ABSTRACTS.

Perforating Gastric Ulcer Shown by X-Ray

Haudek (Holzknecht Archives of Roentgen Ray, July, 1912) has called attention to a diverticulum outside of the stomach shadow, communicating with it by a narrow canal, and retaining at its upper part a collection of gas.

TYLER (Omaha).

Paraffine Injections versus Oil Enemata

The drawbacks of oil enemata are so potent to anyone who has tried them that the suggestion of Lipowski (Fortschritte der Medizin, November 28, 1912) to substitute for them injections of paraffine of a melting point of 40 degrees C., deserves a hearty welcome. Lipowski seems inclined to share the opinion of Boas that it is doubtful if such a thing as spastic constipation really exists. He believes that aside from atonicity of the large intestine, the main factor in constipation is the too rapid absorption of fluid from the lower bowel. He believes that oil enemata, instead of acting as Fleiner supposed, by the production of fatty acids and glycerine, produce their main effects by lessening the absorption of water.

By daily injections of 200 to 300 C. C. of the melted paraffine he gets just as good results, in the great majority of cases, with the advantage that they can be taken at any time and the patient can at once go about his business, without danger of spoiling his clothes or disgracing himself, to say nothing of the fact that there is no risk of the irritation or even poisoning which impure oil sometimes produces. The amount of paraffine is gradually decreased. At the start small saline enemata are sometimes used in addition to the paraffine.

The Status of the Roentgenologist

GIFFORD.

The Berlin Congress of the German Roentgen Society, April 14, 1912, adopted a resolution defining the status of the Roentgenologist as follows:

1. Roentgenology is a duly authorized medical specialty, just as are laryngology, ophthalmology, etc.

2. The Roentgenologist is a medical specialist, and as such, in accordance with the usual medical custom, he is called

in as a medical consultant by the patient or his physician, in order to make or to confirm the diagnosis.

3. The Roentgenologist makes use of Roentgen examinations in addition to the usual clinical examination. He alone decides what particular procedure shall be employed-radiography, radioscopy, orthodiagraphy or teleoroentgenography.

4. All plates, diapositives, tracings, orthodiagrams, and teleoroentgenograms prepared for the diagnosis of the case are the property of the Roentgenologist, just as histological preparations belong to the consulting pathologist. The Roentgenologist will, however, as a matter of courtesy, be always ready, if requested, to place his plates and prints at the disposal of the consulting physician.

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The supply of negatives or prints to sick clubs and insurance companies is a matter of special arrangement. Moreover, in urgent cases it is the usual custom of the Roentgenologist to place the skiagram at the disposal of the surgeon.

6. The Roentgenologist may, at his discretion, place a copy of the plate at the disposal of the patient, either gratuitously or on payment of a fee. This should, however, only be done in those cases where it will cause no harm or needless anxiety to the patient.

TYLER (Omaha).

Problems in the Treatment of Exophthalmic Goitre Musser in the American Journal of the Medical Sciences for June, 1912, reached these conclusions:

1. Endemic goitre should not be treated surgically until proper general treatment has been employed for a long period.

2. Surgical intervention should not be advised in cases of goitre associated with functional or organic disturbances of other secretory organs until the associated disorders are removed or relieved.

3. If relapse occurs in spite of general treatment, or in spite of treatment directed against the disorders of other organs, a goitre should then be treated surgically.

4. Medical treatment should be continued from six to twenty-four months. Favorable results should not be promised unless the patient is under the absolute control of a physician, so that treatment by rest, diet, bathing, physical therapy, and so forth may be carried out with precision and continuity.

5. Surgical intervention requires the same rigid and prolonged after-treatment to give permanent results.

Finally, Musser's conviction is that the surgeon does too much and the internist too little in the treatment of goitre.

Feeble-Minded Immigrants

C. P. Knight, M. D., assistant surgeon, U. S. Public Health Service, Ellis Island, N. Y., writing in the J. A. M. A., January 11, 1913, says: Figures presented by Dr. T. W. Salmon, of the New York State Board of Alienists, show that the state of New York receives 26 per cent of all immigrants coming into the United States and is the destination of more than 80 per cent of the immigrants found on arrival to be insane or mentally defective. Under the headings of idiots, imbeciles and feebleminded, the New York Society for the Prevention of Cruelty to Children, has investigated these conditions among children of the school age and reports that there are 7,000 distinctly feebleminded children in New York, or 1 per cent of the school population. This is in addition to the idots and imbeciles and does not include the morally defective or the border-line cases. Census statistics show that 30 per cent of the feeble-minded children in the general population of the United States are the progeny of aliens or naturalized citizens. The financial outlay for caring for this class of people is enormous. Dr. Anna Moore states that to support a feble-minded person in one of the state institutions costs the state, on the average, $161.20 a year. The financial side of the question is interesting, but more important is the influence of mental defectiveness on the future race of the country. It is an undisputed fact that the feeble-minded showed the birth-rate and the death-rate to be abnormally high; these defectives tend to have many children of whom a great many survive in spite of the high death-rate. The suggestions of Dr. Moore on the control of procreation among the feebleminded, such as a proper segregation law and an efficient marriage law, to reduce the percentage of the mentally defective, are ideal for the present existing conditions, but more effective will be the removal of one of the principal causes, by reducing to a minimum the entrance into this country of the mentally and morally low type of alien. Immigration largely contributes to the high percentage of this class in the United States.

JOSEPH M. AIKIN (Omaha).

The Operation for Congenital Pyloric Stenosis

(Centrablatt fur Chirurgie, Nov. 2, 1912.)

In the Research Society of Munster I have reported two cases of congenital pyloric stenosis cured by operation. In one case I used the method described by Weber (see Berlin Klinl Wochenschrift 1910, No. 17), so called extra mucous pyloroplasty. In the other I attempted only to divide the thickened gate muscle of the pylorus. The last method I can recommend to be tried.

To this extremely simple and quickly performed operative method I ask the following considerations:

1. The previous operative methods used for babies, and especially for weakened babies, are either too profound (as gastro enterostomy, or open pyloroplasty), or in their results uncertain, as dilation of the pylorus after Loreta.

2. The method described by Weber is a distinct advance, where the pyloroplasty is done without opening the mucous membrane since the lumen of the stomach is not opened and the time of the operation much less. It contains, however, the danger of a tear in the pylorus through the mucous membrane, resulting from the joining of the incision in the opposite way to the opening (see Heineki's operation for pylorplasty), then even Weber's two cases, as also my case so operated, had continued vomiting in the first week after the operation, which soon disappeared and can be explained in no other way except as resistance in the patency of the pyloric muscle that in the highest probability was due to the failure of the mucous membrane to dilate.

When one remembers that the cause of hypertrophic pyloric stenosis of congenital origin is not alone the thickening, but also consists of spasm of the pyloric muscle, then must the simple spreading, that is, breaking of the muscle ring, separating the ends as far as possible without the division of the mucous membrane, in this manner the narrowing due to the spasm can be removed with one stroke.

The following is a short history of the condition of the operative case to which I referred:

Hans, G. R., born the 5th of August, 1912; of healthy parentage; weight at birth, 3,625 grams; grew well for five weeks on the breast of the mother. Weight the middle of September, 4,500 grams. Then suddenly began to vomit, which increased more and more; small quantities of urine, slimy small stools,

cold hands and feet, again and again cried with pain. Rapid loss of weight, sudden dietetic disturbance. Weight on the 5th of October, 3,220 grams. The 6th of October admitted to the babies' home; diagnosis, pylorospasm. Expectant treatment without results, vomiting less and sometimes without any for a day, then again copious vomiting. Weight on the 30th of October, 3,050 grams.

October 30th operation, a five-centimeter incision, opening the abdomen in the middle line at the height of the pylorus. Stomach enormously distended. Pylorus more than the thickness of the thumb, cylindrical in form, shining-reddish-white, hard like cartilage. Division of the thickened muscle on the surface of the pylorus, a stitch at the duodenal end of the incision is all that is necessary. The cut was covered only with peritoneum. The pylorus was pylorus was laid back, the abdomen closen closed, a plaster paris band put over the abdomen. Duration of the operation, fifteen minutes. Ether narcosis.

A perfect recovery followed. Within an hour had no more vomiting. Nourishment, small amount of milked mother's milk, fifteen cubic centimeters per hour at first, slowly increasing this amount. Suddenly on the thirteenth day appeared a very severe constipation with toxemia. Mild cathartics given, from then on rapid increase in weight. The effect of the operation was in these two cases almost momentary; vomiting did not recur. The wound healed without reaction. Whatever happened afterwards on account of the exposure of the mucous membrane on the place of the cut has not been observed. It appears, therefore, than an extra covering of this incision with omentum is not necessary. The operation's time would be lengthened thereby and the results are questionable. This operative procedure is as short and easy as it is possible to conceive.

It is here not the intention to study the question of intestinal obstruction due to pyloric stenosis alone, whether determined by operation or by chemical examination appearing in all cases after a few weeks of partial closure. So far it is certain, that the development of intestinal obstruction in a small living patient is extremely dangerous. It cannot be too much impressed not to wait too long, but immediately that the pyloric stenosis is diagnosed the operation should be done, namely-the pylorus divided down to the mucous membrane.

Unfortunately as physicians know, not only children's physicians, but also surgeons, that operative treatment, especially