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with the affect of paralyzing the vasomotor centers. This increased, beneficial pressure may be momentarily augmented by amyl nitrite or morphin, thus terminating the attack. Bodily extension likewise increases the blood pressure and the subsequent decrease in the pulse rate, regulating the coronary blood supply, also acts favorably on the attack. The differential diagnosis between stenocardia and uremic dyspnea is readily identified by the posture; in the former, fear, bodily immobility and retroversion prevail, while in the latter, the patient is in a state of agitation and retroversion, to any degree, is always absent. In the respiratory forms of neuroses, antiversion of the body is the rule. In attacks of laryngeal stenosis the patient suddenly assumes the sitting position, rushes out of bed, tears away any interfering clothing from the body and seeks support to hold himself erect.

The Diagnostic Value of Leucocytes.Grünbaum (Practitioner, Dec., 1905) believes that an accurate leucocyte count is a valuable index in determining the presence of pus in the body. A large increase in the polymorphonuclear neutrophiles, together with a glycogen reaction, an increase in the blood-plates and in the fibrin of the blood is strongly indicative of pus in the economy. When counts are made at short intervals (every four hours) and the leucocytes found to be on the increase the assumption that the inflammation is extending is justifiable. A negative blood examination, on the other hand, does not warrant the exclusion of pus. A palpable gastrio tumor of obscure nature with a pronounced digestive leucocytosis is a strong evidence against malignancy, pointing to an inflammatory trouble, although small cancers of the stomach are frequently associated with a considerable digestive leucocytosis. presence of choline in the blood is an important symptom in the differential diagnosis between hysteria and disseminating spinal sclerosis, as this substance is only found when there is an active process of nerve degeneration going on in the body.

The

THE DIAGNOSIS OF RENAL CALCULUS.-G. L. Hunner, Baltimore (Jour. A. M. A., March 24), remarks that few diseases present more protean symptoms and simulate so varied an array of other maladies as stone in the kidney. Large calculi may exist in and cause destruction of both kidneys without marked symptoms, while minute calculi may give rise to agonizing pains. The more common kidney disease to be considered in the diagnosis of calculus are tuberculosis, pyelitis, pyelo

nephritis and pyonephrosis from the ordinary pus-producing infections, tumor and intermittent hydronephrosis. Each of these is noticed separately. The only positive evidence of renal tuberculosis is the finding of the tubercle bacillus in the urine or producing the disease in animals by inoculation with the diseased urine or tissues. Other symptoms are all more or less unreliable. The differential stain must always be employed in diagnosing tuberculosis from the finding of acid fast bacilli in the urine, as is shown by a case bere reported. It may be impossible to diagnose pyelitis, pyelonephritis or pyonephrosis from an infected nephrolithiasis except by operation, nor is it easy to differentiate between calculus and tumor, and here also the chief dependence is on the urinary examination. A movable kidney and kinking of the ureter may cause attacks closely simulating those of calculus, but the enlarged and movable kidney during the attack and the relief of pain and increased

flow of urine on its return to normal size will

aid the diagnosis. In this connection, Hunner

mentions the unaccountable renal hemor

rhages known as idiopathic hematuria or renal epistaxis, and says there is, he believes, a tendency nowadays to connect these with the chronic interstitial form of Bright's disease. The diseases of neighboring organs noticed as having to the differentiated from calculus of the kidney are gallstones, appendicitis, intestinal obstruction, pancreatic calculus and Henoch's purpura and angio-neurotic edema cases are reported illustrating the difficulties sometimes encountered. The

history of the case, examination of the urine, etc., are generally the main dependence in the differentiation. Kelly's method, injecting the kidney pelvis with a bland solution, is mentioned as one of the best diagnostic aids in case of suspected gallstones. In conclusion he refers to Israel's saying that in diagnosing other than typical cases, one must, first of all, divest himself of the schematic picture so often presented in the text-books.

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SOCIETY PROCEEDINGS

MEDICAL SOCIETY OF THE NEW YORK POLYCLINIC MEDICAL SCHOOL AND HOSPITAL.

Stated meeting held March 5, 1906. The President, Dr. J. J. MacPhee, in the chair.

PARTIAL GASTROECTOMY FOR CARCINOMA.

This patient was presented by Dr. J. I. Edgerton. G. C. H.; male; 41 years of age. Father living and in good health at 78; mother died of stomach trouble, probably cancer, at 58 years of age. Patient had malaria severely 25 years ago, but has had no recurrences. He indulges moderately in tea, coffee and alcohol, and smokes regularly from fifteen to twenty cigarettes daily. For the past thirteen years he suffered with heartburn, which had been more constant during the past two years, during which time he also suffered from nausea and pain in the epigastrium after eating. During the last few months he had burning pains after eating; was hungry all the time, but afraid to satisfy his hunger, for when he took solid food it remained in the stomach for an hour or so, and then was vomited. On one occasion last winter he vomited some mucous streaked with blood. He began washing out the stomach twice a day on October 4th and brought up greenish clumps of mucous resembling

moss.

There was no vertigo. His bowels were constipated, and he lost about twentyfive pounds in weight during the last few months.

On November 27, 1905, the stomach contents contained free hydrochloric acid; moderate reaction; odor butyric. A mass could be felt over the region of the pylorus, and operation was advised and accepted by the patient. The usual preparation of cleansing the stomach by lavage was performed, and in the operation Mayo's technic was followed. The abdomen was opened near the median line and the gastric artery was doubled, ligated and divided near the cardiac. The gastrohepatic omentum was also doubled and ligated close to the liver, leaving most of its structure attached to the stomach. The superior pyloric artery treated in the same manner, and the upper inch or more of the duodenum freed. With the fingers as a guide beneath the pylorus in the lesser cavity of the peritoneum, the right gastroduodenal artery was ligated. The gastrocolic omentum was cut distal to the glands and vessels, up to an ap propriate point on the greater curvature and the left gastroepiploic vessels were ligated.

With a running suture of catgut through

the seared stump the end of the duodenum was closed. The proximal end of stomach was double clamped along the MiouliczHartman line, and divided with a cautery one-fourth inch projection. Then gastrojejunostomy was done.

The tumor was found to occupy the pyloric end of the stomach, extending around the whole circumference. No adhesions were present. There was a delay in finding the nearest point of jejunum that could be brought to the stomach wall, and in taking great pains to suture the opening in the mesocolon so as to prevent hernia into the lesser cavity of the peritoneum.

His temperature at no time following the operation was above 96. degrees F., and there has been no vomiting since operation. He took water in eight hours and liquid nourishment in twenty-four. His bowels were moved by enemas during the first week, but three was no distension; in fact, no more discomfort than from an ordinary exploratory laparotomy alone. The man has gained about twenty-five pounds in weight, and is at his regular employment again with no discomfort whatever referred to his stomach.

CASE OF MORPHINE POISONING.

The report of this case was presented by Dr. D. A. Sinclair. The patient was 63 years of age, weighed 180 pounds, was 5 feet 6 inches in height, full blooded, with marked organic heart disease. He had been coming to the speaker's office for the past two or three years suffering from alcoholism. He was a periodic drinker, and when first seen, two or three years ago, had been treated along the regular lines for such a condition. He informed the speaker that he had been in the habit of receiving injections of morphine from previous doctors and that was the only treatment that did him any good. Accordingly one-fourth of a grain of morphine was injected, which the patient reported at the next visit was of no benefit whatever, stating that it was, he knew, a very small amount-nothing like what he had been used to getting. The dose of morphine was very carefully increased to onehalf grain without any effect, and finally, at the earnest solicitation of the patient and his assurances that he could stand the morphine, the dose was increased to one grain. injection bore out his statements as to his previous experiences and "just about steadied him," without producing any thing but a very short sleep. His subsequent periodic sprees were treated along the same lines, from three-fourths to one grain being used as an injection. It became so much a matter of course to inject this patient and see no unto.

This

war effects whatsoever that there was no hesitation on the part of the speaker about giving him a grain of morphine two or three times day according to the exigencies of the occasion. Between the sprees the man, who was of more than average intelligence, not only abstained from alcohol, but did not have the slightest desire for morphine or any other drug.

The treatment detailed above was carried out until the last spree, about a month ago. On this occasion he presented himself, intoxicated, but retaining all his faculties, and begged for an injection of morphine, saying that he would only be put "on the ragged edge," as he expressed it, if he received the usual dose. He stated that he had taken as many as three grains of morphine without any bad effects, but this statement he afterward denied. He had a very important meeting for the next day, and therefore was desirous of securing a good night's rest. and one-half grains of morphine sulphate were injected into his left arm. In about half an hour the speaker was called to him hurriedly, and found him in a much stupefied condition.

One

a

This was about 8 p.m. a small dose of cocain was injected and the speaker left, returning about 9 o'clock, when the patient was beathing slowly, about five to six minute He was walked up and down until about 11 o'clock, at which time his respirations had diminished to one in two minutes. Up to this time there had been injected bypodermatically 3-5 of a grain of cocain, 4-150 of atropine sulphate, 4-30 of strychnine and 4-10 of nitroglycerine. He had also been given about a quart of strong, black coffee.

The situation being desperate, at the request of the man's family 1-12 of apomorphine sulphate was injected as an emetic and was effectual in about one-half a minute. The patient went steadily into a deep comɑ, became very blue and was apparently dying. Artificial respiration and the administration of oxygen were then resorted to and the tongue pulled forward with artery forceps. At 1:30 p.m. he began breathing at the rate of about four a minute. About a quart of black coffee was given as an enema, and at about 3 a.m. he was breathing about ten times a minute and was conscious.

The oxygen and artificial respiration, together with the cocain, probably saved the man's life.

Two lessons should be learned from this case: (1) not to be importuned into giving any patient a large dose of morphine, even though he is used to it; and (2) not to abandon hope or relax one's efforts, even when the patient is apparently beyond hope, as

this case shows that even in apparently fatal cases life may be saved.

Dr. R. H. M. Dawbarn opened the discussion of this case which, he said, recalled to his mind a case of morphine poisoning which occurred when he was interne at the Nursery and Child's Hospital. He placed the patient on his back and administered atropine (the first dose of which dilated the tubes) until, from morphine poisoning, the patient developed a case of atropine poisoning. Life was saved by artificial respiration, which was kept up for eight hours by the speaker and his assistant, each taking twominute turns. Walking the patient up and down was tried, but the exertion seemed only to make the heart weaker. If he were to criticise the treatment of the case under discussion it would be the giving of depressing narcotics, as after vomiting from an overdose of morphine the patient usually collapsed.

Dr. Maurice Packard said that in a series of experiments in which he had been interested, which were being conducted by Drs. Bodine and Jeffries, they were trying to find out from guinea pigs how much morphine would act as an antidote for a given injection cain is a physioloigcal antidote for morphine. of cocain, acting upon the principle that coPreviously atropine had been used for this similarly, in that both had a tendency to purpose, but atropine and morphine acted depress the smooth muscle fibres as well as secretion, while, on the other hand, cocain stimulates the smooth muscle fibres and increases secretion, as is shown by the druling at the mouth and the frequency of urination. The best possible treatment, he thought, was the stomach tube. After using it once, however, it must be used every half hour, for the mucous membrane of the stomach will repeatedly secrete morphine. With the stomach tube and the proper use of cocain, most of these cases will end in re

covery.

The paper of the evening was read by Dr. E. L. Keyes, Jr., and was entitled

RENAL COLIC.

He said, in part renal colic is usually considered a symptom of kidney stone; but it is not absolutely pathognomic of stone, nor are the position and character of the colic pains always an infallible index of the position of the stone. Indeed, so misleading is renal colic in a certain few cases, and yet so rarely is it a symptom of anything but stone, that think it by no means waste of energy t study attentively some of the cases whic have come under my observation, and i

which renal colic has been a misleading and often a confusing symptom.

The late Dr. Bryson once formulated in a tentative way the theory that stone in the pelvis of the kidney causes pain in the loin radiating down the ureter, while stone at the lower end of the ureter causes frequent and painful urination and pain in the pelvis. This distinction holds true in the great majority of cases; yet I have seen one case that was a striking exception to this rule, in that the only pain suffered from was frequent and painful urination, although he had but one stone, and that lay in the pelvis of his kid

ney.

He

The first patient, a lean asthmatic man, 63 years old, complained of frequent urination. Sixteen years ago he applied for insurance was refused on account of albuminuria. consulted a surgeon, who stated that he had a surgical inflammation of the kidney. Except for the passage of two calculi from the right kidney, eight and five years ago respectively, and except that he had to rise once or twice at night to empty his bladder, there were no symptoms until about a year ago, when his urination became more frequent, and he consulted an eminent urologist who began and has since continued treating him for chronic cystitis attributed to prostatic hypertrophy. His symptoms have grown gradually worse.

Examination showed the right kidney to be readily palpable, somewhat large and tender; the left kidney could just be felt, but was not tender. The urine was hazy with pus; specific gravity 1016; albumin 1% by weight; various casts of many kinds; many red blood cells; a total excretion of from 25 to 30 ounces; the bladder capacity was 8 ounces. The prostate was not enlarged; there was no residual urine. X-ray examination revealed a shadow in the region of the right kidney pelvis, but for various reasons the operation was postponed for eighteen months, when the patient's condition was so unsatisfactory that it became imperative.

Upon opening the right kidney, an oxalate stone was found fitting in the upper end of the ureter and was removed through an incision in the the kidney pelvis. The kidney itself was considerably dilated and covered with small cysts which contained. contained serous bloody and sero-purulent fluid. It was suspected, because of the nature of the symptoms, that there was a stone in the ureter, But careful search failed to reveal one. After operation, instead of passing urine constantly, as he had done heretofore, he had to be catheterized until the second day, when he began to urinate at intervals of from two to four hours. The secretion of urine remained low,

and, finally, at the end of three and a half weeks, the patient died from asthenia and failure of kidney function.

It is noteworthy that in the case we were able to arrive at a diagnosis with the aid of an X-ray photograph, while the practitioner who had previously treated it had failed to make the diagnosis, because he had not employed this expedient.

In contrast to the above case, in which a patient with stone suffered from a pain that did not resemble renal colic, the second case shows the brilliant contrast of a patient with renal colic, but without stone.

The patient, 58 years of age, complained of repeated attacks of renal colic. He never passed blood, never had any anuria or bladder symptoms, although since the first attack he had urinated twice at night and every three hours by day. No lumbar tenderness could be evoked by palpation, nor was it possible to feel either kidney. X-ray photographs showed small sclerotic kidneys, but no shadow suggestive of stone. Examination of urine showed many pus cells, but no bacteria. Macroscopically there was no pus and very few blood cells. He was given an alkaline mixture, advised to drink very freely of water and to exercise to the limit of toleration; and I believe that in January, 1906, he had no further renal colic.

A detailed history was presented of a patient who suffered from most violent attacks of renal colic brought on by digestive causes. A carefully restricted diet, much exercise and water and the administration of betanaphthol, bismuth and salol caused a cessation of these attacks.

In further contrast to this case was case V, in which the colic caused by digestive disturbance was intestinal and not renal, although the pain was precisely that of renal colic.

The last history presented by the speaker was an example of a class of cases which he considered very important. They are relatively infrequent and cause objective symptoms absolutely characteristic of renal stone; yet a careful examination will reveal the fact that they suffer from nothing more than seminal vesiculitis.

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THE MEDICAL FORTNIGHTLY

A Cosmopolitan Biweekly for the General Practitioner

The Medical Fortnightly is devoted to the progress of the Practice and Science of Medicine and Surgery. Its aim is to present topics of interest and importance to physicians, and to this end, in addition to a well-selected corps of Department Editors, it has secured correspondents in the leading medical centers of Europe and America. Contributions of a scientific nature, and original in character, solicited. News of Societies, and of interesting medical topics, cordially invited.

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Contributions and books for review should be addressed to the editors, 319 and 320 Century Building, St. Louis, Mo.

MEDICAL MISCELLANY

THE BOSTON SESSION OF THE AMERICAN MEDICAL ASSOCIATION.-It would seem that the medical profession of Boston intends to have the approaching session of the American Medical Association one long to be remembered for the high grade of its scientific proceedings, the cordiality of its entertainments and the elaborateness of the clinical and exhibition features. The Journal of the American Medical Association, May 5, devotes over 20 pages to the session, giving railroad rates, lists of hotels, meeting places, headquarters, lists of entertainments, excursions and programs, etc. The preliminary programs of the twelve sessions show that the scientific proceedings are to be of great value, and that many distinguished foreigners are to be among the speakers.

EFFECT OF PROPRIETARY LITERATURE ON MEDICAL MEN.-N. S. Davis, Chicago (Jour. A. M. A., May 5), calls attention to the evil effects of medical advertisements, written as they are to sell the goods and not, as a rule, to state the complete truth, even about the really worthy and scientific preparations. Ready-made prescriptions lead to slovenly therapeutics, and if all members of the med. ical profession would refuse to employ ready-made mixtures they would destroy one of the greatest hindrances of rational therapy. Most of us are inclined to accept new things and new ideas without sufficiently testing them or demanding the

approval of recognized authorities, and the advertising methods used almost force them on us. The remedy, he states, lies first, in recognizing the condition; second, in insisting that the teaching of pharmacology and therapeutics in medical school should be confined to the drugs of the pharmacopeia; third, we should take more interest in the pharmacopeia and insist on its containing only drugs of recognized worth and on its revision often enough to include all valuable new ones. Finally, he declares, pharmacologic and therapeutic research should be stimulated.

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Dermatological

Cleveland, May 30-June 1.

Association,

American Pediatric Society, Atlantic City, May 30-June 1.

American Surgical Association, Cleveland, May 30-June 1.

American Laryngological Association, Niagara Falls, May 31-June 2.

American Association of Genito-Urinary Surgeons, New York, June 1-2.

American Academy of Medicine, Boston, June 2-4.

American Association of Life Insurance Examining Surgeons, Boston, June 4. American Gastro-Enterological Association, Boston, June 4-5.

American Urological Association, Boston, June 4-5.

American Proctologic Society, Boston, June 5-6.

American Medico-Psychological Society, Boston, June 12-15.

Massachusetts Medical Society, Boston, June 12-13.

Maine Medical Association, Portland, June 13-15.

Minnesota State Medical Association, Minneapolis, June 20.

West Virginia State Medical Association, Webster Springs, June 20-22.

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