The principal point to be emphasized in such a case as this is the responsibility of the physician in making an early diagnosis. A constantly increasing dysuria is a symptom calling for the most painstaking investigation as to its cause. If a hematuria is added to it, the importance of diagnosis is increased.

The differential diagnosis of the symptom of pain rests between cystitis, tuberculosis and stone. If from stone, it is worse when the patient is moving about and at the end of the act of urination. If from cystitis, the pain is worse at the beginning of urination, and is felt in the glans penis and perineum. If from tuberculosis, the acute pain is spasmodic, coming at the end of urination but there is a constant sense of discomfort in the bladder. This is not aggravated by motion as in stone but is often worse when the patient is at rest.

The differential diagnosis of the hematuria rests between the kidney, bladder tumor, stone and tuberculosis. If the hemorrhage is from the kidney, the urine is free from clots, the blood is dark and the amount of hemorrhage has no connection with instrumentation of the bladder. If from bladder tumor, the hemorrhage is profuse and intermittent, the clots are large and until a cystitis develops there is no pain. With stone, the hemorrhage is terminal and is made worse by exercise. With tuberculosis the blood is bright red, is not affected by exercise and is always aggravated by instrumentation. Positive diagnosis, of course, is made by the demonstration of the tubercle bacillus in the urine.

The prognosis in tuberculosis of the prostate and bladder is always bad though with proper constitutional treatment the progress of the disease can be very materially slowed.

The treatment must be largely constitutional and I doubt very much whether operative treatment is ever of benefit. When the condition becomes one of tubercular cystitis, a great deal of relief is given the patient by drainage of the bladder through a suprapubic opening but this is only temporary.

Glenard's disease, or atoni a gastrica. (College Amphitheater, Prof. E. O. Adams.)

The patient is a young man, occupation, student.

History: After a prolonged period of close application to study, has become considerably emaciated and debilitated. Feels nervous, easily tired, appetite poor and considerable flatulence.

Examination:-Lungs, heart, reflexes, etc., all normal. Tapping the epigastrium elicits a "splashing sound." This shows that both

liquid and air are contained in the stomach, and that the stomach walls are not contracting with a normal degree of firmness upon their contents. The lowest point at which the splashing sound can be produced, also shows that the greater curvature is lower than it should be. This may indicate either dilatation or prolapse of the stomach. As to which condition is present, can be determined by pumping air into the stomach through a stomach tube and then outlining by percussion the entire area of the stomach. In dilatation the lesser curvature will be found in a normal position. In prolapse the lesser curvature will also be found lower than normal. Another way is to use the gastro-diaphane and see the stomach outlined by a zone of light, transilluminating the abdominal walls.

Now, having the patient on the back, abdominal muscles relaxed, place the left hand under the right costal margin, posteriorly. Then place the right hand under the costal margin anteriorly, and ask the patient to take a deep inspiration. Then press the hands firmly toward each other as expiration is performed. In this way the right kidney can be easily palpated, as it slips back into place. This shows that there is a movable right kidney.

These points are sufficient upon which to base a diagnosis of Glenard's disease, or as it is now coming to be called, atonia gastrica. This name has been given it by Dr. A. Rose, who with his well known penchant for correct medical terms, claims that the Greek words from which atonia gastrica are derived, indicate abdominal relaxation, and not relaxation of the stomach alone. It is a condition, which if carefully looked for, will be found quite frequently, though one should be careful and not imagine that it can be found in nearly every case examined, as some have done.

ca.

Various influences have been considered as causing atonia gastriAs predisposing causes, congenital conditions often have much. to do with it. An individual with a long, slender chest and abdomen is especially liable, although other forms are not by any means exempt. If one was poorly nourished in infancy, possibly having rickets, they are more apt to have it. A floating tenth rib is often, though not always present, and has been called Stiller's stigma. In this case it is not present.

Exciting causes may be anything that has a prostrating influence on the general health and strength. This patient says that sometime before the present trouble came on, he had rheumatic fever. Some such sickness as this, typhoid fever, pneumonia, etc., are quite apt to precede the condition. I believe that often a mistake is made in allowing patients to get up too soon after these prostrating dis

eases, before the normal amount of flesh and strength has returned. Notably is this so after parturition. Probably nine cases out of ten, of atonia gastrica, are found in women,—and I believe that the cause of this is, chiefly, because pregnancy and parturition cause so much weakness and relaxation of the abdominal muscles. Many cases would be prevented if the woman would stay longer in bed than is now the custom. Tight lacing has been said to cause the trouble, but, personally, I do not believe there is much in it. My experience teaches that women of the lower and foreign classes who do not wear corsets, but who do get up and go to work soon after sickness and labor, are fully as apt to have the trouble as those who lace. Strains and falls may also cause it.

The symptoms are variable. Sometimes they are undoubtedly absent, but in most cases the ones presented by this patient are found, namely, weakness, nervousness and irritability. However, the digestive symptoms are usually of most importance. In nearly all cases, if the stomach contents are analyzed, hyperchlorrhydria will be found. Therefore, the digestive symptoms will be those found in this condition, combined with an impaired motor function of the stomach, with stagnating contents. In a few cases the secretions are normal or deficient. The weakened motor power is always present. Sometimes the so called mucous colic or membranous enteritis will be present. The symptoms mentioned are simply those of what is commonly called indigestion, and may be present where no atonia gastrica exists. It is therefore only by physical examination that this affection can be diagnosed. Some men who have allowed themselves to become very enthusiastic over this trouble, especially over devising certain methods. of treating it, have accused it of being responsible for almost all the ills of humanity, including adenoids, enlarged turbinates, headaches, refractive errors, goiter, tachycardia, dropsy, thoracic and pelvic troubles, hemorrhoids, enuresis, and so on ad infinitum. Of course it is possible, in some cases, that by dragging down on the abdominal aorta and iliac vessels, the circulation to the lower extremities is somewhat impeded, thus causing an increased determination of blood to the head and chest, causing congestions, hypertrophies, etc; yet one must be careful not to ride any such idea as a hobby, and consider it the potent factor in all cases.

In treating this case, a number of things should be done. First, a nourishing diet, should be ordered, consisting largely of the proteids to build up tissue, and also of the fats, as cream, butter, bacon, olive oil, to build fat around the kidney, to thicken the omentum, and to fill the abdominal crevices generally with fatty pads. If from ten to

twenty pounds can be added to the weight, it will do more than all else to relieve the symptoms. Not too much mental work should be done, but enough physical exercise should be secured to improve the appetite, increase metabolism, and secure muscular tone. Cold baths, electricity, and vibration are also beneficial for this purpose.

With the idea of giving support to the relaxed abdomen, various belts and pads have been devised. Probably the most popular method since the writing of a monograph on the subject by Dr. Rose, is by means of an adhesive plaster bandage. If properly applied, in selected cases this gives an amount of relief almost unbelievable, and as I have found in many cases, will so improve digestion and nutrition that several pounds of flesh will be gained, and the general strength so increased, that, after two or three months the plaster can be left off, with no return of symptoms. The plaster seems to be of more benefit than other bandages, although if the abdomen is not too flat, a good fitting, elastic bandage will do much good, and especially in hot weather is more agreeable than the plaster. Operative measures have been employed for fastening the kidney in place. If the kidney alone is prolapsed, this may be of benefit, but in most cases gastroptosis and enteroptosis are also present, and simply relieving the kidney is not of much value.

The remedies should be chosen after the broadest study of symptoms from a homeopathic standpoint, with the object in mind of improving general health and bodily vitality. If there is a history of rickets in youth, some form of calcarea or phosphorus will often be of use; if due to prostrating diseases, some of the so called tonic remedies, as nux vom., arsenicum, or china; for many cases of women, pulsatilla, sepia, ignatia, or whatever the symptoms indicate. In this case we have a history of excessive study, not much physical exercise, nervous irritability, acid eructations and constipation. As you will notice there is a slight icteric tinge to the skin and conjunctivae. These symptoms all point to nux vomica, 3x.

Congestion, inflammation and finally suppuration of right ovary. Currettage, ovariotomy. Recovery. (College Amphitheater, Prof. P. B. Roper.)

The case we present to you today is an interesting one, because the history, furnished us by the clerk, tells us of a form of trouble which will come to you very frequently in your practice.

Mrs. R., aet. 30, married. Family history negative. Personal history: Married three years. No children. Menstruated at 14, some

times irregular but no pain up to seven years ago, when she took cold and had congestion of right ovary, took cold again, had inflamation and has never entirely recovered. Last February she had neuralgic pains in the ovaries, which have increased in severity in past two months; pains extended to both ovarian regions, worse on right side. Had frequent hemorrhages from uterus. You will note, then, that the patient caught cold, had congestion in ovarian region, then inflammation and metrorrhagia, and never recovered fully. The word neuralgia was used in the history. It isn't a good word to use when studying a case because it tends to side-track you, switch you off from the real pathological condition. We have a report of an inflammatory condition in the pelvis, and the frequent uterine hemorrhage is a common sequel to it.

Under the anesthetic we will make a bimanual examination. First, we find an abraided cervix,-the uterus retroflexed and firmly fixed in hollow of sacrum, and the right side of pelvis, filled with tense. mass as large as your fist. Such conditions exist very frequently with pyosalpinx. In this case there is no specific history. Ovarian cysts feel like this. They are of slow growth and one may have inflammatory trouble existing at the same time. We might have an ectopic pregnancy cyst, but this is of several years duration, with distinct history of catching cold and followed by congestions and inflammation. Pelvic cellulitis. followed by abscess, may be found on one or both sides of uterus, but no cause for such condition is shown. If she had had a cellular inflammation, the tendency would be toward resolution, unless of specific or septic variety. In such case, suppuration would have occurred early in the case and pointed somewhere and broken into bowel, bladder, vagina, over Poupart's ligament or into the abdominal cavity.

Before opening the abdomen we curette the uterus thoroughly, carefully avoiding dragging upon the uterus too much, lest we rupture something. This accident has occurred and necessitated immediate laparotomy. Therefore, in office practice you see you may cause trouble when you are not prepared for abdominal work. We pack the uterus loosely with gauze drainage and leave a strip in the vagina for 24 hours.

Upon opening the abdominal cavity in Trendelenberg position. we come first to the omentum, which is adherent to bladder and bowels. Separating adhesions. and tying off and cutting some places, we expose to view a shining, tense, mass, -adherent all around to bowels and pelvic walls. Slowly separating the different structures, we can liberate it from everything but the rectum where adhesions