People rightly look to physicians to take the lead in the movement to bring the whole food question up to the level modern progress has made in other sciences and to introduce a knowledge and practice of the right use of food into the lives of the people, and so to heighten marvelously the health and vitality of humanity, and physicians regard any means of prevention of diseases as the noblest aim and use of medical science. GALLSTONE ILEUS. BY DR. L. A. SHERIDAN, WILKES-BARRE, PA. In 1908, Lesk, of Vienna, reported five cases of gallstone ileus, in which the patients were cured by operation with one exception. He went over eight other cases, in which there was no operation, the termination either being fatal at once or recovery taking place. He tabulated the details of 148 other cases which he had taken from the literature. The patients were mostly women; the clinical picture being remarkable for the mildness of the symptoms during the time it took the gallstone to slough its way through the gall-bladdder wall and that of the duodenum, which is the usual means of communication. The latter fact was discovered in twenty-two cases that came to autopsy. Usually in these cases the vomiting occurred early, the temperature remained normal, while there was only moderate leucocytosis. There were periods of total obstruction, alternating with periods in which the bowel was open. As a result of the stone migrating, successive sections of the intestine were involved, thus causing over exertion and exhaustion of different segments. According to Treves, it is impossible for any stone, which is large enough to cause intestinal obstruction, to pass by way of the common duct. The following case is interesting from the fact that there was no operation and the patient made a complete recovery. History-Mrs. C., a white woman, aged 67 years. Up to this time she had been fairly healthy, suffering only from a uterine prolapse, which was the result of her single confine ment. Present illness--In February, 1908, while visiting in Delaware, she was attacked by severe abdominal pain, accompanied by vomiting. She was given an indefinite diagnosis of stomach and liver trouble. At the time she returned home she had lost considerable weight, and the eyes and skin were tinged slightly yellow. The abdomen was considerably distended and there was some tenderness in the epigastrium and right hypochondrium. The tenderness gradually disappeared and she was able to resume her household duties after several weeks. On August 7, of the same year, she had an attack of violent abdominal pain. The temperature was 99.5 degrees, the pulse 90. There was retching, some distention, and the point of greatest tenderness was over the region of the gall-bladder. Morphin and atropin were given hypodermically. During the succeeding five days she had all the symptoms of partial obstruction, the abdomen distended and tender, vomiting of stomach contents and bile, and later stercoracous matter. There were intervals of quiescence, in which buttermilk could be taken and retained. Although constipation was complete, there were times when considerable gas passed per rectum. On the afternoon of the 12th the obstruction became complete. The abdomen was ballooned and tense, pain increased, and the vomiting became continuous, the ejected matter being fecal. Rectal and vaginal examination revealed nothing as to the situation of the obstruction. During the evening a futile effort was made to use high medicated enemas. Later the colon was flushed through a high rectal tube, using plenty of water as hot as could be borne. Early the following morning she passed the stone I have shown. After this rigorous experience it required about six weeks for the patient to recuperate. TUBERCULOSIS AND CARCINOMA. BY DR. J. T. WILLIAMS, WILKES-BARRE, Pa. Case reported by courtesy of Dr. Charles Long, Hospital Service, 1908. Family history-Free from malignancy and other hereditary disorders. Personal history-Children's diseases, negative, no history of any infectious disease; denies veneral trouble and no evidences present of having had the same; beer drinker, twenty glasses a day; cigarette smoker, fifty a day, duration not elicited; hard worker and irregular hours; best weight, 160 pounds; intellect, below par for his class; no evidences of having a constitutional ailment previous to present illness except a slight cough. History of present illness, June, 1908-Began to lose appetite, excessive diarrhoea began, had a constant eructation of gas. Had pain in epigastrium and excessive pain immediately after eating. Cough increased; no night sweating; abdomen and other parts free from swelling and oedema. Stools contained no blood; lost fifty pounds in a few months. Physical examination-Skin leaky, anaemic, no lesions; senses, normal; eye reactions normal; mucous membranes pale; mouth fair; tongue clean; teeth fair; throat fair; cervical glands enlarged both sides; lungs, chest resonance dull on right upper quadrant; auscultation negative; heart negative; liver and spleen enlarged; area of tenderness directly over stomach axillary and inguinal glands enlarged; examination for nervous change a negative; extremeties progressive in emaciation; slight sclerosis of vessels. Tests-X-ray for chest and abdomen; chest, deposits in right upper lobe; abdomen, contracted stomach; urinalysis, Spg. 1020, reaction acid; total solids, 46.60 per 1,000 cc.; albumen and sugar negative; casts negative; epithelium and blood cells negative; diazo positive; blood, hemoglobin 65 to 70 per cent. leukocytes 18.800; reds, 2,720,000. Sputum-Several examinations; T. B. negative; blood streaked; black deposits; frothy; diplococci in abundance. Stomach contents-Free HCL, absent; total acidity, .01095; Boas-Oppler, bac. negative. Stool examinations-Semi-liquid; dark brown; not viscid; occult blood negative; bacteria, ordinary; starch digestion good; epithelium abundant; leukocytes abundant; yeast cells few; fat globules abundant; no fatty acid crystals; sarcinae and Boas-Oppler bac. negative. Aesophageal bougie test for stricture-Two strictures located; first, 221⁄2 cm. from teeth; second, 341⁄2 cm. from teeth; bougie tip passed with no great difficulty causing the patient considerable pain, however, accompanied by severe nausea; the passing of the bougie tip over the strictures gives a sensation of their being nodular or irregular. Tuberculin tests-First, November 7, Moro unguent, no local reaction in forty-eight hours; unguent applied at 3 p. m., rise of temperature at 8 p. m., same day to 101.4; November 13, at 10:45 a. m., Moro unguent again applied, no local reaction; November 21, 3 p. m. Calmette opthalmic tuberculin test applied, no reaction; November 22, von Pirquette vaccine applied; no results; December 2, at 4:45; slight reaction to tests. Autopsy report-Death occurred at 12:30 a.m., December 16, 1908; autopsy same day; body that of an emaciated anemic man of middle age; on opening the abdomen the peritoneum was found to be glistening; very pale; pigmentation in areas; post mortem and hemorrhagic; excess of fluid present, 32 fluid ounces; spleen densely adherent anaemic with marked atrophy; substance dark in color but consistency normal; capsule very adherent and wrinkled; right kidney, few small cysts in substance under capsule strips, easily cut surface shows no abnormality; supra renal capsule enlarged and presenting some form of liquifaction necrosis; left kidney, tissue normal, capsule not adherent, supra renal capsule not found to be diseased; liver, large, mottled in appearance, few adhesions, old, fibrous, cut with ease, presenting a fatty degeneration and interstitial hepatitis; pancreas showed no internal change. Peri pancreatitis had been present with adhesions; stomach rather smaller than normal; in the cardio esophageal area a mass was found forming adhesions with the pancreas with immobilization of parts. Upon opening the stomach in situ a cauliflower mass was found about the size of a lemon; forming a valve-like closure to the aesophagus; showing an almost impossible passage for vomitus. This mass was irregular, nodular, hemorrhagic, necrotic and ulcerative in make up, extending downward upon the cardiac surface. Scattered about the surface of the stomach were found masses and ulcers of various sizes. On the lesser curvature a perforating ulcer was found (opening made undoubtedly during post mortem manipulation). Pylorus indurated not malignant. In the ileum were found several ulcers, tubercular in type, encircling the mucous membrane, forming a ring around the surface, extending thirty-six inches from valve. Malignant nodule found six feet from pylorus; appendix normal. Colon-Mucous membrane much thickened and hemorrhagic; chronic hemorrhagic colitis; sigmoid flexure seat of large thickened necrotic hemorrhagic ulcer 5 cm. in diameter, presenting appearance of a degenerated carcinomatous mass. Chest-Heart normal brown induration of muscle, pericarditis adhesive and fluid in excess. Both lungs present, marked anthracosis. (Pleural fluid normal.) Right pleura free from adhesions. (Pleural fluid normal.) Left pleura free of adhesions. Thickened evidence of old pleurisy minus adhesions. Lungs-Left upper lobe mass of nodules. Peri bronchial glands enlarged and anthracosized, not caseous microscopically; bronchi full of watery mucous; crepitation impaired in upper lobe, old calcareous healed in tubercular masses, in upper lobe deposits infiltrated with anthracite dust; right lung, bronchial fluid watery mucous; area of calcareous infiltration of apex; small cavity in middle of lower lobe; microscopically, nodules in lungs were tubercular; mass in stomach carcincina; ulcers of stomach were peptic with undermined mucous membrane around edge; supra renal gland round cell infiltration with degeneration and absorption process; fecal ulcer in caecum, carcinoma. |