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an enlargement of the glands, first in the neck, afterwards in axilla and groin ; no pain or inconvenience. About three months ago says he took a cold and had a severe cough, mostly dry; there was pain in the abdomen, aggravated by motion; insomnia due to cough ; little appetite.

At present he feels well; coughs but little; no pain in the abdomen; the enlarged gland in right groin causes some pain at times; appetite good; no insomnia.

Status praesens-General examination : Mind clear.
Well nourished, but a little pale.
Eyes normal; tongue negative.

A tumor on the left side of the face the size of a pigeon's egg, just below the ear; a somewhat larger one just anterior to this one midway between angle of the jaw and point of chin.

Right side the same, except tumors are smaller. A number of still smaller ones can be seen upon the back of the neck and between the ears.

Small scars on lips and herpes.
Chest full, well formed; expansion good.

Many enlarged glands are found, the largest in the neck and axilla. These tumors are all firm and elastic to the touch; freely movable. They are scattered promiscuously, a great many in inguinal region.

Percussion of chest, heart and lungs reveals nothing abnormal. Liver dullness begins at sixth rib and extends down three and a half inches. Upon border of splenic dullness, eighth rib, lower border not defined.

Abdomen negative. Genitalia negative. Extremities negative.

Blood Examination-5-30-'98, 5 P. M.--Hemoglobin, 60 per cent; white corpuscles, 122,500 ; red corpuscles, 2,594,000; W:R::

1:22.

excess.

Microscopical Examination-Lymphocytes largely in Polynuclear neutrophiles and a few eosinophiles and basilophiles run here and there.

The relation of lymphocytes to polymorphonuclear: leucocytes::eosinophiles :myelocytes.

Some poikilocytosis, a few microcytes and macrocytes.

Blood Examination--5-4-'98, 7. P. M.-Hemoglobin, 63 per cent; white corpuscles, 120,900; red corpuscles, 2,750,000. W:R:: 1:23.

Microscopical Examination-Lymphocytes to polymorphonuclear leucocytes as eosinophites are to myelocytes. 95 4.2: :0.5.X.

6-5-'98-L:P::E.M. 96.0:35:10.5:06.

Blood Examination6-8-'98, II A. M.-Hemoglobin, 75 per cent; white corpuscles, 83,900; red corpuscles, 4,221,000. W:R:: I= 50.

Lymphocytes (small): Polymorphonuclear leucocytes as eosinophiles are to myelocytes. 95.6:3.6::0.8:0.

Highest temperature, 100; highest pulse rate, 110.

This patient was treated for some little time with considerable doses of Fowler's solution, with a notable increase in haemoglobin and decrease in the number of leucocytes. This case was supposed to be from clinical examination, a case of Hodgkins' disease, and a microscopical examination of the blood was essential for a differential diagnosis. The blood examination showed a decrease in leucocytes and the increase in erythrocytes and hæmoglobin under arsenic.

Another case of considerable interest was a woman thirty-eight years of age, who had suffered from dyspnea, palpitation of the heart, vertigo, loss of appetite, and general weakness and malaise for over two years. She had been unsuccessfully operated on twice for a lacerated cervix, the surgeon supposing this to be the cause of her condition. Examination showed a greatly enlarged spleen and an enlarged and tender liver. There was a soft blowing systolic murmur heard over the apex of the heart. The blood examination showed the percentage of white to red blood corpuscles as 1 :8. The condition was readily recognized as one of splenic leukemia. By the persistent use of blood-iron preparations she improved. The clinical evidences in many of this class of cases are sufficient to enable the careful diagnostician to determine the disease. It is sometimes impossible, however, without the microscopical examination to determine positively the class of anemia or the severity, and a careful blood examination should invariably be made.

Colicky pain, of the hepatic type and distribution, usually signifies the presence of a foreign body, generally a calculus, in the ducts.

Jaundice, preceded by colicky pain, is practically always due to gall-stones; without pain, to new growths, outside pressure or infective inflammation.

EXAMINATION IN DIAGNOSIS-BUSHNELL.

565

NECESSITY FOR THOROUGH EXAMINATION IN

DIAGNOSIS.

CHARLES H. BUSHNELL, M. D., CHICAGO, ILL.

The following case in point will serve to illustrate the necessity of careful and thorough physical examination of every patient, as well as a careful investigation of every symptom given. No matter how plain the statement of symptoms may be or how correct the patient's diagnosis may appear, it is very easy to be mistaken, es pecially when a woman will complain of pain and distress in her stomach—though inquiry may show it to be in the region of the ovaries; another will complain of "kidney trouble” and pain in the kidneys, while questioning develops the location of the pain to be the region of the sacral plexus of nerves; and the patient here reported persistently called the pain and irritation of chronic cystitis a "burning in the womb."

Mrs. C., aged 30, was brought to my office, suffering, so she said, from some trouble of the womb and rectum. Her family history was negative.

Personal history: First menstruated at 14, no pain or trouble; when about 16 got wet during a menstrual period, and since then has had more or less trouble continually. Four years later was married, and has been doctoring almost continually ever since. Has had no children, and no history of ever being pregnant, though after an examination and treatment by Dr. J. B. Murphy she had a seve uterine hemorrhage, and suspected it might have been a miscarriage, though Dr. Murphy said it was not.

Had cystitis once some years ago and recovered apparently.

Has had hemorrhage (internal) for seven or eight years and has been constipated since childhood, until at the time I first saw her, her bowels would only move after taking incredible doses of drastic cathartics, and then only once or twice a week.

Treatment during all this time had been directed to the womb trouble and somewhat to the hemorrhoids, the latter having been treated with carbolic acid injections some years ago and pronounced cured. The acute attack of cystitis was treated by irrigation of the bladder and internal medication.

Examination: Subjective symptoms, pain in the back and in the lower portion of the abdomen and groins; heaviness and weight in

womb; intense pain in defection and urination, and necessity for frequent micturition; persistent headache all over the head and pain in the eyes with inability to see to read because of the pain, and a blurring sensation in front of the eyes. Constipation stated before, while the most annoying and persistent symptom seemed to be, as she described it, a “constant burning in the womb," with terrible weight and heaviness and deep constant pain in right side in region of the ovary; despondency and desire to die.

Objective symptoms were a hunted, worried look and a peculiar deliberateness in every movement as if afraid to speak or move for fear of pain. Digital examination was almost impossible, but was made, causing evidently an agony of pain and suffering to the patient whenever any pressure upon the urethra or bladder was made through the vagina.

The uterus was found retroverted and slightly retroflexedslightly sensitive to the touch, while the least movement of the uterus caused pain in region of the bladder, and in right ovary; slightly eroded cervix, and a thick glairy mucous escaping from the external os, vaginal walls rough, liarsh and thickened to the touch, and partly protruding from ostium vagina.

Examination of the rectum revealed several hemorrhoids and several irritable and sensitive papillae and pockets of mucous membrane.

Diagnosis: Chronic cystitis, with endometritis and hemorrhoids, and a possible congestion and inflammation of right ovary.

Advised treatment for the cystitis, and a curetteinent and operation for the hemorrhoids.

One week's treatment greatly relieved the pain in bladder, and in fact all the symptoms were decidedly improved as soon as the bladder was attended to by irrigations with borolyptol solutions in the usual manner, with a slight amount of the solution left remaining after irrigation, with saw palmetto and santal and passiflora internally.

Then a curettement was performed and the hemorrhoids removed by the knife and actual cautery, under chloroform anesthesia.

Following the operation the recovery from the other symptoms was remarkable; constipation gradually overcome and all difficulty removed except the same burning in the womb(to use the patient's words), which was also gradually overcome by continuing the saw palmetto and santal for the bladder, where the "burning sensation” really was.

It would seem that much of this woman's suffering might have been relieved long before had her physician recognized and treated the cystitis instead of taking the patient's diagnosis and treated only the uterine difficulty.

Are there not others in a similar condition?

CLEANING OUT THE ALIMENTARY CANAL.

J. R. LANDERS, M. D., BERNADOTTE, ILL.

While some continue to preach “clean out," etc., the idea does not seem to have aroused the interest it justly merits. Many do not seem to comprehend the significance of an unclean or feces-loaded itiimentary canal; or that it may cause perpctuation of symptoms, cr aggravate, enlarge, amplify or intensify them. Not only among the laity do we find persons who believe that a daily movement precludes the possibility of a poisoned, vitiated bowel; much less can they believe that the accumulation of days, weeks or months, may be hidden away in the intestinal tract (but practicians, too, make the same mistake), or that a dose of salts that has produced a motion or two has left behind any, fecal material; especially if there has been a watery discharge. A case or two may better illustrate my meaning:

A traveling man, aged thirty-five, called me to see him at his hotel. I found him with a temperature of 102 F., complaining of slight headache, the tongue only slightly coated. He said his bowels moved regularly every day. I could find no other reason for this condition, so I concluded it must be that the focus of poison was in the bowels. I gave him calomel and podophyllin followed by a saline. The bowels acted freely to all appearance. intestinal antiseptics and quinine arsenate.

After twenty-four hours, there seemed no particular change, so I gave remedies again to clean out the bowel, which acted well again. Continued intestinal antiseptics and quinine arsenate. Still no change. Gave high enema twice; very good results. At the end of ten days the patient was about as at first. I concluded I had just gotten sufficient effect to keep him from getting worse; meanwhile he was sure he needed no more cleaning out. I told

I then gave

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