patient lying on the back and the knees drawn up so as to relax the abdominal muscles as much as possible. Some cases may require the kneechest or standing position to be assumed. With all the care one is able to bestow upon an examination it is frequently difficult to determine whether a tumor is located in the stomach. Impacted feces in the colon have been mistaken for a cancer of the stomach. It is well to give a laxative in doubtful cases to remove all fecal accumulations.

The bowels are normal in only four or five per cent of the cases. The rule is constipation; but sometimes diarrhea exists, and often toward the close of the case it may be obstinate and distressing. If hemorrhage has occurred the stools are likely to be black. The diarrhea is sometimes an evidence of a catarrhal condition of the intestinal mucous membrane produced by the irritation of hard fecal masses or products of decomposition which have not been quickly carried away. If a gastro-intestinal fistula is formed the cancerous debris and products of fermentation in the stomach may be passed immediately into the intestines above or into the colon and produce irritation causing even lienteric diarrhea.

The urine sometimes contains albumen, acetone and diacetic acid; and indican is often in excess. Peptonurea is not frequent, but is occasionally

seen.

The skin is ordinarily dry and harsh, and has a peculiar sallow or anemic appearance the cancerous cachexia. The approach of anemia is gradual, but this is one of the most constant symptoms. Not only is the hemoglobin greatly reduced, but the red corpuscles also are diminished in number, sometimes as low as 50 per cent; the relative, if not the actual, number of white corpuscles is increased, so that a degree of leucocytosis exists. The anemia in some cases approaches the pernicious type. Nucleated red corpuscles, poiklocytes and microcytes are found. In the method of production and in the fact that emaciation increases progressively with the anemia the condition here differs from pernicious anemia. The loss of strength seems out of proportion to the pathological condition, and a peculiar wrinkling of the skin and pinched features often marked by brownish spots indicate the progess of the disease. Anasarca and ascites results frequently from the same anemic condition; ascites may often be due to metastatic or secondary peritonitis. Under such circumstances anemic murmurs, palpitation and dyspnea are common and may be accompanied by increased weakness, with rapid and feeble pulse. The eyes sink in, the cheeks become prominent and the patient appears older than he is. Depression and melancholy may alternate with restlessness and excitement. Headaches, neuralgias, dizziness and tinnitus aurium may help to make the patient miserable.

The lungs, liver, intestines and other organs may be the seat of secondary growths, with characteristic symptoms. Perforation with its well. marked symptoms of pain and shock may occur. Acetonurea and uremia are occasionally complications in the later stages of the disease.

The temperature may be normal, not unfrequently it is subnormal; but it often happens that the fatal termination is heralded by an increase of temperature. The fever varies in degree and its course is irregular

(100.4 deg. to 102.2 deg., and rarely 104 deg. F.); and Ewald says it may assume a hectic character.

Certain complicaions are sometimes observed. Gall-stones are said sometimes to occur in conjunction with cancer of the stomach (Hughes). Jaundice may occur due to pressure of the growth, or some secondary growth exerted upon the bile ducts. Peritonitis, pleurisy, pericarditis with effusions occur from secondary growths. Tuberculosis and chronic nephritis may be present. Thrombi may produce painful or disastrous results. Chronic gastritis is a common complication, and often a precursor, apparently of this disease. Dilatation is a direct result of the growth in many cases, especially in the pyloric variety.

Diagnosis. The most reliable symptoms upon which to base a general diagnosis are pain, vomiting, a tumor in the stomach and hemorrhage. A chemical diagnosis depends chiefly upon the absence of hydrochloric acid. Dilatation, particles of tumor in the wash water after lavage, or in the vomit, and emaciation are valuable aids in making a diagnosis.

The pain is gnawing, burning, lancinating, cutting, boring, constant. It is sometimes described as an ache, a dull pain, increased by eating, somewhat alleviated, but not entirely removed by vomiting. It is occasionally absent, especially in the aged. Vomiting is characteristic. If the tumor is at the cardia vomiting occurs very soon after a meal, and does not present the pathognomonic character. If the tumor is at the pylorus the vomiting may be delayed two or three hours or longer, and if the stomach is largely dilated it may not be emptied for two or three days. If the delay is great the quantity rejected from the stomach may be enormous. Vomiting does not remove, but may diminish pain. The matters vomited are various. Usually the vomit consists of mucus, broken down tissue, food and debris or fermentation products, coffee-grounds sediments, or a deposit resembling the dregs of unstrained beef soup or beef-tea. The most important feature of this is the discovery in the vomited matter (or in the wash water of lavage) the cancer cells or debris of morbid or broken-down tissue. A great variety of fungi, yeast cells, sarcinae, bacteria and variously formed cells and detritus, which go together to form what is recognized as the cancerous vomit. Not a single element of those just mentioned is sufficient, but the combination of many is needed to determine the cancerous nature of the stomach contents. I think with Ewald, that we cannot be sure of the cancerous nature of the disease from an examination of the vomited matter, unless we meet with concentrically stratified aggregations of cells, true cancer cell-nests.

As already stated, free hydrochloric acid is usually absent except in the irritative stages of the disease (Golding Bird), and diminishes in proportion to the patient's loss of strength. This condition likewise prevails in atrophy of the stomach, and a differential diagnosis must be made. The decreased quantity of HCl permits an increase in the organic acids, especially lactic acid (Boas). According to Boas lactic acid ocurring in the stomach, not introduced with the food, occurs exclusively in cancer of this viscus; but he admits that cancers may occur without the presence of

this acid in excess As a rule, however, the latter are cases in which hydrochloric acid occurs. Klemperer, Thayer, Rosenheim and others do not consider the presence of lactic acid pathognomonic.

The third important consideration in the diagnosis of gastric canceris the presence of a tumor, particles of which are sometimes seen in the vomit, or in the wash-water if lavage has been used. Hemorrhage is an important sign of cancer when taken in connection with the vomiting, and the par ticular character which the ejected matters present. The presence in the stools of decomposed blood is to be remembered in this relation.

The symptoms which will aid in making a diagnosis may be briefly recapitulated as follows:

1. Pain, constant, gnawing, boring, burning. 2. Vomiting periodical coffee grounds material giving some relief from but not removing pain. 3. Tumor, discovered by hand or particles found in wash water. 4. Absence of hydrochloric acid and presence of lactic acid in the stomach contents. 5. Tumor, with dilatation, or with hematemesis 6. Emaciation, with some or all of the foregoing symptoms. 7. Dyspepsia, continung for a considerable time (six months to a year), with some or all of hese symptoms.

A differential diagnosis must be made between cancer and some other diseases of the stomach.

Ulcer chronic gastric catarrh, and functional dyspepsia have been mistaken for this disease. Benign stenosis of the pylorus must be carefully eliminated in making a diagnosis. The long existence of this condition, the presence of hydrochloric acid and the absence of pain will be valuable aids in separating this from cancer of the stomach. The pains of gastralgia, locomotor ataxia and other neurotic conditions can be differentiated by studying the history of the case.

Prognosis. These cases usually terminate fatally in one year from the beginning of the symptoms, and many are met which end in death in three or six months from the first appearance of active symptoms.. Occasionally cases are seen which are prolonged to a year and a half or two

years.

In cases supervening upon ulcer or chronic catarrh, dyspeptic symptoms may exist for a longer period than two years, but it is not usually possible to point to the time the pathological process becomes cancerous. Rarely cases terminate fatally in four or six weeks. The duration depends, in a general way, (1) upon the location, cancers occurring at the orifices running a more rapid course; (2) upon the variety of tumor, the medullary form growing more rapidly; (3) upon complications, as hemorrhage and ulceration, which may produce sudden death.

(TO BE CONTINUED.)

Monographs on Nervous Diseases

With Especial Reference to Hygiene, Nursing and Therapeutics.

Infantile Paralysis.

BY F. SAVARY PEARCE, M. D.,

PHILADELPHIA,

Professor of Nervous and Mental Diseases in the Medico-Chirurgical College of Philadelphia; Neurologist to the Philadelphia Hospital.

NFANTILE paralysis or anterio-poliomyelitis is an acute inflammatory disease probably infectious, occurring more frequently in warm weather and in children under ten years of age. The onset is ushered in by high fever, nausea and vomiting, there may be slight delirium from the fever but seldom unconsciousness. The child is generally restless, and now complains of parasthesia of one or more extremities with considerable hyperesthesia when the member is handled. With this there may be some generalized tenderness of the deeper structures. At the end of twenty-four hours, the fever will have pretty well subsided, the patient now suffering no discomfiture. It will be found at this stage that one of the extremities is greatly enfeebled, the sensation having returned to normal. The child can move the extremity but little if at all, the deep reflexes will be found wanting in the paralyzed limb. Within a few days, there may be pretty marked recovery of some of the muscles of the extremity, but others will be found to have remained permanently paralyzed. At the end of a fortnight or more, reaction of degeneration will be found to exist in the affected muscles, and the limb now begins to waste rapidly. In marked paralysis which is the more frequent, the patient will be unable to walk or only do so with great difficulty, there being a limpid halting gait if it can be at all accomplished. Or the paralysis may be localized to a few muscles permitting the foot to be turned in or out owing to this weakness, when it would be essential to apply some form of apparatus to correct the deformity. If the paralysis is of the upper extremity, the member will hang in limpid palsy by the side. The paralyzed extremities become, in any case, somewhat cyanosed, cold, and wasted. The general health of the child is remarkably well preserved. As the child comes to maturity, lateral curvature of the spine is very apt to develop owing to the disproportionate shortness of the lower extremity. In the case of paralysis of the upper extremity, the chest may be much smaller on the affected side, due to lack of exercise and muscular development. The intelligence of these children is generally precocious, since the enforced physical apathy probably produces a compensatory action of the psychic centers in the brain. It should also be stated, the sphincter muscles are seldom involved and that the somatic and vegetative functions remain quite normal. I have not observed that life was curtailed by infantile paralysis of monoplegic type, and have known a number of

cases live to sixty years of age. It should also be stated in support of the infectious nature of the diseases, no nervous heredity is not found in the family of the patient. The pathological condition is of an inflammatory lesion limited to the anterior horns of the gray matter of the spinal cord. Thus in the decussation of the multipolar cells, trophic disturbance as well as paralysis naturally follows in the extremity to which these neurons supply nutritions and motion. The absence of the deep reflexes and of the currents of reaction of degeneration, is due to this same defective lesion.

Treatment of infantile palsy is symptomatic; since regeneration of the damaged nerve cells cannot be, by medicine, re-established. We can, however, very much help the patient through massage and galvanism carried over prolonged periods (months); the younger the patient, the greater necessity for these measures in order to keep up as far as possible, the development of the wasted limb and to prevent contracture deformities as already stated. The protection of the surface should be very carefully guarded, especially in the palsied extremities. To this end wool underclothing should be worn and frequent bathing of the skin with 80 per cent alcohol or salt water, preferably sea water, should be given. The use of tonics, especially strychnia is the drug par excellence in those cases requiring general therapeutic measures; some authors have advised the hypodermic injection of strychnia into the paralyzed muscles in rare cases of localized palsy of individual groups of muscles.

The Mechanical or Combined Plastic and Mechanical Treatment of Retrodeviations of the Womb (Rosenwasser, American Journal of Surgery and Gynecology, November, 1901). The writer wishes to emphasize the opinion that too many serious operations for retrodeviations are being performed where safer, simple and equally successful procedures would suffice. Of 116 patients treated for retroversion, 63 of the second and third degree were selected as proper subjects for purely mechanical treatment. They were treated by means of the pessary alone, or the necessary plastic operation was supplemented by a pessary. Of the 116, 11 were cured; 15 symptomatically cured; 26 improved; 11 not improved. From this experience Dr. Rosenwasser draws the following conclusions: 1. A retroverted womb uncomplicated by disease should be replaced and supported by a pessary. 2. Retroversion complicated by a diseased womb, or by impaired pelvic floor, the womb being movable, require preliminary plastic operation before using a pessary. 3. Suspension operations should not be done simultaneosly with the plastic in face of the probability that a pessary can sustain the womb in position. 4. Retroversion complicated by aggravated prolapsus requires simultaneous plastic and suspension operations to effect a cure. 5. The treatment of retroversion with a fixed uterus is that for pelvic inflammation. Whenever the latter requires laparotomy, or colpotomy, the retroversion becomes subject to such surgical treatment as may appear best suited to the particular case. 6. Retroversion, simple or complicated, in which mechanical support and plastic operation have failed to cure or to relieve, and in which the symptoms demand relief, constitutes a proper indication for a suspension operation.