show that the use of this drug is habit-forming. In some cases he found it to be effective in 24 to 48 hours, in other cases only after a week or more.

Sands(8) has recently reported a study of 86 female psychotic epileptic patients at the Manhattan State Hospital, Wards Island. Sands used the luminal-sodium preparation usually in doses of three-fourths of a grain three times a day. A very good impression of the efficacy of this drug can be obtained from a comparison of the total number of seizures in May, 1919, when the drug was not used, with May, 1920, when it was in use. There were 502 recorded seizures in May, 1919, while in May, 1920, there were only 8 recorded seizures. Over 60% of the patients in the ward May, 1920, were there in May, 1919. There was also a very definitely favorable influence on the menstrual function of the patients.

LUMINAL

Luminal is a white, odorless, and somewhat bitter powder that is virtually insoluble in cold water. Chemically, luminal is phenyl-ethyl-barbituric acid. It is therefore closely related to veronal which is diethyl-barbituric acid. The sodium compound of luminal, luminal-sodium, is a white crystalline, hygroscopic powder very easily soluble in water. Aqueous solutions decompose rather rapidly, and should not be kept over one week. Luminal can be obtained in 11⁄2 gr. tablets and in the powder form. Luminal-sodium can be obtained only in the powder form.

METHOD OF ADMINISTRATION

The use of this drug is usually begun by having the patient take 11⁄2 grains of luminal each night. The drug is usually prescribed in capsule form or in papers, the patient b-e ing directed to dissolve the contents of one in hot milk and to take just before retiring. It has also usually been my custom to prescribe bromide for a short period at the beginning of the course of treatment with luminal. In this connection I usually have the patient take either a dram of Elixir Sodium Bromid three times daily; or, one of the Triple Bromid Tablets, grains 7, three times daily. It has been my experience that those cases in which bromid is combined with the luminal at the outset do much better than those in which the luminal is used alone.

The patient is usually instructed to return in three to five days. If at this time it is found that the seizures are being controlled, or, if no seizures have occurred, the

size of dose is allowed to remain the same. If on the other hand seizures have been as frequent as before, the dose is increased. In no case has more than 3 grains been given at a single dose; nor has the dose been repeated more than twice in the 24 hours. If a quite rapid effect is desired, it is possible to use the luminal-sodium preparation in a 20% solution subcutaneously.

It has been my experience that with many of the patients that after a month or six weeks the dose may be reduced in size without recurrence of the seizures. In some cases, however, the drug seems to lose a portion of its efficacy, and the dose must be increased somewhat. After the dosage has been established to satisfaction, the patients are seen at three to four-week intervals.

THE RESULTS OF LUMINAL THERAPY

In the past two years I have had the opportunity of treating approximately 100 cases occurring in private practice and at the neurologic clinic of Harper Hospital and Children's Free Hospital with this drug. In no instance, with possibly one exception to be mentioned later, has there been any bad results. In no instance have the seizures increased in frequency. In practically all cases there has been a diminution in either the number or severity of the seizures, and in many instances the seizures have disappeared. The report of a fairly typical case is as follows:

CASE 1-E. McF. Married, housewife, age 36. The patient was first seen September 2, 1920, and gave this history: No nervous or mental disease or epilepsy in the family. Birth was normal. Developed normally. Had measles, chicken pox and pneumonia. Never had any spasms as a child. Married at 19. Five pregnancies, one living child. Has never had any severe injuries. There is an indefinite history of a "fainting attack" about 15 years ago while pregnant. About seven years ago she began to have definite grand mal seizures which were preceded by an aura and in which she frequently fell and injured herself, and lost control of the bladder. In general it may be said that she had these attacks about twice each week. In 1915 and again in 1917 there was a period of two weeks in which she was stuporous, disoriented and had delusions. Her memory became very poor after the onset of the present trouble. The longest interval without a spell had been three months.

Examination showed a rather frail woman who otherwise physically seemed quite normal. She had, however, the rather typical facies of an epileptic. Her memory was exceedingly poor. She could not recall whether she reached the office by street car or automobile. The neurological examination was quite negative except for X-Ray some blurring of the optic disc edges. plates of the head and the blood Wassermann were negative.

She was placed upon luminal grains, two each night, and Elixir Sodium Bromid, 1 dram after

each meal. The bromid was soon discontinued. On October 23rd she developed a rather generalized fine maculo-papular rash. The luminal was discontinued and on November 7th she had a seizure. On November 16th luminal was started again and has been continued up until the present time. A note made December 2nd says that the family are decidedly of the opinion that, the patient's memory is tremendously improved. On January 29th it is noted that the patient ran out of medicine on Tuesday and did not have the medicine refilled. On the following Friday she had two severe seizures. This case serves as a rather typical example of what I have encountered in treatment with luminal. Admittedly not

all patients are benefited to such an extent.

The report of the single patient in which a bad result seemingly followed upon the use of luminal, whether it may be said to be due to the luminal or not, is as follows:

This

CASE 2-R. C., male, age 17, student. patient was first seen November 26th, 1920. The presence of nervous or mental disease or of epilepsy in the family was denied. The patient is one of twin children; the other of whom is living and is perfectly normal. The patient was the second of the twins born and is said to have been the weaker. He had so-called "internal spasms" for three to four weeks after birth; but, otherwise was normal. As a child he had chicken pox, tonsilitis, and a bilateral otitis. There is a history of several falls in which the patient struck his head. When about 8 years old he was struck on the head with a baseball bat, but he continued with his play.

several

When 11 years old he had his first grand mal epileptic seizure. These recurred for times at intervals of two to three months. The patient was put on bromides which he has continued up until seeing me. While taking bromid he was free from seizures for a period of almost five years. He had continued in school almost up until the time he saw me.

Examination showed a surly young man, who presented a rather typical epileptic appearance and whose attitude was virtually that of not wanting to get well. Physical examination was negative as was the blood Wassermann and X-ray plates of the skull. The neurologic examination revealed increased tendon jerk, ataxia of the hands and slightly blurred optic disc edges. The patient was put upon luminal grains, two each night, and Elixir Sodium Bromid, one dram after meals.

December 7, 1920, a note was made that the patient was intensely irritable, but had had no seizures.

He

December 13. 1920, the father stated that he had attempted to run away from home, and had to be forcibly returned. A few days after this he became somewhat unclear, threatened to kill his brother and actually assaulted the father. was sent to the Psychopathic Ward of the Receiving Hospital, where he remained for three days. at the end of which time he returned home. About February 1, 1921, he passed into another of these unclear states in which he pursued his brother with a knife, almost breaking down a door to reach him. He was again sent to Receiving Hospital, from which, after a few days, he returned home much as before.

This patient shortly after being put upon luminal treatment first manifested psychic equivalents.

Whether these would have appeared if the

luminal had not been given is, of course, impossible to say.

There remains another group of epilepsies in which the seizures are symptomatic of some definitely ascertainable organic condition. Of these symptomatic epilepsies I have had the opportunity of treating but a few. The following record is of a posttraumatic epilepsy.

CASE 3-R. J.. male, single, age 24. There is no history of epilepsy or nervous and mental disease in the family. Patient's birth was normal. He was healthy as a child. When 18 years old he was knocked to the ground by a speeding automobile. He was removed to a hospital; and, after two days of unconsciousness, had a cranial decompression. Following this he was aphasic and had to be taught to speak, Five years later he had a grand mal epileptic seizure. Two months afterwards he had three attacks in a single day. He was taken to the Mayo Clinic, but nothing is Isaid to have been done. He shortly had several more seizures and in September of the same year he had a second cranial operation, immediately following which he had several more seizures. These seizures then returned regularly at intervals of three to four weeks. Examination of th patient was negative except for the evidence of the cranial operations and for some thickness and hesitancy in speech which was a residual of the aphasia. The patient was placed upon luminal, and upon bromid for a short time. The patient has now been ten months under treatment, and has had but one seizure and that a comparatively mild one. The family are very much pleased with the results of the treatment, and say that he has neither looked nor seemed so well since before his injury.

Many of those who have previously reported upon the use of luminal have mentioned that with cessation of treatment the attacks return with greater severity than before taking luminal. This in my experience has not been the case, although it is quite true that they frequently reappear shortly after stopping the drug.

tic Dementia. 36:248, 1914. 5-Grinker, J.

Monatschr. f. Psychiat, u. Neurol. Experience with Luminal in Epilepsy. J. A. M. A. 75:588. Aug. 28, 1920. 6-Dercum, F. X. On the Complete Control of Epileptic Seizures by Luminal. Therap. Gaz. 43:609. Sept. 15, 1919.

7-Kirk, C. C. Analysis of More Than 200 Cases of Epilepsy Treated with Luminal. Am. Jour. Insan. 77:559. April, 1921.

8-Sands, I. J. Luminal Therapy in the Control of Epileptic Seizures. Arch. Neurol, and Psych. 5:305. March, 1921.

DISCUSSION

DR. C. D. CAMP, Ann Arbor: I think Dr. Stanton's paper is a very good one and the subject deserves discussion.

I have used luminal. In my mind it has always been a question of substituting luminal for sodium bromide or the bromides in cases where the patient does not bear bromides well, either because he has skin eruptions from bromides or because his stomach does not stand the bromides or for some other similar reason. I know there is a very considerable benefit from alternating bromides with luminal; alternating routinely without any special indications. Give the one drug for one month and the other for another month.

It should be borne in mind, I think, that the modern viewpoint is that this is not a disease, but is rather a syndrome which produces results from a variety of causes and that in every case a cause should be carefully searched for, We should only resort to drugs like bromides and luminal and other sedatives when we have definitely arrived at the conclusion that we can not find the cause and we simply have to manage the case. It does not appear that luminal is a drug which is, strictly speaking, a treatment. It is rather an adjuvant in the management of cases.

DR. R. L. DIXON, Wahjamego: I wish he had gone a little further into the literature covering the other side of the question as it is written up in the literature.

You could have substituted the word barbital for luminal in Dr. Stanton's paper and it would have read just the same. There have been times during the last 25 years when you could have substituted eight or ten other drugs for the word luminal and could have presented a very proper discussion of the treatment of epilepsy.

Here is one point I think we should considerthat the treatment of epilepsy is not essentially simply and wholly inhibiting and diminishing or decreasing the number of seizures. That may be the last thing you should do to the epileptic patient. But that is the sensational feature. That is the thing the family think of. When the seizure has abated, the family reports that the patient has improved, and we are likely to be misled on that account. I know of many cases of epilepsy where to prevent the seizures is doing that patient no good.

I think this paper on luminal therapy would be very well if we would limit it to the restriction of an epileptic seizure, but not consider it as a treatment process for epilepsy.

Now, I can see cases of epilepsy in which bromides should be used. I can see cases where a number of drugs should be used. I don't know of any cases where luminal should be used.

I believe if Dr. Stanton will read the adverse literature he will find just as dependable men as those he has quoted who will say it is the most pernicious and most destructive drug ever proposed for the treatment of epilepsy. Its specific effect on the patient is in the very line in which the patient's greatest affliction is. The mere matter of convulsions is not the most important thing in a case of epilepsy. The matter of having the fit is not the thing that sends the patient to the institution. It is the epileptic's mental makeup and particularly his lack of judgment. He is on his way downhill anyway, and luminal gives him a kick and sends him down farther. Bromides will kick him down hill too, but he will quit sliding sooner after bromides than luminal.

It is my opinion that luminal is to be used very exceptionally in the treatment of epilepsy.

DR. J. L. CHESTER, Detroit: In March, 1920, I attended Dr. Fenger's clinic in Chicago, in which he showed many cases in which the treatment had been luminal. Of course, in each of those cases there had been a thorough study made. Bromides had been tried and they were better and felt better. I remember one case particularly of a barber tending to business three years without a seizure. Soon after I came home, a patient came to me from Emmett, where I had practiced for a number of years, who had fits for about two years, the patient 18 years old, a high school student. He had to give up work on account of the seizures. After making a careful study of the case, we tried giving a half-grain each night in a glass of milk. His seizures stopped. He felt better and went on with his high school work. This year, the year after he began the treatment, he stopped taking luminal and the convulsions began. So he is again

resuming his treatment.

I will relate one more case that has been under treatment about two months. It is a more striking case than any I have seen, even in Dr. Fenger's clinic. I was treating this case for edema and nephritis. As this patient got better, the family said to me, "We have a girl here 13 years old who has had epilepsy since childhood. We have had many doctors treat her. Now she has about seven or eight convulsions a day. Is there anything you can do for her"" I said, "The best thing you can do is to send this child on to Dr. Dixon." They did not want to send her to an institution. They wanted me to prescribe. I prescribed a grain and a half of luminal taken at night in a glass of milk. The nurse reports to me that she has not had a convulsion for two weeks. This is three weeks ago. She feels better. I think it is a valuable drug in epilepsy.

DR. CONRAD GEORG, SR., Ann Arbor: I have a few words to say on this subject. When Dr. Camp calls the disease a syndrome, of course he is thinking of the general case.

Several years ago, I think it is six years ago, a great surgeon from Cincinnati who has a great clinic, published a work in the Journal of the 'American Medical Association on epilepsy. In his work on the cecum he had been struck with the fact that epileptic seizures had accompanied the case. He did not operate for the epilepsy, but with no practical definite pathological reasons he found that the epileptic seizures ceased. He investigated further. I refer you to the work of Dr. Smith of Cincinnati in, I think, 1916. He isolated a bacillus, calling it the bacillus epilepticus.

Now, we old country doctors and general practitioners who are doomed to extinction-we used to hold to shotgun doses. Whenever we hear a thing is good, we use it. We can speak before scientific societies as experts showing where we have success.

Now, we have drugs which act by absorption in the alimentary tract. They do not interfere with cell action. They do not destroy the resisting forces of the cell, but they take the germ along.

Now, a year ago a case came under my care of a young lady, 25 years old, who had epileptic seizures from the time of puberty. They kept on regularly along until it terminated in epilepsy and she had regularly three or four heavy seizures during the menstrual period and at other times moderate seizures. Heavy seizures during the menstrual period. She came under my care about a year ago. I placed her immediately under the sylicate of aluminum. Aluminum and charcoal as an adjuvant. Because I had used that like water, with no more thinking about it in that class of people. Then I added aluminum. She took two tablets a day. A grain and a half in each tablet.

Now, since last July, about July, I saw her last, last week. This young lady has had not a single epileptic seizure. I would say further when I saw her first the mentality was low. She had no interest in the external world. Her thoughts were confined to herself. Her mentality now is that of a young lady looking out on life ahead. Without any diminution of her functions.

I have treated epilepsy probably as long as any

man in this room. I have seen it stopped under nitrate of silver treatment. I have seen it continue under the nitrate of silver treatment. I have never seen any permanent recovery under the bromides, and I have used the bromides heavily. I have used them until we had bromide acne.

I think with luminal it does not act like bromide in subduing the mental function. The mental function is active and alert, and I believe it is the treatment of the day. Now, as to the action of the silicate of aluminum, what effect it has and what should be attributed to the luminal, I can't say, because they are both used.

DR. C. B. STOCKWELL, Port Huron: I arise to the idea of emphasizing the use of that drug in certain cases. At one time I had a case of epilepsy in which the prognosis was given as utterly hopeless. Some 10 or 12 seizures a day in a child five years old. The parent said he would rather have the child die than grow up in such a state as he was then in.. I had just had my attention called to the fluid extract, and I said if you are willing that I should push this remedy, I would be glad to do it. He gave me the authority. The dose was given as five to 15 drops. We kept increasing that dose three times a day until he got up to one ounce and a half. As I increased it up to that point. the conditions improved. When I got to that point the seizures were so few, I gradually reduced the amount and he became permanently well. That was some 15 years ago. The last seizure must have been all of 20 years ago. The mentality was preserved. The boy is a bright, energetic young man.

I feel that some times those drugs we take empirically, put down as just so many drugs-we should push them under such circumstances, push them to the extreme.

It stopped the seizure. I think it is just as well to keep that in mind, that some times we can get results by increasing doses.

DR. N. H. JACKSON, Wehjamego: From the case just cited by the doctor, it makes me conclude that the patient did not have epilepsy. After three and one-half years of constant work, having dozens under my care daily and doing considerable work along that line, I have come to the conclusion that epilepsy is the most incurable of all mental dis

eases.

We must not lose sight of the fact that every case which has convulsions is not an epileptic, and that every case of epilepsy may not have convulsions. We have a number of epileptics in our institution who never had a convulsion. And they are just as epileptic as when they are having seizures every day. The mental condition is the true guide to a diagnosis of epilepsy from my point of view. I believe that the less drugs we give these people to control their seizures, the better it is for our patients.

Also, the patients who come to our institution, who have been taking drugs constantly, make us a lot of trouble for a time, until we get them to live without drugs. In the last three and one-half years, I have used less than five pounds of bromides. It would be a small amount for a practitioner in general practice. I use it at times when a dose of bromides is good for an epileptic or a dose of some other sedative, just as you give it to a case in general practice when it is indicated.

Our patients, most of them, improve. The condition in general, and the number of seizures are less, without bromides. By proper regulation of food and proper hours of sleep and the general regulation of their living.

I don't think any physician should ever kid himself to think he has cured a case of epilepsy, if it was really epilepsy, and if they have fits.

DR. P. N. LEECH, Chicago: The essayist brought out the fact that luminal was closely related to veronal. Veronal is, of course, the proprietary name. It may be of interest to know the difference. One is simply phenyl-ethyl-barbituric acid and the other is di-ethyl-barbituric acid.

This leads me to comment on whether or not it is safe to say that luminal is not habit-forming. The same claim was made for veronal when it was

brought out. At present. veronal can not be sold as such in England. It would be very strange if luminal would not become a habit-forming drug, too.

I would like to ask Dr. Stanton whether he has looked up any real evidence of the fact of the habitforming qualities of luminal as compared with those of veronal.

DR. J. M. STANTON, Detroit, (closing): Dr. Camp says he thinks luminal may be considered as veronal. I think the difference between those is largely a matter of choice of words. He also spoke of alternating bromides and luminal. I have had no particular experience, and really can't say anything about it. Bromides combined with luminal, I have decided, gives better results than luminal alone.

With regard to the question of luminal not being a treatment for epilepsy, it is rather difficult to know how to deal with that sort of proposition. After all, the seizures are the main outstanding obfection to the condition. If we are going to use any methods to control these, it would be simply fair to treat them for this condition.

I think Dr. Dixon, in his discussion, takes the more or less typical attitude of the institutional man in regard to the management of epileptics. After all, the convulsive seizures in about 95 per cent of the cases is the main thing that stigmatizes the epileptic as an epileptic, as judged from the men about him. From a pure etiological attitude there may be a question, but we all don't have an institution where we can have our epileptics have their seizures. The family complains about the seizures and the patients compalin about them. After all, if we can relieve the seizures in those cases, I think we have done a tremendous amount of good.

Dr. Leech thinks, perhaps 10 years from now luminal will be a habit-forming substance. Perhaps it will. I am only telling my experience. I do not offer it as a remedy in all cases.

In regard to Dr. Leech as to the habit-forming elements in using luminal. It is quite true that veronal is habit-forming. Because luminal has a chemical formula similar to veronal does not prove anything. Morphine and apomorphine have somewhat similar chemical formulaes. I know of no case where these patients that are receiving luminal have acquired the habit. They may have had the habit forced upon them.

PERFORATING GASTRIC ULCERS

V. L. TUPPER, M. D. BAY CITY, MICH.

Gastric ulcers are common lesions. English and German investigators have found them to exist in five percent of people dying from all causes. Scholl in 3,467 autopsies, found healed and unhealed gastric and duodenal ulcers in 17 per cent.

Yet comparatively few of the many who suffer with this complaint are treated for it. The trouble and expense necessary to put a patient to in order to prove the existence of a gastric or duodenal ulcer, has, I believe, been the greatest factor in the neglect of this malady on the part of the profession, and not ignorance on the part of physicians as to the methods.

Twenty-four to 26 percent of gastric and duodenal ulcers perforate according to the Rochester clinic, but how many of the sudden deaths in people on whom autopsies

are not held, are due to perforating ulcers may never be known. We believe, many.

Gastric and duodenal ulcers are found in large surgical clinics to be more common in men than women in the proportion of 75 to 25. In women they exist more often between the age of 25 to 40 and in men between 40 and 60, but they may occur at any age.

This type of ulcer is found wherever the acid chyme of the stomach reaches the lower end of the oesophagus, the stomach and the duodenum. It is located in 90% of cases in the lesser curvature of the stomach and the first part of the duodenum. They vary greatly in size, diameter and thickness. In the duodenum the ulcer is generally small and most often very near the pylorus and on the anterior wall. In the gastric wall the lesion may be from microscopic size to six inches in its greatest extent. The thickness of a perforating ulcer may be but little or no greater than that of the gastric wall and it may be an inch and a half thick. Their thickness and irregular contour lead the operator often to believe that they are malignant as a percentage of them, of course, are.

As clinically perforating gastric and duodenal ulcers present practically the same symptoms and the same indications for treatment they will both be included in our discussion.

The acutely forming and perforating ulcer is usually small and the hole in it looks as though it were punched out.

The chronic, thick, callous form of ulcer perforates by extension of its crater, which is situated where its blood supply is poorest and its resistance to the digesting enzyme least. This may be at its center or near its edge and the opening of the perforation may be of any form and size. Balfour contends that all callous or cronic ulcers are perforating, for by removing the peritoneal coat and a little or more tissue the crater of the ulcer is met with. He treats them all as perforating ulcers, by cauterizing the crater well, and stitching and inverting.

Those most prone to perforate are those situated on the free anterior wall, where the motility of the stomach does not allow of adhesions to contiguous structures.

The gastric muscularis offers considerable resistance to perforation, and the majority of ulcers go no further, but infection or increasingly poorer blood supply and often trauma lead to extension of the crater through the wall.

There are two main types of ulcer that

perforate. First, those that have formed acutely and extend rapidly through all coats of the stomach. These ulcers often give no symptoms till perforation occurs. They are often multiple and two or more may perforate at the same time. We have had two of this type in young men under 30 years. The openings through the wall were clean and about the diameter of a 32 and a 38 bullet, and the edges of the ulcers were but little thicker than the gastric wall.

Second, those that perforate late in their course when more or less thickening and cicatrization has taken place.

These callous ulcers may again be classified into those that perforate acutely and freely discharge the gastric content and those that perforate slowly causing a perigastritis and adhesions or cause abscess. The adhesions may bind the stomach or duodenum to the liver gallbladder, colon or intestines. The perforation may extend into any of these organs or an abscess caused by the perforation may burrow into the gall-bladder, causing septic cholangitis, into the hilus of a kidney causing pyelitis or into the colon or intestine. Such an abscess may burrow through the diaphram and pleura causing pyopneumothorax, pneumopericarditis or mediastinitis. These abscesses have burrowed down behind the peritoneum into the pelvis and even through the abdominal wall.

The possibility of perforation of an ulcer on the anterior wall of the stomach and duodenum is much greater than on a part of the wall lying adjacent to other structures.

The patient who suffers an acute perforation does so, usually after a heavy meal and some exertion as coughing and sneezing or from a blow on the abdomen. The epigastric pain is intense, he falls or throws himself down writhing in agony, becomes livid or pale, the skin clammy, the pulse rapid, but this in some, becomes very slow; vomiting may occur with bloody vomiting and the act greatly increases the pain as does coughing or taking a deep breath. He wishes to remain in one position and not be disturbed. The abdomen is rigid. With a stethascope the gurgling of fluid through the opening may at times be heard.

The diagnosis of the case at this time is easy and especially, if there is a history of previous stomach trouble.

Later the patient becomes much more comfortable. The pulse and temperature may be normal and now a physician visiting him may not be impressed with the seriousness of the condition. Here the board