mille; lactic acid present. With Ewald meal five muscular tone of the stomach walls. This is further days after, the total amount, 80 c. c.; free HCl, 1.82 substantiated by the fact that, at first, suction was per mille; total HCl, 2.59 per mille; lactic acid necessary to remove the contents, but at last volunpresent. tary compression on the part of the patient was suffi Ewald. 88 c. c. .9 1.3 Yes. Albumin. 15 c. c. None. None. Yes. Ewald. 40 c. c. None. Yes. O'N. Albumin. 60 c. c. 1.82 2.62 Yes. cient. The case of M. M., followed for one month with five examinations, showed a persistently low amount of HCl varying from entire absence to a total of .8 per mille. Here also the rennin was found to be active in dilutions of 1-180 and repeated microscopic examinations showed no cancer cells, when examined by the methods proposed by Hemmeter. The case of Mary M., followed for seven weeks with seven examinations, showed the most marked variations in the HCl, due probably to nervous origin. They were respectively 1.3, .6, 0, 1.35, .8, 1.38 and 1.5 per mille, under the same conditions of meal, time of removal, etc. Lactic acid was also present when HCl was below .8 per mille, which must have come from the previous meal, since only albumin was used. On one occasion, bile was present in the stomach contents, which indicated only reflex vomiting from the introduction of the tube, since it was not persistent. In the case of J. G. three examinations made in one week showed a total HCl of respectively .04, 1.3 and 1.2 per mille, and total amounts withdrawn of 102 c. c., 42 c. c. and 97 c. c. had a total HCl of .8 per mille. DISCUSSION OF DIFFERENT FEATURES. The case of T. L. came nearest to being one of continuous secretion of gastric juice. At periods of from fourteen to sixteen hours after food had been taken, there were removed from the stomach on five occasions amounts respectively of 55 c. c., 80 c. c., 30 c. c., 87 c. c and 19 c. c. This was of an almost watery consistency, perfectly clear, containing The first impression that one would derive from no food particles whatever, whose total HCl was .9, such a comparison would be that more HCl would be .7, .8 and .4 per mille. After an albumin test meal, found with animal albumin than with vegetable albu-260 c. c. of stomach contents were withdrawn which min. By referring to our results, however, we find that HCl in the Ewald meal exceeds the HCl in the albumin meal four times out of seven. Another thing which attracts our attention is that the lactic acid is present in the Ewald meal and not in the albumin meal in all cases but two, where it is present in both. Another thing quite noticeable, that with the Ewald meal the amount withdrawn is generally larger than with the albumin meal. It is very probable that this is due to the greater need of a vegetable albumin for fluid to accomplish its digestion, or chemically speaking, its hydration. There is unquestionably an osmosis or interchange of fluids between the blood on the one side and the contents of the stomach on the other. Included among these results are two Ewald meals. The rest, however, were from albumin meals. The amounts withdrawn at intervals of an hour seem to depend largely upon the muscular tone of the stomach. It is very difficult, however, to set a limit beyond which we may say that hypotony or dilatation CHEMICAL NATURE OF GASTRIC CONTENTS WITH exists, and under which the stomach is normal. From REFERENCE TO HCL, AMOUNT, ETC. the other conditions involved, it seems that with the The course of some of the cases affords some inter-albumin meal we may say that there is lack of musesting observations. On A. J., who complained of cular tone when 100 c. c. or more can be withdrawn. gaseous, non-acid eructations, vomiting, etc., eight This is especially true if it is necessary to use suction, examinations were made, covering a period of two or if in introducing water for purposes of lavage it months. Starting with an entire absence of HCl, the cannot be withdrawn readily, or a whirling motion in amount gradually increased until at the close the HCl the funnel is noticed upon its introduction. The had reached 1.8 parts per mille. On account of the presence of free HCl was always determined by diearly lack of the HCl, a quantitative test for rennin methyl-amido-azo-benzol, and was found present in 60 was made, which showed that milk could be coagulated examinations and absent in 13. Lactic acid was with a dilution of 1-80 of the stomach contents, a re-determined by the modified Uffelman test in the folsult not far from normal. Lactic acid was invariably lowing way: One drop of ferric chloride was placed present. The increase of amount withdrawn from in a test tube, the test tube filled with water, this then 12 c. c. to 72 c. c. may have been due to the increased divided into equal parts in two test tubes, each filled up with water, and a drop or two of the filtered stom-a patent pylorus. These conditions can only be ach contents added to one, the other serving as a con- differentiated by blowing up the stomach with air. trol. As demonstrated by this test, lactic acid was Under normal conditions no air can pass through the found 40 times, 9 times with no free HCl, and twice pylorus on account of its spasmodic closure, and hence the entire absence of free HCl was accompanied also the intestines cannot become distended. by the absence of lactic acid. This is contrary to the teachings of Boas, who claims that lactic acid is absent when HCl is present to any appreciable amount, one hour after the meal. As our supposition is that the lactic acid must come from the previous meal, and be indicative of atony, then it should be associated with a large amount of contents. This cannot be demonstrated, however, since it is found when the amount of contents withdrawn varied all the way from 10 to 102 c. c. Lactic acid was also found when the free HCl rose to 1.8 per mille. As combined HCl has no inhibitory action upon the formation of volatile acids by their respective bacilli, no account was taken of it. A more detailed account of this association is given as follows: Lactic acid was found twice with a free HCl, of 1.8 per mille, once with 1.7, twice with 1.6, once with 1.5, twice with 1.3, twice with 1 per mille, and so on down. Its presence followed certain cases, as that of A. J., throughout the course of examination. The latter never lost the lactic acid in spite of the fact that his HCl steadily increased from nothing to 1.8 per mille. In the 40 cases where free and combined or total Less than .5 total HCl per mille 1.5 66 1.5 46 2 66 2 66 2.5 44 2.5 66 Over 3 per mille. Rennin was always looked for where the total HCl was very much diminished, and no free HCl was present. The quantitative method of Boas was employed, which is as follows: One c. c. of stomach contents was diluted with water to 10 c. c. Five of this was taken in a test tube, and was again diluted to 10 c. c., and 5 c. c. more taken. The process continued until we had four test tubes with 5 c. c. of diluted contents in dilutions of 1-10, 1-20, 1-40 and 1-80. To each of these were added 5 c. c. of cooled boiled milk and a few minims of calcium chloride solution. We now have dilutions of 1-20, 1-40, 1–80 and 1–160. A control test is always prepared to guard against the possibility of spontaneous coagulation, consisting of 5 c. c. of milk, 5 c. c. of water, and the same amount of calcium chloride. These tubes are all placed in a brood oven, at a temperature of 30°, for from twenty to thirty minutes, and then note made of the coagulation. Coagulation normally should take place in dilutions of from 1-80 to 1-160. The importance of this test cannot be over-estimated in cases of suspected cancer, being of vastly more importance than diminution of HCl or the presence of lactic acid. In all of our cases, coagulation was found in dilutions of 1-80 or over. In every case the contents were also examined with the microscope, and while several times fragments of mucous membrane of the stomach were found, nothing was seen approximating the peculiar arrangement of these cells in cancer of the stomach. These results were also verified by Dr. Timothy Leary, our pathologist, who kindly offered to assist in these examinations. Yeast fungi were always present; no degree of acidity nor use of albumin stayed their growth in any way. No sarcina were found, fairly good evidence that in all cases no marked dilatation nor narrowing of the pylorus was present. Among the interesting points brought out was the unreliability of the presence of lactic acid as a diagnostic symptom. It was present in the majority of cases where the Ewald meal was used, and also in very many cases where the albumin meal was used, and as a diagnostic symptom seems to have lost its significance. It is also quite evident that impaired As compared with the results of H. F. Hewes, motility is the most important condition in the sowhere the limits of normal total HCl were from 1.1 called nervous dyspepsias, arising probably from the to 2.6, and the average from 1.2 to 2.5 per mille, 21 fall lack of enervation dependent upon shock or worry. within these limits, 9 below and 10 above. Bile was It may be present with either impaired or superabunpresent twice, and with the bile there was once associ- dant secretion of HCl. The former condition is ated pancreatic juice, which was demonstrated by the probably the more distressing from the formation of fact that the stomach contents in alkaline medium organic acids and gases. The importance of this could both digest albumin and convert starch. Bile motility can also be demonstrated by laboratory exis not so rare in stomach contents, but is much more periments in artificial digestion, where shaking the apt to be present in the first withdrawal in a patient, contents of flask or container accelerates in such a from the retching accompanying the introduction of marked degree the process of digestion. It is of inthe tube. After the patient has become accustomed terest also that the increased flow of gastric juice is to this introduction, the presence of bile is much less frequent. If it persists a long period, Boas considers it a sign of the constriction of the duodenum, while Bouveret prefers to regard it not only as evidence of a constriction of the duodenum, but also of 1 Boston Medical and Surgical Journal, vol. cxlii, No. 20. always accompanied by a relative increase in the amount of HCl, or it may be that lack of motility and diminished HCl are associated, and the small quantity withdrawn is due to our inability to remove the total contents of the stomach. Finally, dried egg albumin in the form of tablets seems to fulfil all the conditions that attach to a successful test meal. SPINAL CARIES WITH ABSCESS: ANALYSIS BY ERNEST B. YOUNG, M.D BOSTON. It would seem that abscess formation has little relation to the extent of the deformity, as those with no kyphos or a slight kyphos far exceed in number the cases with great deformity. The large kyphoses appear almost entirely when the disease begins early in life. After the twentieth year there is only one case of moderate and one of bad deformity. In one case there were two kyphoses of moderate size, one in the dorsal and one in the lumbar spine. Abscess. - In 83 cases there are: Psoas abscesses Cervical 60 2 63 (including 5 double psoas). Psoas abscess is the most common when either the dorsal or lumbar spine is attacked, while double psoas and double lumbar abscesses are quite rare. Abscesses associated with cervical or sacral disease are apparently quite uncommon. Psoas and lumbar abscesses, when occurring in the same person, generally point on the same side of the median line; but in some few cases there is a psoas abscess upon one side of the median plane and a lumbar abscess upon the other. As would be expected, in a few instances the pus has forced its way under Poupart's ligament and in one case has burrowed downward from a lumbar abscess into the superficial fascia of the thigh. IT has been the good fortune of the writer to be able to collect 78 cases of spinal caries complicated with abscess, and to obtain reports of the condition of those living at periods of from one to thirty-five years after the beginning of the disease, as well as the date of death of those who have already succumbed. The average time of the reports is about four and one-half With the exception of 18 years after the onset. cases, all the material comes from hospital clinics, as it is among the lower strata of society that spinal caries flourishes. These classes are the ones most liable to trauma and strains from the nature of their employments, while poor and insufficient food, bad air and inability to properly care for themselves make them good subjects for tuberculous invasion. The cases are in no way selected, except that nothing has been included where there was any doubt as to diagnosis. In addition to the cases where it has been possible to obtain full reports, a few have been utilized where the data at hand were known to be correct, even though not quite complete in all particulars. Age and sex. It will be seen from the cases considered under this heading, 52 males and 26 females, that the disease throughout life is about twice as frequent among males, although at different periods the It is impossible to get any reliable data concerning ratio changes somewhat. The onset in 38 out of 78 the duration of abscesses or the date of first appearcases occurred before the tenth This is un-ance. Often the patient has been ignorant of its doubtedly due to the fact that both sexes are active presence even when filling one whole side of the aband liable to injuries at this time. From ten to twenty domen and pelvis. In 2 cases the abscess has come years the ratio changes very little, but from twenty to on during treatment. These are the severe cases and thirty years the males outnumber the females nearly both are dead. The sinuses have remained open for 5 to 1; for the female has ceased to be active as the many years in some instances, and in others have male and at this time many of the men are perform-closed within a few months. Some have the sinuses ing the hardest kinds of manual labor. The figures heal promptly only to break out again from time to seem to bear out the importance of trauma as an etio- time. Most of the sinuses remain open for a year or logical factor in the disease; for as the female becomes less active, the frequency of the disease decreases, while in the male the two periods of greatest liability to injury, childhood and young manhood are each marked by a rise in the number of afflicted. After the thirtieth year, when the epiphyses of the vertebræ are firmly united, its occurrence in either sex is quite rare; yet even during the remaining years of life the males outnumber the females 2 to 1. Only 11 cases have been collected where the first symptoms occurred after thirty years of age. The youngest case was eight months old when the abscess appeared, and the oldest sixty-seven years. year. Seat of disease. - Caries of the dorsal spine leads most often to abscess formation. Cervical and sacral disease with abscess seems rare at any time of life. Of 77 tabulated cases there are: two, so far as can be learned, and in many cases, even with the patient in good health, they still persist. Pain of any amount seems to become a prominent feature in many adult cases only when the abscess has reached such a size as to produce psoas contrac tion. While in children pain is generally referred to the abdomen, in the adult it is generally referred to the back, there being only two or three adults who have complained of abdominal pain. Treatment. In by far the greatest number the abscess has been treated by incision; but some have been collected of aspiration and spontaneous opening, as well as a few where the abscess has remained closed. Of 77 cases, 37 under ten years and 40 over ten years, the treatment was as follows: Remaining closed. 43 Incision. . Two cases included under incision were aspirated, and incised shortly after. One adult and one child have been aspirated many times. One case, which opened spontaneously, was incised later. Prognosis. Many of the cases have been treated in general hospitals, which have as a rule no orthopedic department, and hence the after treatment has been either entirely neglected, or only partially carried out. At the same time it must not be forgotten that Fair Under ten years. Over ten years. Total. 3 6 9 19 8 27 4 3 7 11 28 while of those commencing at beyond this period, four years and two months. Average time elapsed since operation in the first class is five years and two months, and for the second about three and a half years. Abscess. SUMMARY. 17 50" The prognosis of spinal caries with abscess, apart from the cases where the abscess opens spontaneously, seems to be very slightly influenced by the treatment accorded the abscess, although undoubtedly affected by the proper fixation of the spine. Considering the series as a whole, we may say that the mortality is about 35% at an average period of three years and nine months after the first symptoms, and that the mortality is slightly greater among those in whom the disease commences before the tenth year. Unfortunately the number of patients from whom reports have been received is not very large, but undoubtedly the spontaneous opening is the most favorWhen the abscess remains closed, the able outcome. mortality is almost as large as when treated by incision or aspiration. There seems to be a decided danger of general tuberculous invasion in these cases, as 3 out of 4 deaths were caused by tubercular meningitis. Causes of death. In both children and adults the most common cause of death seems to be a gradual deterioration of whole system, as most reports say: 2 (after two and four years)." Failed gradually after leaving the hospital." The causes of death in a few cases where it was possible to get a reliable report are given below: General tuberculosis, 4; amyloid, 1; tubercular meningitis, 3; shock of operation, 2; sepsis and renal, 1; phthisis, Average duration of disease slightly over six and a half years. Of 8 cases treated by aspiration alone the statistics 1. In 2 other cases, both adults, tuberculosis has attacked the genito-urinary system, and 1 is now in the last stages of the disease. In closing, I wish to thank the staff of the Children's Hospital and the staff of the Massachusetts General Hospital for allowing me the use of their records, and also many friends who have kindly furnished me Average duration of disease about eight years; aver-cases from their private practice. age time elapsed since operation, three years and two months; out of 4 children 3 are dead. Incision has been the method used in 48 cases; 32 under ten years and 16 over ten years. BY ALBERT H. FREIBERG, M.D., CINCINNATI, O., Orthopedic Surgeon to the Cincinnati, Presbyterian and Jewish Hospitals. THE use of celluloid as material for flat-foot supports was first suggested, as far as the writer is aware, by Kirsch. By him, as well as by Schanz, in two subsequent publications, the advantages and disadvanCondition at onset. Present condition. tages of its use were pointed out. Lightness, the Over Ten Years. 0 9 16 2 16 Average duration of disease in cases commencing under ten years is about six years and ten months; absence of any tendency to corrode, cleanliness therefore, and the ease with which the plates can be made innocuous to foot wear have been considered its advantages; in addition to this a certain elasticity which is necessarily lacking in metal supports and which is said to contribute toward the comfort of the patient as well as the efficiency of the brace. On the other hand it is acknowledged that celluloid that the writer believes the following method to be plates are less durable that steel ones, that material less objectionable than the use of soot or other black of the very best quality must be obtained in order to material, and that it furnishes at once a permanent obtain uniform results and that this is not always record. easy. It remained also to be proved whether or not celluloid plates possessed the rigidity requisite for their usefulness in the treatment of flat foot. The impressions are taken upon pieces of cardboard obtained from the paper stockhouse under the trade name of "black showcard." A piece being cut In undertaking to test the value of this material for of proper size, say 5 x 12 inches, it is fastened to a the manufacture of flat-foot plates, the writer felt also board of slightly larger size with drawing tacks, and the need of improvement in the process of working its dull black surface is rapidly coated with a fairly it. When placed in boiling water for a few minutes thick solution of shellac in alcohol. In the meanwhile celluloid becomes quite soft and flaccid, but upon re- the patient has been rubbing his foot in a pan upon moving it from the water it rapidly stiffens, so that it whose bottom ordinary talcum powder has been evenly cannot easily be manipulated with the hands. This, sprinkled. The patient should bear his weight upon however, is the method recommended by Schanz in the foot and rub in the powder thoroughly by moving both of his communications on the subject. After a the foot about. When the spirit in the shellac has few attempts made according to Schanz's directions, evaporated sufficiently to leave a sticky feel, but withthe writer abandoned the method of shaping the ma- out adhering to the finger, the board is taken to the terial freehand as being necessarily inaccurate and patient, from whose foot the excess of powder has unsatisfactory. The procedure of Kirsch seemed to been blown, and he is told to bear his weight upon it. promise more, involving, as it did, the use of the plas-While he is doing so the contour of the foot may be ter cast and might be briefly described as follows: scratched in with a suitable sharp instrument. It is The corrected plaster cast is made in the usual way well now to draw in with white ink the outline of the and having cut a piece of sheet celluloid to the desired impression as well as the contour of the foot. The shape, it is applied to the cast by means of a towel, result is shown in the figure. By interposing tissue the ends of which are twisted over the dorsal aspect of the cast, the middle being in contact with the sole. The twisted ends being held, the cast is now lowered into boiling water, and after a few seconds have elapsed the continued twisting of the towel ends is expected to bring the celluloid sufficiently into contact with the cast, and upon removing the whole from the boiling water and dipping it into cold for a few minutes the maximum stiffness is acquired. After experiment with this method the writer finds that in addition to being quite troublesome the adaptation of the plate to the sole of the cast is far from being exact. In addition, however, it is believed that the use of the plaster cast in the usual manner can be improved upon both as regards accuracy and simplicity, as well in the case of metal as of celluloid, however, as material for the plate and in the treatment of flat foot. It is assumed that it is the object of the flat-foot brace to support the depressed or weakened arch so much as is compatible with comfort, and therefore to the extent permitted by the flexibility of the foot. The flexibility of the foot, however, is a factor which will be found to vary within fairly wide limits, even in feet which are not the seat of the inflammatory stiffness so frequently present in flat foot. The amount of correction which must be made in the plaster cast is an uncertain thing and one which is really done by guess, so that it is believed to be a common experience that more or less change is required to be made in the finished plate in order to make it comfortable or efficient in the maximum, as the case may be. After considerable experiment with the following method, it is believed that it can be offered as being simpler, but also more exact than the use of a corrected plaster cast. paper between each pair of impressions, they may be conveniently and indefinitely preserved. To make the pattern, a piece of tissue paper is placed upon the impression, and the pattern may now be drawn with the outline of the impression and the contour of the foot in plain view. The paper is now cut out, and from this paper pattern another is cut in sheet lead about inch in thickness (known as 4pound lead). This lead pattern is now hammered by rough guess into the shape of the future support, a horn hammer or the handle of a file being used for this purpose. Due regard must be had for the "balance" of the support while so doing. The hammering of the sole has a tendency to make the whole piece curl, and it is well from time to time to press that which is to come in contact with the sole of the shoe against a plane surface so as to be able to properly estimate the amount of arch which is being A pattern is first to be made which differs accord-given. ing to the type of support which it is desired to produce. This is made upon an impression of the sole of the foot according to the method of Schanz, except 1 Schanz: Zeitschr. f. orth. Chir., Bd. vi, S. 495; Schanz u. Mayer Zeitschr. f. orth. Chir., Bd. viii, S. 25. 2 Kirsch: Centrbl. f. Chir. 1896, S. 837. This having been done, the pattern is fitted to the patient's foot and with a very little practice one is able to obtain a perfect fit with a few taps of the hammer. The patient can assist one by telling whether there is too much pressure in one spot or whether the whole pressure is disagreeable. It will |