ounces; clear, amber, acid, 1028, no albumin, no sediment, a few white cells, no blood.

May 7-morning: The bowels not having moved, a simple enema was given, with the result of a large bloody stool, very dark color. General condition of the patient splendid. Temperature 98.4°, pulse 88, respiration 24. He complains of nothing but thirst. Abdomen entirely negative. Urine analysis O. K. Voided spontaneously. Patient given water by mouth and in the afternoon milk in small quantities. Afternoon: Feeling splendidly with the exception of a slight headache.

May 8 General condition good, having passed a splendid night. Complains of little or no pain this morning. Voids urine spontaneously. Bowels moved by enema with large semiform, slightly blood-tinged stool. Temperature 6 A. M. 97.4°, pulse 88, respiration 24. The general management continued. Strained soup was given at noon. At 2:30 patient complained of feeling very cold. External heat applied. Voided eight ounces. of urine, which, upon examination, was identical with that of May 6. At 3 o'clock the patient's temperature was 101.6°, pulse 112, respiration 26. He complains of considerable pain in the back over the lumbar region. Bowels moved and voided urine spontaneously. At 5 o'clock condition about the same, but patient is nauseated. Bowels moved again, containing a slight amount of disorganized blood clots. The patient's condition this evening is not satisfactory. Complains Complains of pain in his right side in the lower portion of his abdomen and on the upper left side. Temperature 101.6°, pulse 116, respiration 26. His bowels moved rather frequently, three stools up to 10 o'clock. They were small and fluid, containing no macroscopic blood. His temperature at 9 P. M. 101.6°, pulse 126, respiration 24. Patient at this time became nauseated and vomited a small amount of light-yellow fluid. Patient's condition is not so good as it was earlier in the evening; rather restless. I saw the patient at 11:30 P. M. and found him in a very serious condition. Temperature 101.6°, pulse scarcely palpable at wrist, respiration 20. His expression was one of extreme anxiety and he was very restless. He had not voided urine since very early in the morning. An operation was advised at this time but refused. In view of the fact of the rapidly increasing and weak . pulse, normal salt solution was given by rectum, which was expelled. Submammary injections were then resorted to and adrenalin, m. 30, given. At 12 o'clock patient's condition very unsatisfactory and another submammary injection given. At 3:30 A. M.,

patient restless, temperature 102°, pulse not countable. He was given ice to suck. A small dark-colored stool. At 5:30 A. M. an intravenous of twenty ounces of normal salt solution, with adrenalin 15 m., were administered. The report for night was: Patient rested practically none, complained of little or no pain, voided very little urine with stools, bowels having moved three times, no blood noticed.

May 9, morning: Patient passed eight ounces of urine, light amber, rather cloudy, acid, no albumin, no sugar, a few epithelial white cells, no blood. Patient consented to operation, concealed and secondary hemorrhage being suspected. At 8 A. M. taken to operating-room. A laparotomy performed, the abdominal viscera inspected with practically negative result. During anesthesia the patient very nearly succumbed, heroic measures being necessary to keep patient alive, salines, adrenalin and heart stimulants being adminstered, direct cardiac massage resorted to. He was removed from the table practically pulseless. At noon his condition was condsiderably better than it had been in the past twenty-four hours. His pulse a little stronger and the patient rests a great deal more. The rectum very irritable; would not retain normal salt solutions, so they were discontinued. Heart stimulant, strychnine and sparteine, continued. Patient was slightly nauseated, small amount dark brown fluid. Hot blankets and general stimulants, though not so active, continued. At 4:30 patient complains of paroxysmal pains in the lower abdomen, accompanied by ineffectual desire to pass water and involuntary movement of the bowels, consisting of considerable mucus and a little blood. Temperature 96.6°, pulse 120, respiration 32 at 6 P. M. Vomiting continued at intervals, as did the paroxysmal pains. He was catheterized of 1 ounces of urine at 8 P. M. Pulse 120, respiration 38. Slightly nauseated. Patient is slightly restless and continues to have paroxysmal pains in abdomen. These are rather severe and rack the patient considerably. His temperature 98°, pulse 120, respiration 38.

May 10: General condition apparently somewhat better than it was before or any time since the operation, the only symptom being the jerking pain in the abdomen and a slight headache. Codeia was given for the pain with benefit, and patient rested a little better. Pains continued at intervals of about five minutes. No urine being voided since 8 P. M. of the 9th until 3 P. M., when a small amount was passed with a stool. His temperature at this time was 98.4°, pulse 124,

and very irregular; respiration 36. Patient is awakened by pain, which is accompanied by the expulsion of a few drops of urine. Stimulants continued. Albumen water and peptonized milk given at intervals. At midnight patient became nauseated again.

May 11: This nausea continued intermittently all day. Vomiting set in and the general condition of the patient is only fair. Temperature 100°, pulse 130, respiration 36. Little or no material change has taken place. In view of the fact that the patient has not voided anything except a few drops of urine, accompanied by the still existing paroxysmal pains in the abdomen, was catheterized, only one ounce being procured. This examination negative. Light amber, cloudy, acid, no albumin, no sugar, a few white cells, epithelium. Patient had not vomited for a number of hours, having retained considerable hot

water.

May 12: During the day vomited three or four times. Temperature 94.4°, pulse 96, respiration 34 at 9 A. M., patient comparatively fair, stimulants for the most part being discontinued. He vomited occasionally, bowels moved frequently and the pains complained of previously have discontinued. No urine has been voided since catheterized up to 11 o'clock, when a small amount was voided involuntarily with the stool. General condition of the patient poor. He continued to decline until 6:45 P. M., when the patient died. All efforts to secure secretion of the urine were unsuccessful. The patient for the last forty-eight hours passed not over two and a half ounces of measured urine, which is of negative chemical and microscopic character.

Autopsy. Body that of a well-developed, well-nourished adult, white, male. Evidence of intravenous and submammary injections. Perfectly healed laparotomy wound in the upper half of the abdomen noted. On opening the abdomen localized fibrinous peritonitis was found immediately beneath the incision. It did not extend beyond or involve any other part of the peritoneal cavity.

Thoracic cavity opened. Right lung bound down rather firmly by old pleuritic adhesions over the upper and middle lobe. The left lung was perfectly free, the posterior and lower lobe being markedly edematous.

The heart was considerably enlarged, rather fatty, the right side being filled with coagulated blood. No pathological lesions. were demonstrable.

Abdomen: The intestine and stomach were removed; no external pathologic phenomenon noted. They were opened and the stomach in relation with the lesser cur

vature, on anterior and posterior wall about two and a half inches from the pyloric orifice, were found two large scars of healed gastric ulcers, in the immediate neighborhood of which were found two small superficial fissures, quite deep. The liver was enlarged and somewhat fatty. The gall-bladder O. K. The spleen was small and its upper pole was rather firmly matted to the diaphragm by adhesions. It was considerably deformed, and at the hilum a bony plaque three-quarters by one-quarter of an inch was noted in the vessel. A probe inserted found the same patulous though markedly compressed. Spleen hardened before section. Was fibrous and in one area softened. The left kidney at the lower pole completely cystic, a cyst the size of a child's fist being present. Very little kidney structure is present on this side. The right kidney very markedly enlarged, very pale and fatty. On section a well-organized thrombus was found in one of the major branches of the renal artery, evidently being formed in different stages of coagulation, which were demonstrable. The ureter prac

tically normal, as was the bladder. No evidence of injury of the pelvis or any other bones being observed. The pancreas showed no pathologic lesion.

In my opinion the hemorrhage originated in the gastric fissures of the stomach from injury caused by the concussion. A clot from the syphilitic (?) atheromatous splenic vessel was dislodged by the force of the injury, and as an embolus lodged in right renal artery, causing thrombosis (progressive) of right renal artery and almost total suppression of urine and consequent auuria, of which the patient died.

Ovarian Cyst, Dislocated Kidney and Adherent Cecum.

Two

Patient an actress, aged twenty-one years. Has been on the stage three years. years ago, in 1905, she underwent in New York an operation for suppurative appendicitis, from which she made a good recovery after a tedious convalescence lasting over a period of several weeks, possibly eight or ten.

The beginning of the trouble from which the patient was suffering when she presented herself to me for examination dates back to the spring of 1906. At that time she weighed 180 pounds and was enjoying good health. She suddenly developed symptoms of indigestion, with accompanying distress on the part of the stomach and abdomen. There was sour stomach, nervousness, loss of weight, the latter being 145 pounds when she came to me. She also complained of hot Alushes,

nervous tremor, loss of appetite, with at times an exaggerated condition of the latter, accompanied by a hungry, gnawing feeling, with a more or less constant general feeling of loss of energy, with fatigue. There was present recurrent abdominal distress, with shifting pains of a dull, aching character, due to the presence of stagnant gas in the abdomen, percussion and palpation of the latter eliciting distension and tenderness at different points at various times, these two conditions being particularly marked in the upper right quadrant and over and below the cecum. The right kidney was distinctly movable and the hepatic flexure tender and distended. Considerable tenderness was present in this region. Menstruation had been scanty, painful and irregular for nearly a year. A discharge streaked with blood came from the external os, while the mucous membrane about the lattet was terribly swollen, thickened, red and everted. Vaginal examination revealed a larger tender resilient mass in the region of the right ovary, which was taken to be a cyst.

Operation. On Wednesday, April 10, 1907, I did a laparotomy, after first curetting the patient, at the Good Samaritan Hospital. Ovarian cyst larger than a closed fist was enucleated from the post-pelvic peritoneum and removed, while a very considerable adhesion of the cecum was also enucleated, leaving, however, a firm portion adherent at the point, which I took to be the peritoneal stump, and the diagnosis of movable kidney was confirmed under anesthesia. I could not fix the latter in position, however, as two operations at a time are usually sufficient for one patient. The stitches were removed on the ninth day, the patient having made an uninterrupted recovery, leaving the house in perfect condition on the sixteenth day after the operation.

The one particular feature which remains to be established by this case is whether the complicating symptoms produced by the dislocated kidney will clear away. Close watch will be kept on this patient and report of this point be made later. The point which makes this case of particular interest is that it belongs to that class in which there is an association of abdominal lesions, the pathological value of each of which can be estimated alone by the post-operative results. Whether this patient will have to again be operated upon for the correction of the movable kidney, or whether the correction of those conditions as indicated will afford the peritoneum sufficient relief to recoup itself in the kidney matter, remains to be seen.

POINTS IN DIAGNOSIS.

In a hemorrhagic cystitis always suspect a calculus. HERPES ZOSTER is never recurrent; herpes simplex is frequently so.

SIMPLE acne is exceedingly common in young syphilitic subjects.

SCALES occur in eczema, psoriasis, pityriasis, ichthyosis and syphilis.

IN scarlatina there is absence of the peculiar shining or glazed condition found in erysipelas.

SYPHILITIC chancres are always a constitutional affection, the chancroid a local disease, herpes a neurosis.

A RECTAL examination will settle any doubt in distinguishing between acute cystitis and acute prostatitis.

Tincture of belladonna has produced a scarlatiniform eruption in children. There were no throat symptoms.

SIMPLE gastric ulcer is rare in children. Pain, tenderness on pressure, hemorrhage and vomiting, when present, are conclusive evidence.

EPITHELIOMATOUS warty growths on the dorsum of the hands of aged persons are not to be confounded with tuberculous lesions.

IN sterility one naturally thinks of tubal disease, causing a mechanical obstruction to the passage of the ovum or spermatozoa.

USE an aspirating needle to distinguish between a simple pleurisy and empyema in children. Strictest asepsis is required, of course.

ALWAYS make an examination of the parts affected in pruritus. Affected regions are in order of frequency those most accessible to the hands.

CHLOROSIS must be distinguished from the pseudochlorosis of tuberculosis, syphilis, and rachitis. Blood examination will settle the difficulty.

ALWAYS be sure to use a small drop of blood in examining for the plasmodium. Failure to detect⚫it may be due to excessive overlapping.

PERHAPS there are still a few physicians who report to the Health Department that "dropsy" was the cause of death in a fatal case of renal or cardiac dis

ease.

NOTCHED teeth, those classic sign-posts in the congenital syphilis of children, are frequently absent in luetic affections of the throat. Morell MacKenzie said so.

IN diseases of the lymph nodes in children the important thing is to exclude tubercular and syphilitic enlargement of the glands. Get acquainted with the

parents.

THE discovery of tubercle bacilli in the urine would be presumptive evidence of the existence of tuberculosis in the prostate. Should there be tubercular lesions elsewhere in the body, with a suspicious family history, and in addition some hard nodules discoverable by rectal touch, the diagnosis is almost certain.

THREE Symptoms are prominent in the diagnosis of acute appendicitis: Sudden onset of paroxysmal pain, localized usually in the right iliac fossa; tenderness on pressure at the site of the appendix, rigidity of the abdominal walls. The other usual accompanying symptoms, nausea, vomiting, etc., are secondary to the three given above.

A PUERILE OBJECTION TO A MILK
COMMISSION.

Canton (Ohio) physicians are demanding the establishment of a milk commission to insist on consumers receiving pure milk. Strange to say, Health Officer A. V. Smith, of that city, objects to this, because "the ill-effects of milk are not brought about at the dairy or in the bottle, but come after the milk gets into the possession of the consumer." It seems a piece of folly to make such a statement. As well permit the abattoir to dispose of tubercular meat, since the consumer will probably not be very careful in preparing it anyway. It is comparatively easy to teach people how to keep milk in good condition when it arrives, pure and sweet. But stop the contamination at the source. Then the consumer will be less subject to risk, even though he may be a trifle faulty in its care when delivered to him.

Anent this matter, it is pertinent to speak of what has been accomplished in Cincinnati by supervising the sale of milk. In THE LANCET-CLINIC of June 1, 1907, there appeared a report of the Milk Commission to the Academy of Medicine of Cincinnati. One must use the superlative degree in praising the work of this commission. Its supervision of both "certified" and "inspected" milk has produced gratifying results. Of the former, owing to the security which the people feel in the supervision which is now maintained, an average of 8,060 pints

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in

pints weekly in November. Of the spected" milk 2,184 quarts are being used weekly. The commission believes, what is a generally accepted fact, that "the importance of the general supply of milk in our large cities is chiefly one of educating the public up to a point where it will demand the same."

It is to be hoped that the health officer of the progressive city of Canton will be forced by the pressure of an enlightened public opinion, created by the medical profession of that city, to change his views, which are not in accord with twentieth century facts.

AS IN A LOOKING-GLASS. "Oh, wad some Power the giftie gie us To see oursels as ithers see us.' Bobby Burns surely did not have in mind the medical profession when he penned the above lines, especially not the "unco guid" members thereof. It was refreshing to read the comments by the editor of The New Idea, a drug journal, anent our New York friend's proposition to establish a chain of drug-stores, owned and controlled by stock companies of physicians, under the auspices of the A. M. A. The plan was printed in full in a recent issue of the New York State Journal of Medicine. The editor of The New Idea, commenting upon the above plan, says:

"Add to this the fact that the American Medical Association is possessed of considerable available capital, increasing annually by thousands of dollars, and that many men believe it will sooner or later be forced into some form of so-called co-operative drug merchandising by the hot heads and extremists, who apparently exert considerable influence in its councils, and you have a rational basis for the suspicion that an organized movement against the drug trade is not beyond the realm of possibility.

As a fair specimen of his premises, we may take the prescription which he cites as an example of the way substitution is carried on: The profit on that prescription, honestly compounded, would be thirtyeight cents, and on the substitution job, ten cents; that is to say, the dishonest pharmacist is so fond of substituting that he will sacrifice three-fourths of his profit to do so!

"To be sure, by way of criticism of his plan, one might point to that ethical tenet which forbids phy

sicians to be financially interested in the amount of medicine consumed-or at least purchased-by their patients, but the code has undergone marked changes in the past few years, and no doubt might be found sufficiently elastic, like a political platform, to admit of its adherents doing what they wish.

"Instead of indignantly refuting the wholesale charges of dishonesty brought against them, bolstered up by doctored statistics emanating from interested sources, they (the druggists) have contented themselves with half-hearted denial. Instead of saying frankly to their medical critics, "We have our 'crooks' just as you do, and probably in equal proportions to yours, but we insist on being judged as a whole instead of by our exceptions," there are merely incoherent excuses and lame defense. Instead of saying "We are probably more keenly conscious of our own shortcomings than you imagine and are bravely trying to locate the offenders who bring disrepute upon us all, inconsiderable though their numnumber be," the tone is too often apologetic, though this should be a day of militant pharmacy!

There is less for either druggists or doctors to apologize for than ever before; the evils that admittedly exist in both professions are recognized; neither side can pose as "holier than thou" without knowing full well that its own house sadly needs to be set right in some respects. It would seem therefore that self-appointed medical critics of pharmacy might well occupy their spare time with desirable medical reforms and leave to conscientious pharmacists the work of reforming the drug trade."

It so

The above is so wholesome and manly we could not help reproducing it here. plainly shows how we are straining at gnats and swallowing dromedaries. The plan to establish co-operative drug-stores has not as yet been acted upon, and we feel sure no action is contemplated. But as regards our throwing stones, while our domiciles are constructed of rather brittle substance, this article shows the futil!ty thereof. It may be well to quote here part of the Sermon on the Mount: "Judge not, that ye be not judged.

For with what judgment ye judge, ye shall be judged: and with what measure ye mete, it shall be measured to you again.

"And why beholdest thou the mote that is in thy brother's eye, but considerest not the beam that is in thine own eye?

"Or how wilt thou say to thy brother, Let me pull out the mote out of thine eye; and, behold, a beam is in thine own eye?

"Thou hypocrite, first cast out the beam out of thine own eye; and then shalt thou see clearly to cast out the mote out of thy brother's eye."

G. S.

EDITORIAL NOTES.

THE Interstate Medical Journal has forwarded to medical editors advance sheets of the July issue, announcing its consolidation with the St. Louis Courier of Medicine. If the literary and scientific excellence is maintained in future issues, St. Louis will have done much to overcome a reputation in medicine which has not always been enviable. "Modern Aids to the Torture of the Sick," in the July issue, is a happy presentation of a humorous subject. In it a sick man discourses on the psychology that is not taught in nurses' training schools. "Nurses should strive, not through definite knowledge attained, in the treatment of the sick man as a thing in bed, to compass their work; but rather should they rely upon their true women's hearts and natural feminine tact to gain the status with their patients that the sick man so urgently and pleadingly calls for."

THE Augusta (Ga.) Herald, in line with hundreds of other lay publications, completely misunderstands the position of medical men in reference to advertising. In a recent issue it speaks warmly and with justice of the superior intelligence and skill of Augusta physicians. There is a large influx of winter guests and residents into that city, many of whom seek the South at that season in search of health, and therefore require the services of local physicians. Hence, the paper wants doctors and the patients, who need each other, to get together and do business. In other words, why should not the medical profession recognize the value of decent and legitimate advertising?" The Herald calls upon members of the profession to take up the question of a proper revision of the code of ethics in regard to advertising. Physicians in Augusta ought to write a letter to their paper, explaining fully the reason why they cannot advertise their skill.

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ONE of the results of the determination of the Texas Board of Health to declare a quarantine against persons in the advanced stages of tuberculosis will be the awakening of the American people to a realization of the communicability of the white plague. The in