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fifteen grains of salicylate of soda with five minims nux vomica in elixir of pepsin, and a glass of water every three hours, together with a gargle containing twenty-five per cent of hydrogen peroxide, four times a day. The bowels were moved with sulphate of magnesia. On the third day this patient went to work feeling much better, but after laboring several hours became weak, and by noon had severe pains in the wrists. He managed to work all day, and consulted me in the evening. Examination revealed a temperature of 102°, pulse 100, full and bounding; wrists swollen, red and painful to the touch. The heart and chest sounds were normal. Patient was advised to repair to bed and remain there until well. I could not keep him in bed, however, as he claimed he felt better when about. An erythematous eruption appeared over his body, and the joint symptoms followed the usual course, attacking nearly all the joints from time to time. Endocarditis and hypertrophy followed, and, despite all that was done, he died on the sixtieth day.

Case II-An unmarried lady, twenty years old, domestic, family history good, previous health and habits good, consulted me complaining of sore throat and pain in all the joints. Examination revealed tonsils enlarged, and covered with a follicular exudate. Temperature 100°, pulse 90; chest and heart sounds normal. She was told to go home and retire to bed and not get up until well. A diet of milk and gruel was prescribed. Medicinal treatment contemplated salicylate of soda and alkalies internally, with a gargle locally. Patient continued her work for two days, when I called and found her in bed, suffering intense pain in her left knee-joint. No other joints were involved. She was taken to a hospital, where every attention was given her. An ice-bag was placed over the heart, and medication was given according to symptoms. Consultation was held several times, and the prognosis was considered favorable. The pain and swelling continued in the left knee-joint and endocarditis developed at the end of the first week, death occurring on the fourteenth day.

Case III-A boy, seventeen years old, laborer, appeared at my office with an ordinary follicular tonsillitis. He had been sick for four days. Temperature 101°, pulse 100; heart and chest normal; urine contained albumin. I saw him at his home again the next day and found him in great pain; temperature 104°, pulse 110; dyspnea, coated tongue, diarrhea, and cold perspiration. Pain was referred to limbs and heart. An ice-bag was applied over the precordia; one-fortieth grain of sulphate of strychnine was given per orem, three times a day, with infusion of digitalis, and twenty cubic centimeters of antistreptococcic serum were injected daily. I saw him again at night and found his left kneejoint enormously swollen and inflamed. Patient was seen in consultation by several physicians. The endocarditis and swelling of the left limb continued until death, which occurred on the sixth day.

Case IV-A married woman, twenty-four years old, housewife. I was called to her home to attend her in confinement. Patient had always enjoyed good health. She was in labor about twer twenty hours,

and I delivered her with instruments. The perineum was lacerated and I repaired this damage at the time. The usual asepsis was observed. preceding and during the puerperium. On the fourth day the nurse advised me that the patient was restless and had some fever. Examination revealed a temperature of 102°, pulse 110, respiration 24. Vaginal examination showed a membranous exudate on vulva and cervix. This was treated locally and twenty cubic centimeters of antistreptococcic serum injected. Patient was examined at about 10 o'clock. that night and local treatment applied. I washed my hands in a lysol solution as on other occasions and went home. About I o'clock I awoke with a pain in my right index finger. I could not sleep so I arose and found on examination a vesicle on the palmar aspect of the finger near the tip. I had a rigor and a very restless feeling; sore all over my body. By morning I had a typical tonsillitis and infected finger. I was quite sick for three days, two other fingers becoming infected, first with a vesicle, and then a pustule, which eventually healed. No culture was taken. I have not been able to decide whether I infected the patient, or whether she infected me. She recovered in about one week.

Case V-A man, twenty-two years old, bank clerk, called at my office suffering from a slight attack of tonsillitis. The usual remedies were prescribed, and the patient advised to stay at home and keep perfectly quiet. He told me the next morning that he felt much better, and that as business was urgent at the bank, he thought he would return to work. I did not hear from him for several days, when he came to my office complaining of a pain in his head. Examination showed a normal temperature, chest and heart. I prescribed three grains of the sulphate of quinine and one-fourth grain of the sulphate of codeine, to be taken every three hours. I also admonished him to remain quiet. The next day he had temperature and severe pain in the head and ear. I suspected otitis media and ordered hot dry heat Pain became severe and after examination I performed peracentesis of the drum, which afforded no relief. Pressure over the antrum and tip of the mastoid caused great pain, and mastoiditis was diagnosed, for the relief of which an operation was performed.

Case VI.—A school girl, sixteen years old. Patient had large serrated tonsils, was anemic, and suffered with frequent headaches. I diagnosed neuralgia and suppurative tonsillitis. Tonsillectomy was performed August 7, 1904. Her general health improved gradually and she has been free from throat trouble, headache and neuralgia since.

Case VII-A school girl, fifteen years old. Patient had very large tonsils with frequent attacks of follicular tonsillitis. She always complained of severe earache during these attacks, and suffered with headache and shortness of breath on exertion. I advised removal of tonsils, but her parents objected. She is now seventeen years old and is nearly

deaf in her left ear. She also has tachycardia, the pulse rate being 140 to 150. There is a slight hypertrophy, but no murmur or exophthalmic goiter. An interesting feature in this case is the family history. Her father and mother are healthy. The family consists of four girls and three boys. These children all had very large tonsils, were mouth breathers, had nasal catarrh and were sick a great deal. The oldest girl, aged nineteen, is anemic and subject to hysteræpileptic attacks. The younger ones had frequent attacks of sore throat and spasms. Four years ago I removed the tonsils of the six-year old girl and she has been in perfect health since.

Patient has suf-
His tonsils are

Case VIII-A man, age twenty-eight, machinist. fered with numerous attacks of follicular tonsillitis. hypertrophied and flabby. Two years ago, after an attack, he complained of tinnitus aurium, from which he is a constant sufferer.

From the above cases and others I am convinced that infection takes place through the tonsils, and that the follicles and crypts are the receptacles for the streptococcus, staphylococcus, Klebs-Loeffler, tubercle bacillus and other forms of microorganisms. Upon examination we frequently find the tonsil diseased with sinuses leading into little pockets of pus. I have examined a number of patients suffering with endocarditis, hypertrophy of heart, pleuritis deafness and rheumatism, and giving history of perfect health before an attack of sore throat, for which they did nothing, or continued to work while taking medicine. I believe the toxins are disseminated through the lymphatics and blood-vessels, as the cervical and inguinal lymphatics are tender and enlarged, and arteritis, phlebitis, and embolism occurs in the bloodvessels. Patients suffering with tonsillitis should be warned of the danger of going out too soon. Absolute rest is most essential and the treatment should be thorough. The tonsils should be treated locally with a gargle of acetezone, normal saline solution, or one of the alkaline solutions on the market. Internal medication as indicated, and I have a preference for salicylate of soda. Existing anemia should not be overlooked. The tincture of chloride of iron in large doses has a good effect. The heart, lungs, pleura, intestinal canal and kidneys should be carefully watched. The diet should consist of milk, cereals and vegetables, meat, coffee, tea, or alcohol being prohibited. Troublesome and enlarged tonsils should be removed, preferably with a snare, as this prevents hemorrhage. If only a small piece is extirpated, allowing drainage, good results follow in cases where the tonsils cannot be enucleated. Cauterization causes scar-tissue formation which is painful and does not give satisfactory results.

That tonsillitis is a local manifestation of a general infection, having a selective tendency to attack all the serous membranes, lymphatics and blood-vessels of the body, I am certain. I have reported the above cases rather than some terminating in uneventful recovery, with which we are all familiar.







DOCTOR EDWARD L. Keyes, JR., read a paper on this subject. 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 I think it by no means waste of energy to study attentively some of the cases which have come under my observation and in which renal colic has been a misleading and often a confusing symptom.

The late Doctor 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 was from frequent and painful urination, although the patient had but one stone, and that lay in the pelvis of his kidney.

The first patient, a lean asthmatic man, sixty-three years old, complained of frequent urination. Sixteen years ago he applied for insurance and was refused on account of albuminuria. He 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 one per cent by weight; various casts of many kinds; many red blood cells; a total excretion of from twenty-five to thirty ounces; the bladder capacity was eight and one-half 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 inperative.

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 kidney pelvis. The kidney itself was considerably dilated and covered with small cysts which contained serous, bloody and seropurulent 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 catherized 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 this case we were able to arrive at a diagnosis with the aid of an r-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, fifty-eight 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, no bacteria, and but very few blood cells. Macroscopically there was no pus. 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 is omitted 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 beta-naphthol, bismuth and salol caused a cessation of these attacks.

In further contrast to this case was one, 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 of which I have record is an example of a class of cases which I consider 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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