complained much of flatulence and eight grains of aspirin at intervals of four hours alleviated this considerably and made him very comfortable. The second plate was a very brief exposure taken January 3d. It shows the same points as the preceding skiagraph and in addition gives an outline of the less dense tissues. We can readily make out what appears to be the aneurismal sack which is about the size of a cocoanut, and which is continuous with a shadow corresponding to the course of the aorta. Through the valuable assistance of Dr. R. Lee Spire I am enabled to present a schematic line drawing which illustrates the anatomical changes very clearly. LITERATURE REFERENCES. Baginsky, Adolf. 1908.-Klinische Beiträge. Aneurysma der Bauchaorta. Arch f. Kinderh., Stuttg., v. 48, pp. 1-18. Hertz, Edg., & Bodineau, L. 1912.-Duration of life in ruptured aneurism of the abdominal aorta. Tribune Med., Am. ed., N. Y., v. 8, pp. 267-270. Lamy. 1912.-Anevrysme double thoracique et abdominale de l'aorte. Bull. Mem. Soc. Anat. de Par., v. 87, pp. 147-148. Matas, Rudolph. 1909.-Surgery of the vascular system. Aneurism of the aorta. Keen's Surgery, Phila. & Lond., v. 5, pp. 311-314. McGraw, Theodore A. 1909.-Aneurisms in young people. Ann. Surg.. Phila., v. 50, pp. 59–65. Nixon, J. A. 1912.-Abdominal aneurism in a girl aged twenty due to congenital syphilis, with tables of collected cases of abdominal aneurism. St. Bartholomew's Hosp. Rep., 1911, v. 47, pp. 43-66. Nunnely, F. P. 1906.-Aneurysm of the abdominal aorta. 121 pp. Lond. Osler, William. 1909.-The Schorstein Lecture on syphilis and aneurism. Brit. M. J., Lond., v. 2, pp. 1509-1514. Wohlauer, Franz. 1909.-Technik und Anwendungsgebiet der Roentgenuntersuchung. 126 pp., 74 figs. Stuttgart. Dr. Lemon wished merely to demonstrate a point made in the paper by Dr. Pfender, namely, the greater facility with which thoracic aneurism can be shown by skiagraphy. [He then exhibited some skiagrams of thoracic aneurisms.] Dr. D. S. Lamb exhibited a number of specimens of abdominal aortic aneurysms from the collection at the Army Medical Museum. Dr. Hynson complimented the essayist upon the paper and especially upon the enterprise which prompted him to exhibit the patient; the trouble involved in bringing such a patient to the Society was apparent, but abundant compensation is to be found in the greatly increased value of the case report when the condition can be seen in the patient himself. Dr. Claytor remarked that even with the skiagram as an aid it is sometimes difficult in thoracic cases to determine whether the condition present is merely a dilated aorta or a true aneurysm. When sacculation occurs then the differentiation becomes simpler. Dr. Frankland said that in the discussion the condition had been treated as a hopeless one from a therapeutic standpoint. He arose to speak of two cases in which he had administered calcium chlorid, with the hope of increasing the coagulability of the blood and so promote clotting in the aneurysmal sac; the probability of such an effect has been doubted, but in his two cases he had reason to believe that the treatment had been beneficial. The first case was that of an old woman, with an abdominal aortic aneurysm, arising apparently from the anterior aspect of the vessel; under calcium chlorid the symptoms greatly improved while the patient remained under his care; and now, many months afterward, while she is no longer in his care, she appears to be in good health. The second case was a popliteal aneurysm; calcium chlorid was administered; some time later, the patient dying of another condition, at the autopsy the aneurysmal sac was found filled with a firm clot. Dr. J. D. Thomas said that the determination of an aneurysm of the abdominal aorta is a difficult matter, and especially in nervous patients with pulsating aorta, in which cases the point of maximum pulsation is just at the point of maximum frequency. Dr. Pfender thanked the speakers for their participation in the discussion, and especially Dr. Lamb for bringing the exceedingly interesting specimens. The point made by Dr. Claytor was well taken, but the skiagraphic evidence would have value in any case whether positive or negative. The condition of Dr. Pfender's patient tends to grow steadily worse; the man realizes that he must shortly die, and if any surgeon in Washington thinks he can help the condition, the patient is ready to take the chances involved. PERFORATING ULCER OF THE DUODENUM.* BY D. S. LAMB, A. M., M. D. Washington, D. C. In the Army Medical Museum are six specimens of perforating ulcer of the duodénum. All are from men; three were coroner's cases in Washington; the other three were soldiers at army posts. In all of them the ulcer adjoined the pyloric valve and is a typical funnel-shaped ulcer; in one case there are two ulcers. In all of them the perforation was followed promptly by extravasation of intestinal contents into abdominal cavity, and peritonitis; death occurred in two cases on the second day of the perforation, in one case on the fourth day, in one case on the seventh day, and in the other two cases the time is not stated. The ages ranged from 20 to 54 years. The symptoms indicating the ulcer stage were not pathognomonic. The occurrence of perforation caused the usual symptoms of acute pain, cramps in abdomen, rigidity of abdominal muscles, face pinched, vomiting, hiccough, tympanites, cold sweats, collapse. The site of pain varied from the level of the umbilicus to the hypogastrium. In one case an exploratory laparotomy was done without discovering the perforation. As to the symptoms of the ulcer, in one case frequent vomiting is mentioned. In another case, the only symptom mentioned is indigestion. In a third, gastric catarrh. In a fourth, nausea, waterbrash, uneasy feeling in stomach. In a fifth, there was no history at all. In the sixth, it is stated that there was a feeling of fulness after meals, poor appetite, bad taste, coated tongue, constipation, occasional sour eructation; finally it is said that the patient had acute gastritis. Nothing pathognomonic for any of the cases. Dr. Hynson said that the subject of ulceration of the stomach and duodenum was of great interest to him. As to the etiology of the condition little is known; but there can be no doubt that there is some common cause. All the cases represented by the specimens, if studied according to the methods of present-day practice, would probably have been recognized during life. The idea that ulcers of the stomach can be caused by the irritation of food particles would seem to be unsound, because ulcers of the stomach and duodenum are all classed together and are probably due to the same causes, and as food is reduced to soft chyme when it enters the duodenum, mechanical irritation cannot cause duodenal ulcers. The relation between extensive skin burns and duodenal ulcer has often been pointed out, and the Reported, with specimens, to the Medical Society, January 15, 1913. cause of the secondary ulceration is very obscure; had Dr. Lamb any explanation of this phenomenon to offer? Dr. Lamb said that ulcers of the duodenum following surface burns are always found near the outlet of the bile duct, and it would seem that there is some relation between the ulceration and the secretions of the liver when altered as a result of the burns. Such ulcers are not found above the level of the orifice of the common bile duct. LUETIN REACTION IN SYPHILIS.* BY C. AUGUSTUS SIMPSON, M. D., We all know the difficulty of diagnosing visible syphilitic lesions, even for the physician trained in that specialty. Its similarity to other diseases is often very striking. In its obscure forms, without external manifestations, we must often rely on the history of the case, presence of scars, leucoplakia, enlarged glands, peculiar headaches, Wassermann reaction, histo-pathology and therapeutic test. Under certain conditions, with all these methods, we may still be unable to say that the patient has syphilis. The Wassermann test, when positive, is a very valuable one, but, besides not being specific to syphilis alone, it is not absolutely decisive in all cases, especially in the tertiary form when the lipoidal substances appear to be reduced and free compliment is present in the serum. Should the reaction be negative it may mean that the patient has had treatment, that his syphilis has not been active enough to stimulate the production in the blood of lipoids or other substances upon which the Wassermann reaction depends, or that the patient has recently taken alcohol. Besides this, it gives us little means of prognosticating the case, for, after giving salvarsan and mercury, we know that the patient still has syphilis and that the reaction will again become positive. The situation is exactly what we are confronted with in gonorrhoea. The failure to find the gonococcus in an old case of gonorrhoea is often wrongly interpreted as a cure, but it is quite as good an index of complete eradication of the disease as a negative Wassermann is for a cured syphilis. Therefore, relying mostly on the Wassermann reaction in the presence of treated syphilis, we have had no method whereby we could prove that the patient had syphilis, or, if we were sure that the patient was luetic, we could not prove that the treatment he had taken had produced a cure. It is on account of these obscure * Read before the Medical Society, February 12, 1913. |