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which may attain to the degree of a fine crepitation. It may be elicitated by causing the patient to cough, after which it may be hear at the end of the next deep inspiration.

9. X-Ray.-Radioscopic appearance are usually observed in subapical regions and they show sometimes the presence of consolidated areas before sputum test and physical signs. The value of the X-ray as a means of diagnosis is confined to those who are expert in the use of method.

10. Tuberculin.-The use of tuberculin is a much debated one. Some claim it is very reliable while others claim quite the reverse.

Some object to its use, as it is liable to bring into action many cases of latent tuberculosis.

11. Heredity plays a most important part and is conceded by all to be a leading factor in making a diagnosis. The general opinion is that tuberculosis is not transmitted directly to the offspring but rather an impaired constitution which does not withstand disease and so becomes more liable to infection.

Environment history of attacks of pneumonia, influenza, measles and the like, as well as many other conditions should be borne in mind.

A patient, then, coming to us complaining of feeling tired upon exertion, appetite poor, digestive organs out of order, slight cough, and pain in chest possibly, a history of loss in weight, temperature elevated slightly, pulse quickened, pupils dilated, possibly a history of spitting of blood, we should be on the lookout for incipient tuberculosis, make our diagnosis as early as possible and place our patient in best condition to resist the disease.

PNEUMONIA WITH MENINGITIS.-W. H. Axtell, Bellingham, Wash. (Jour. A. M. A., March 3), reports a case of acute lobar pneumonia with pleurisy, running a typical course with crisis on the eighth day, but complicated with meningitis. This appeared first on the third day with severe frontal headache and some stiffness of the nuchal muscles and violent delirium, highest at the crisis of the disease.. All the symptoms, however, disappeared under simple supporting treatment with ice caps to the head and cool sponging to reduce temperature. The patient was discharged fully convalescent on the twenty-first day; there have been no later mental symp. toms. The special points of interest noted in the case are the absence of any cardiac symptoms and typical course of the lung disorder which was unaffected by the meningitis.

PAIN.

J T. REDDICK, M. D. PADUCAH, KY.

WE all know what pain is, but to give a satisfactory definition of it has taxed the brains of lexicographers and encyclopedists. Some one has said it is an "excess of the sense of touch;" another, "hyperesthesia of the sensory fibres." Dunglison, in his medical dictionary, says it is a disagreeable sensation which scarcely admits of definition. Dorland defines pain as "distress or suffering." Foster's Encyclopedic Medical Dictionary says "local sensation of distress due to injury or disease." The Reference Handbook of the Medical Sciences says, "From a restricted philosophical view, pain may be regarded as a reaction of the organism, in part or as a whole, to harmful influences; giving a warning in consciousness that some activity prejudicial to the health of the tissues is operative."

When we consider that nine-tenths or

more of the patients we see are first apprised of a departure from their normal condition, and induced to seek relief, by reason of pain in some part of the body, then, we must take into consideration the diagnostic significance of pain, and the great value of that particular symptom, in estimating the morbid condition, and the intelligent application of therapeutic measures.

Pain is nature's method of sounding the alarm. A differential diagnosis is often possible in obscure pathological conditions by a careful study of the nature and amount of pain complained of, and hence it behooves us to be careful not to obtund by opiates or other means this important symptom-this signboard-pointing us unerringly to a correct solution of a diseased condition.

"Pain (1) being purely a subjective symptom, its intensity must be estimated by the statements of the sufferer, by the manifestations of its presence, and by the nature of any lesion which may be discovered as its probable cause. The variations in pain sensibility are very great, and are racial as well as individual. The most important variations, however, are personal or individual. The congenitally neurotic patient will complain bitterly of pain from a cause which in one of dull sensibility will give rise to slight discomfort."

The manner of life and occupation may modify the susceptibility to pain. The habitual endurance of hardship blunts the pain sense, and, conversely, the person guarded

Read before McCracken County Medical Society, Paducah, Ky., January 24th, 1906.

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"There are also differences in the manner of statement. Some patients as a matter of pride, practice understatement of their subjective sensations, while others from various motives habitually magnify their sufferings, and in most instances without the slightest intention of deceiving the physician. arises largely from the unconscious egotism of illness and a desire to obtain relief by impressing the medical attendant with its press. ing necessity. In estimating the severity of pain, the facial expression and bodily manifestations of pain are of much value. A statement made with a cheerful countenance, that the speaker is, at the present moment suffering "horrible agony" does not square with the facts, and this combination is of diagnostic value as indicative of self-deception, hysteria or a habit of chronic emphasis.' "In the majority of cases in which really severe pain is present the respiration is rapid, the pupils are dilated, the skin is wet with perspiration, the pulse is apt to be tense, there is a feel of faintness, and not infrequently a large amount of limpid urine is passed within a brief period-symptoms, some of which cannot be simulated.

The character of pain is of diagnostic importance. For instance, a tenesmic pain accompanied with a straining or bearing down effort, we find in a colitis, proctitis, cystitis or urethritis; in the neuralgias and colics we have a paroxysmal or remitting pain.

The excruciating, persistent, dominant pain in head and back of neck, with fixation, retraction of the head, fever and tenderness along the spine is characteristic of cerebrospinal meningitis.

The acute, sharp, "stitch" in the side, intensified by inspiration as well as by voluntary motion of the affected side, accompanied by fever, and dry, distressing cough, which is restrained as much as possible, hurried, jerky, painful respiration, gives the clinical picture found in pleuritis and pleuro-pneumonia.

The intense, constant pains in the joints, aggravated by the slightest movement or even shaking of the patient, accompanied by fever and swelling of the parts, is characteristic of

acute articular rheumatism.

In diseases of the abdominal and pelvio organs we have the greatest variety and character of pains. In toxic gastritis the patient experiences pain in pharynx, along the ster

num, and in epigastric region of a violent and burning character.

"The most prominent symptom of gastrio ulcer is pain. (2) The pain of ulcer has sev. eral important characteristics: it appears in paroxysms, it is strictly localized, it occurs at the time of digestion and is influenced by the character of food. The location of the paroxysmal pain usually corresponds to the place that is most sensitive to pressure. Simple ulcer of the stomach produces pain only when the organ is irritated, and the most common irritation is the food. When the stomach is empty and is not irritated in any way, the ulcer is rarely painful."

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"The immediate(3) symptoms of acute perforation in gastric ulcer, are first, sudden, agonizing, overwhelming pain in the region of the stomach, sometimes tearing in character often with the sensation of something having given away. The pain is frequently so in tolerable that the patient falls to the ground and he may become unconscious."

"In appendicitis pain is the chief symptom. (4) McBurney's description is as follows: In every case of appendicitis the seat of greatest pain, determined by the pressure of one finger, has been very exactly between an inch and a half and two inches from the anterior-superior spinous process of the ilium in a straight line drawn from that process to the umbilicus. He considers that tenderness there in the early stages of an attack, is evidence of appendicitis and occurs in no other acute disease.

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attention is the stomach. I agree that things are hardly settled now, but with men like Mayo, Sheldon and others at work, it is only a matter of time. The drop of experience I may hope to add is the only valid excuse for a paper that must necessarily be as incomplete as this one.

Into every office comes those cases giving history of long continued stomach trouble. They have a history extending back over fifteen or twenty years. They have been to almost every doctor in the county, and no benefit. They have taken every conceivable form of patent medicine, and no betterment. They are back to us again with the plea that we do somthing to relieve them. If we take time with them, and we should take time, we will find a condition as follows: They are complaining of pain in region of stomach: they are markedly constipated, and always neurasthenic: they are showing signs of secondary anemia: they have an atonic condition of the muscular wall of the stomach, and a more or less dilated gastric pouch, and an accompanying gastritis more or less acute. Such cases as above, are beyond the help of medicine, but can be relieved by surgical interference completely and permanently. The question of permanency that arose with my first case, is only partially answered in the affirmative

My limited experience hardly warrants a positive statement as to all cases, but to some of those sufferers I am convinced you can offer a cure. We will all admit the fact that overwork of the gastric muscles will produce atony with an elongation of muscular fibers. If this condition exists for some time, we will have an enlarged stomach cavity, a dilata

tion.

In these cases your examination of stomach shows the chemistry of that organ to be normal, so far as the digestants are concerned. The trouble, as expressed by Mayo, is that the mechanics of the stomach, and not its chemics are at fault. Hence in these cases, the administration of any or all the therapeutic agents are of no value, and the case must be relegated into surgery. Do not understand that this condition can exist an indefinite time without showing some secretory disturbance, but when they exist, they are usually secondary.

If you can countenance this statement, that the primary trouble is motor, as the result of atony, then the symptoms follow is this sequence: We have an atony of gastric muscles, as a result of overwork: the stomach loses its power to force contents through pylorus; to empty the stomach: the accumulation of substances in stomach farther

stretches or dilates the stomach, and drainage becomes more imperfect.

The food undergoes fermentative changes, just as urine does, in a faulty bladder, and the same irritation takes place in mucous membrane of the stomach, as in the bladder. This fermentative material in stomach produces a gastritis; hence the constant complaint of pain. There is an inflammatory. thickening, and the pylorus is narrowed, and this vicious cycle is begun. With a condition of fermentation going on within the stomach, and this partially digested vitiated material leaking into the bowels, it is not to be wondered at that we have marked constipation as a symptom.

The anemia, which is a secondary symptom, showing itself frequently enough to be considered, is the result of improperly prepared food. Assimilation of contents of stomach and bowels is practically impossible, and the impoverishing of blood must be the result. Pearce, Myers, Ranney, Bouchard will agree that neurasthenia is traceable to poisons, toxemia, to autoinfection and anemia. The stomach forms a beautiful machine for the generation of toxins, and so does an overloaded bowel. Besides being a perfect incubator, offers the most elaborate mechanism for the absorption of its produot. Vomiting may, or may not be a constant symptom, but eruption of sour fluids and gases is usual, with occasional attack of vomiting. The above are prominent symptoms that indicate surgical interference. All of the symptoms are relieved by gastroenterostomy.

I will cite three cases, as they serve to bring more strongly the symptoms into prominence:

CASE I.-N. Colvin, Wyaconda, Mo.; farmer, aged 53, came to my office in Novemextending over a period of some twenty years. ber, 1904, complaining of stomach trouble Early in history vomited considerable blood, which had ceased some years previous, an almost constant pain in epigastrium, with periodic attacks of vomiting lasting from a few days to weeks, when they would suddenly cease, only to start again in a few weeks or months. He also complained of marked constipation. He was emaciated, and of that dirty bronze color so significant of malignant involvement. He was anemic. He was markedly neurasthenic. The stomach examination was negative as to closure of pylorus. Free hydrochloric acid found in three of four examinations. Organic acids normal. Blood count showed secondary anemia. Stomach inflated with air showed some dilatation. He had taken all the chemical and animal diges

tants singly and combined, with no effect. We used stomach tube, and taught patient its use. Relieved some of pain, and the washings got away with large amounts of glairy mucus with no permanent results. The starvation plan tried. Kept everything off stomach, and fed per rectum for two weeks. No results. I then proposed to make a junction between stomach and loop of bowel and see what drainage would do for him. He accepted, and in January it made a union between the posterior wall of stomach and jejunum. I operated by means of the Murphy button.

Fed by rectum first six days. For first three days gave nothing by the mouth, after that time allowed a little water and some milk. Patient made a very rapid recovery, passing button on thirteenth day, and leaving hospital one week later.

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the time of operation, I found stomach dilated, and walls somewhat thinned. A slight thickening at pylorus, but no occlusion, only a little narrowing. A careful search failed to reveal any scars form an old ulcer. man has been free for over a year of any symptoms of old trouble. He has gained and held his weight, and a letter a few weeks ago states that he can eat anything and feel good afterwards.

CASE II.-H. Rodgers, operator of lineotype, age 28. Came to office at time No. 1 was under treatment, complaining of indigestion; the beginning of trouble dated back eight years, first year's work on machine. He attributed his trouble to antimony used in the type metal. He had the pain in epigastrium; he never vomited, but at different times during the day rifted up a mouth full of sour fluid. He was anemic, constipated and neurasthenic. Examination showed under air distension the stomach dilated. Test meal given showed motor power of stomach lacking. Free hydrochloric acid present. Diagnosis was an atonic condition, with at least partial retention of the food. 'Operation proposed, and consent withheld, pending results of case No. 1. Operated January 20, made a posterior-gastro-jejunostomy without loops, after Mayo's method. Used button.

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Button passed at end of third week, and patient was back on full diet by the fifth week. From second day allowed light soups and milk by mouth, supplemented by rectal feeding. There was no loss of flesh while in bed. present man is well, weighs 147 pounds, as against 115 before operation. Pain Pain gone, constipation relieved and neurosis entirely absent. He works and eats as well as ever in his life.

CASE III.-W. Kimbrough, Carthage, Ill., aged 35. Symptoms of stomach disturbance extending over eighteen years. He gave th

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usual details of his stomach trouble. He had pain at pit of stomach. He did not vomit but was frequently belching sour fluids and gases. His bowels never emptied themselves and the enema. He was always worse during except under whip of large quantities of salts the winter; was for a number of years fairly comfortable during the summer, but the last two years saw little difference between the mic; showed that weird collections of nerHe was pale, cadaverous and aneVous symptoms known as neurasthenia. The examination showed some dilatation, and by giving patient a sharp shake, you could get that diagnostic splash. Chemical examination showed free acid constantly present, but in small amounts; fermentative material abundRemoval of test meal three hours after eating found stomach practically full. Under air and water stomach was found dilated. Operated November 17. Stomach thin, mucous membrane highly injected and some narrowing at pylorus. I used the Monprofit method of operation. I had no regurgitation in the two previous cases, but felt I might expect it.

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So as patient was in good condition, I made the double anastomosis, as a safeguard. All symptoms subsided almost immediately upon operation. The man was in hospital about five weeks. One button was passed four weeks after the operation. The other one is still within the patient; it is causing no symptoms. It may have fallen back into the stomach. It is a possibility we nay expect in using the Murphy button. It is not the technic of operation, but the cause, I have here under consideration.

I appreciate that from three cases hardly any conclusions can be drawn that are positive. But to the three cited here we can add Sheldon's and Pond's case, and the results are worthy of consideration.

That certain cases of chronic dyspepsia are not amendable to internal medicine, but can be cured by gastro-enterostomy is certain. The choice of operation the choice of the doctor in charge.

I leave the paper with you, in hopes that in caring for at least some of your chronic you may find something of interest and help dyspeptics.

ADULTERATED COMMUNION WINE.- The Health Commission of New York City had some "communion wine" analyzed and found wood alcohol, hard cider and anilin dyes to be the chief ingredients.

SANITARY CARS.-The Ohio State Health Board now requires all companies operating steam or electric cars, not entirely confined to one municipality, to provide cuspidors for the travelling public.

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The Physiopathological Problem of Responsibility.

THE question of responsibility in mental disease has ever been a difficult problem, both for the physician and the lawyer to solve. old The traditions founded upon the timeworn precedents of the law where the right and seems all wrong test sufficient for the jurists, has not been found sufficient from a purely medico-psychological standpoint.

Of late there is renewed interest in these perplexing problems, and along this line a scholarly contribution by J. Grasset (Journal de Psychologie, Normale et Pathologique; Journal Nervous and Mental Disease, Vol.33, No. 2, p. 135) on "The Physiopathological Problems of Responsibility," in which the author says there is much confusion among medical witnesses regarding the degree of responsibility and in seeking an explanation he says, "There is a superior (conscious) and an inferior (subconscious) mind. The medical witness should, at first, seek to carefully separate the philosophical question of responsibility from the medical or psychophysiological question. He should limit himself strictly to the latter. Can he do so? Yes, for it will be conceded by court and expert alike that abnormal mentalization must be dependent upon abnormal antomo-physiological conditions, and a discussion of these conditions is the medical expert's particular province. The disease of legal responsibility that is to be associated with these abnormal states of mentalization, borne witness to by the medical experts, is a question solely for the court to decide. Medical responsibility is, or may be, something quite different from legal responsibility, hence the confusion surround

ing this question when it is under discussion in a criminal court.

Grasset then further discusses medical responsibility, and shows that there are three sets of mental diseases, as it were, in each of which the responsibility is quite different. In the first place, he distinguishes clearly those affections of the superior mind (mental diseases) from those of the inferior mind (psychic diseases). Herein he shows that the terms pscy hic and mental are not synonymous. Psychic is synonymous with cortical and is therefore far more general in its significance than is mental, which in signification, is rather more limited and refers functionally only to the prefontal lobe.

Irresponsibility accompanies the diseases of the superior mind, the true mental diseases; responsibility or partial responsibility accompanies always the diseases of the inferior mind, the mere psychoses. Mania is an illustration of the former, hysteria of the latter. Psychic maladies that complicate mental affections must also presuppose irreThe mentalization will of sponsibility. course be abnormal in both mental and psychic diseases as well as in their mutual complications. The medical expert may consistently testify to this fact and indicate, as shown above, how responsibility, from the medical point of view, may accompany one set of diseases, attenuated responsibility another set, and complete irresponsibility still another set. It is not for him to assert, in his capacity as medical expert, how philosuphy or law is to regard the degree of responsibility in there respective conditions."

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This is a decided step for advancement in medico-legal science, which physicians will do successfully draw the lines of difference in well to observe and follow in practice. degree; in other words, to fit the responsibility to the individual not the crime will necessitate a training in mental disease both clinical and pathological greater than is given philosophical knowledge of the characteristo the average physician Again, a broad tics of man must be an accomplishment of

the would be medical expert, in order that he may with cultured ability recognize, discriminate and differentiate degree of responsibility. F. P. N.

CHANGE IN DATE OF BOARD MEETING.The State Board of Health of Missouri has postponed its meeting in Kansas City to April 16, 17, 18. An examination of applicants will be held at the Barnes Medical College, St. Louis, on April 10, 11, 12.

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