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Dr. Guthrie's paper emphasizes the necessity of a very careful history to differentiate the cause of the stomach symptoms, whether due to ulcer, gall-bladder disease, or appendicitis. We are too apt to make an indefinite diagnosis and leave the exact diagnosis to an exploring incision.

DR. CORRIGAN.-Out of one hundred cases of stomach trouble, fifty are due to dilatation, prolapse and neurotic states having a patent pylorus, and are, therefore, not surgical; fifteen of the remainder are due to a diseased appendix, twelve to gallstones, ten to ulcer, ten to cancer of the stomach, and the remainder to some implication of the midgut, as tuberculosis of the caecum, chronic intussusception, etc.—(Mayo).

While this classification is more or less arbitrary, it brings to notice the fact that stomach troubles are more frequently due to disease of the appendix or gall-bladder than to the stomach itself.

Dr. Walter DAVIS.-I would like to speak of a case I had in a woman, whose history showed undoubted symptoms of gall-stones, and when I first saw her I should have diagnosed gall-stones had I not had a week with the Mayos and the benefit of some of the points just mentioned by Dr. Guthrie.

The only symptom was the sharp epigastric attack but it shaded off, lacking the symptoms of ulcer. I watched her for five days and then found she had symptoms in the lower abdomen.

The pulse was slow, the temperature 992, and the leucocyte count 20,000.

DR. DONALD GUTHRIE.-In closing: There is just one point that I wish to make clear, and that is, that in ulcer, uncomplicated, the patient will have long periods of ease between attacks, even years, and that the symptoms during an attack are readily controlled by food, alkalies and irrigation. In chronic appendicitis we have a history of early youthful attacks, and food instead of giving ease gives distress.

An occasional error in the medical diagnosis is excusable, when you see men who have hundreds of cases coming to operation are not cock sure enough to say, this is gall-stones, this ulcer, and this chronic appendicitis.

As cancer is very likely to become engrafted on these old ulcers, the important thing is to make a surgical diagnosis. Any one can give a test meal; have a stomach tube in the office, have the patient take an evening meal with rice and raisins, and if you find in the morning remnants of the food in the stomach contents, the case should have the benefit of a surgical exploration.


Mrs. C., age 52, in May, 1909, was taken with severe pain in the left side, shooting back to the left kidney but not down the ureter. She then had a sudden intense desire to urinate and filled a chamber with pure blood and clots, after which she experienced complete relief of pain, although tenderness and soreness in the region of the left kidney remained. This occurred three times that day and daily thereafter until July, with occasional intermission of three or four days, when the urine was normal in appearance. In all these attacks the history was the same, namely, the sudden pain, the passage of a pint or quart of blood and clots, followed by sudden relief of pain and occurring three or four times a day, the urine passed in intervals being normal in color and quantity.

In July, 1909, she entered Mercy Hospital and came under the care of Dr. E. S. Dougherty. During her first three days in the hospital she had her usual attacks, passing a pint or more of blood and clots three or four times a day. Under treatment the blood and pain disappeared and the patient was discharged and had no attacks for three weeks. Then the trouble returned and continued daily, with the usual occasional intermission of three or four days, until she re-entered the hospital on January 7, 1910, during my service. I kept her under observation for several days. On examination, I found slight tenderness on bi-manual manipulation of the left kidney. Each day three to four times she passed a pint or more of blood and clots, each passage of blood being preceded by intense pain and followed by sudden and complete relief. My diagnosis was either stone in the kidney or malignant trouble, or possibly both. In an effort to confirm the diagnosis, Dr. Neuberger took a picture but found that the patient was too large and fat for the X-ray to accomplish anything.

On January 9, assisted by Dr. McKee, I operated, making the straight incision. Upon reaching the kidney, I found it too

large to deliver through the incision. I therefore extended it into the curved incision out toward the anterior superior spine. Even then, because of its size, I found it hard to deliver. After delivery, I laid it open along the curved border down to the pelvis. I found this stone, which you have seen and which completely filled one of the calices, forming a perfect cast of the calix. The large size and appearance of the kidney led me to believe it malignant, so I tied the blood vessels and ureter and excised the organ. Subsequent microscopic examination by Dr. Neuberger showed the trouble to be small around cell sarcoma of the melanotic variety. The patient rallied nicely, voiding thirty-five ounces of urine during the first twenty-four hours after the operation. This would tend to prove that the diseased kidney had been able to do little or no work for some time, the right kidney having gradually assumed the work of both organs. The patient did remarkably well, and, although still in the hospital, she is up and walking about, eating well, voiding from forty to fifty ounces of urine daily and enjoying apparently good health. Her urine is entirely normal.

One peculiar feature of the case is the fact that notwithstanding the great loss of blood, the patient had at no time the appearance of anaemia but always possessed a good color. No blood examination was made.



The second case I have to report is interesting because of the diagnosis. The patient is an unmarried woman, 25 years of age. In March, 1908, she was taken with severe lancinating pains in the right axillary region. The next day she found an eruption in the right axilla which resembled the eruption of herpes zoster, being composed of pin-head vesicles, filled with clear serum and very painful. In a few days these vesicles, covering a patch of axillary skin about two inches in diameter, dried up, and the skin turned jet black, and within a few days

more sloughed away, leaving a healthy looking granulating surface. I etherized her and on March 13 cut out this granulating but painful patch, stitched the skin together and got union by first intention. On April 11 the same trouble appeared in the left axilla, going through exactly the same process. I excised this and got union by first intention. May, the trouble appeared on the skin of both breasts. Again I operated with good results. A few weeks later the trouble appeared in the right axilla. After the black slough came away I healed the granulating surface with ointments. In July, the disease broke out on the calf of the right leg, this time involving a patch of skin about four inches square. Again I operated with good result. By this time I was so puzzled that I sent the patient to an eminent skin specialist in Philadelphia, the disease having returned in both axillas. After treating and observing the case for a few weeks, he sent the patient home, with a letter to me suggesting a line of treatment to prevent return of the disease. Although admitting the case was puzzling, he made a positive diagnosis of keloid. I was not satisfied with this diagnosis, and as I continued to watch the return and temporary cure of the disease, its periodicity struck me. I asked the patient if she noticed any relation between the return of the disease and the occurrence of menstruation, but she had not observed it. I then cautioned her to observe, and, sure enough, menstruation began the day after lancinating pains appeared in the axilla. The vesicles appeared, the black slough came away and the granulating surface healed up in about ten days. I found the disease continued to return with each menstruation, sometimes in one or both axilles, sometimes on one or both breasts, and again on one or both legs, each time going through the same course and healing up in about ten days. Otherwise, menstruation was perfectly normal, causing very little pain and lasting three or four days, with the normal amount of blood. The patient was also in perfect health otherwise. Under the circumstances, I felt an abdominal operation was justifiable, and in September, 1909, I removed both ovaries. Since then there has been no return of the disease.


BY DR. MILLer, Wilkes-Barre, Pa.

Mrs. G. Admitted to the City Hospital, December 29, 1909.


Family history-Negative.

First menstruation-Twelve years.

Previous pregnancies-Two.

I. First born with instruments.


Second child born with no difficulty but had an adherent placenta.

Data of third pregnancy:

Date of last menstruation-April 9 to 12, 1909.


General condition during pregnancy-Good.


Oedema Slight.

Nausea-During first three months.


Leucorrhoa-Yellow since quickening.

Pulse and heart action-Good.

Inspection on admission :

Breasts-Soft and flabby.


Striae Few.

Abdominal conformation-Large jug-shaped tumor.

Foetal movements-Present.


Position of back-Right side.

Position extremities-Left.

Position of head-Presenting.

Tension of abdominal wall-Relaxed.


Foetal heart beat-Present.

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