organs are involved. The metro-salpingites, the periuterine hæmatoceles, the inflamed cysts of the ovary, very often supply this cortège of peritoneal symptoms. It will therefore be necessary, by the touch, to diagnosticate these different affections, causes of the symptoms which we have described. If nothing is found on the side of the uterus or of the annexes, attention must be directed to that of the coecum. Appendicitis and typhlitis will be recognized by the palpation of the right iliac fossa which almost always determines at that point a more intense pain than in the other points of the abdomen. Palpation permits us also to recognize a peculiar empatement of the region, and sometimes even a tumefaction which leaves no doubt. It must be remembered that the meteorism may be hardly apparent, or even may not exist at all, and that one may even discover some contracture of the muscles of the right side of the abdomen. Past events have a great importance in this diagnosis. They will reveal the existence of one or several anterior painful attacks. They will show the bad state of the intestine manifesting itself by diarrhoea and by bad digestion. They will show finally the frequently sudden commencement of the attack which succeeds an effort to lift a weight, or which shows itself after a repast more copious than usual, If the attentive examination of the cœcal region has yielded no information, one will have to think about a more or less circumscribed form of peritonitis. Among the latter, tuberculous peritonitis ought always to be looked for, for it is capable, in its acute form or during an exacerbation, of giving rise to the peritoneal reactions that we are now studying. The slowness of the evolution, the presence of ascites, the nature of the pains, which are less severe, and the general state of the subject will enable us to make the diagnosis. Finally, it is important to understand that the infections of the liver are capable of giving rise to perihepatitis which betrays itself also by peritoneal symptoms and to examine the liver with great care, when the pain has made its début at its level, and when we do not find elsewhere the cause of the symptoms which present themselves. B. There is an intestinal occlusion which is manifested by other signs. than the arrest of fecal matters and of gases. The vomited matters that were at the commencement alimentary or bilious are not long in becoming frankly fecaloid, and the meteorism is considerable. There is therefore an obstacle to the course of the intestinal matters; this obstacle, must be sought for, but first, it must be understood that there are intestinal paralyses marked by peritonitis which produce what is called pseudo-occlusion, the false intestinal occlusion. Peritonitis by perforation is a type of it. This latter will be distinguished from true intestinal occlusion, by the following characters: the vomitings, although capable of becoming fecaloid in peritonitis by perforation, assume this character less commonly and may remain bilious for a long time. In a certain number of cases, the patients have been able to pass some gas by the anus. The meteorism is less considerable than in occlusion. The sonorousness does not occupy the whole extent of the abdomen, and, as Duplay has pointed out, there sometimes exists in the regions of the flanks, in the hypogastrium, some flatness, an indication of a peritoneal effusion; one also sometimes finds the bruit hydroaérique (see exploration of the peritoneum). Besides, the symptoms make their début by an extremely severe pain, which may be readily localized at a point of the abdomen, a character which but rarely presents itself in internal strangulation. Finally, the thermometer may afford some indications by showing in the case of peritonitis, a more or less decided elevation of the temperature, which remains normal, or which falls in true intestinal occlusion. The history of the disease will put us upon the right track. We may be in presence of a perforation caused by typhoid fever, or due to an ulcer of the stomach; but in the majority of cases, we will have to deal with a perforation of the appendix, which will be suspected by the possible existence of anterior appendicular colècs, by the suddenness of the attack seizing the individual, so to speak, in full health, by the localization of the pain, on the right side, and also by the age of the subject. Having recognized the fact that one had encountered a true intestinal occlusion, after having, be it understood, eliminated the accidents of any poisoning or symptoms of cholera, it is necessary to make every effort to ascertain the variety of acute occlusion before which one finds oneself. One will commence by carefully examining all the openings capable of giving place to a strangulated hernia; the inguinal, the crural rings, the umbilicus and the linea alba; in the region of the inguinal canal, one will carefully palpate the parts, remembering the possibility of an interstitial hernia, above all if the patient is cryptorchide, the examination will be conducted with the view of the possibile reduction en masse of the hernial sac and its contents, particularly if taxis has been practised. Finally, one will practise or will have practised by an assistant, because of the possibility of intervention, a careful rectal examination by touch, which will denote the absence of any obstacle in that quarter, whether it be imagination, or contraction; this done, every effort will be made to diagnosticate the variety of intestinal occlusion presenting itself. Is it an imagination, a volvulus, a strangulation caused by a band, by a diverticulum, or by an accidental ring? Imagination alone, as Duplay has authoritatively remarked, can be recognized with some degree of certainty by the following symptoms: the occlusion is generally incomplete and the distention of the belly is inconsiderable. There are often sanguinolent stools, formed of a mixture of mucus and of glairy matters; these stools may be accompanied by tenesmus. In many cases, palpation of the abdomen will allow us to determine a soft tumor, painful to pressure, slightly mobile and presenting the form of a sausage. Finally ileo-colic and ileo-coccal imaginations, are more frequent moreover, the absence of the cœcum and of the ascending colon in the right flank will be noted and a certain depression of the iliac fossa of the same side, which contrasts with a more or less voluminous prominence of the left side. Imagination is peculiarly frequent among children. Volvulus will only afford presumption. It is very often seated upon the sigmoid flexure and is principally met with in adult life and in old age. Wahl claims that the twisted krackle is enormously dilated and that palpation, under anæsthesia, permits us to recognize it: It has also been said that the attacks of vomiting were delayed but a little while. All these signs are of the most doubtful character. We will say the same for internal strangulation, whether it be caused by a diverticulum, by an accidental fibrous ring, or by a bridle. It may be suspected from the acuteness of the pain, the suddenness and the rapid appearance of the symptoms. Besides attention may be directed to strangulation by band, when we shall discover some peritoneal trouble in the past history of the patient, or when a woman is concerned who has undergone a laparotomy. Chronic occlusion is, at a given moment, capable of giving rise to the signs of acute occlusion; but the symptoms are very much less clearly defined; the vomited matters at a later period become fecaloid; the meteorism less considerable. Upon interrogating the patient, one will recognize anterior disorders, very distinct indications of false obstruction, with a momentary arrest of the fecal matters and sometimes even of the gases. These sypmtoms are met with principally in aged persons, and in the great majority of cases, one finds oneself in presence of a neoplasm of the rectum which the touch will reveal, or of the iliac fossæ which palpation will demonstrate. If it is a question of a narrowing of the small intestine, or of the large intestine, the diagnosis will be impossible; the disorders of digestion, the slow and aggravating course of the affection, will alone afford some suspicion. The contraction of the rectum will always be recognized by the touch. As to foreign bodies obstructing the calibre of the intestine, biliary calculi alone are capable of producing veritably acute symptoms. Occlusion determined by the presence of a cholelith will be recognized by the fact that it is observed almost exclusively among women who have passed the second half of life. Far from having been preceded by manifestations on the part of the liver, the premonitory or anterior icterus is the more generally absent; but we may discover in the past history of the patient the appearance of pains in the right hypochondrium and quite often a primary at tack of vomiting coincident with an obstinate constipation. Finally, a primary biliary calculus may have already been passed in the stools, which permits the diagnosis to be made. We call attention also to occlusion by fecal masses, which is the type of chronic occlusion, but which, however, has given rise to acute manifestations. One has, in general, to deal with women of very constipated habit, and palpation of the colon in its different parts permits of the determination of a series of rounded masses, echelonned upon the large intestine, of a firm consistence, but sometimes sufficiently soft to be molded under pressure. Is it possible to diagnosticate the seat of the occlusion? Many signs have been described as permitting the solution of this important question. Some have rested upon the localization of the pain at the commencement, upon the date of the appearance and the nature of the vomited matters, precocious and non-fecaloid when the obstacle is situated at the commencement of the small intestine; precocious and fecaloid when it resides at the end; tardy and rapidly fecaloid when the large intestine is involved. Observation contradicts these purely theoretical views, and the same may be said about the urine, which is all the more scanty the higher the occlusion is located, by reason of the diminution of the surface of absorption. Some have thought to succeed by the rectum in overcoming the obstacle by the introduction of sounds; the hand as Simon dangerously advised, or by fluids. It has been claimed that the capacity of the large intestine being two litres, according to the quantity of water which enters it, one could either eliminate the large intestine or ascertain the height at which it was obstructed, but practice has not answered to theory, for a normal intestine may be intolerant and reject the injection. The form of the abdomen has been invoked by Laugier. The abdomen would project forward in cases of obstruction of the small intestine; flattened and framed in by the dilated large intestine when the obstacle is located at the sigmoid flexure, or at the commencement of the rectum. Unfortunately the meteorism is so great that in all the varieties of occlusion it gives the same form to the belly. Finally, Bouveret (de Lyon) has drawn attention to the signs of dilatation of the cœcum. This dilatation of the cœcum would indicate an obstruction in the large intestine; but in order to demonstrate it, there must be none of that ever precocious distention of the abdomen which interferes with the manœuvres necessary to recognize it. As we see it is almost impossible to say where the occlusion is situated, which, however, is a matter of great importance in the selection of the operation (laparotomy or artificial anus). SELECTIONS. THE PRESIDENTIAL ADDRESS ON THE INTER-DEPENDENCE OF SCIENCE AND THE HEALING ART. Delivered before the British Association for the Advancement of Science at Liverpool on Sept. 16, 1896. By SIR JOSEPH LISTER, BART., M.B., LOND., F.R.C.S. MY LORD MAYOR, MY LORDS, LADIES, AND GENTLEMEN-I have first to express my deep sense of gratitude for the great honor conferred upon me by my election to the high office which I occupy to-day. It came upon me as a great surprise. The engrossing claims of surgery have prevented me for many years from attending the meetings of the association, which excludes from her sections medicine in all its branches. This severance of the art of healing from the work of the association was right and indeed inevitable. Not that medicine has little in common with science. The surgeon never performs an operation without the aid of anatomy and physiology; and in what is often the most difficult part of his duty, the selection of the right course to follow, he, like the physician, is guided by pathology, the science of the nature of disease, which, though very difficult from the complexity of its subject matter, has made during the last half century astonishing progress, so that the practice of medicine in every department is becoming more and more based on science as distinguished from empiricism. I propose on the present occasion to bring before you some illustrations of the inter-dependence of science and the healing art. [Sir Joseph Lister then referred as the first two of his illustrations to the Roentgen rays and anæsthetics, reminding his hearers that as regards the latter agents this was the jubilee year of the discovery of ether. He continued:] My next illustration may be taken from the work of Pasteur on fermentation. The prevailing opinion regarding this class of phenomena when they first engaged his attention was that they were occasioned primarily by the oxygen of the air acting upon unstable animal or vegetable products, which, breaking up under its influence, communicated disturbance to other organic materials in their vicinity and thus led to their decomposition. Cagniard-Latour had indeed shown several years before that yeast consists essentially of the cells of a microscopic fungus which grows as the sweetwort ferments, and he had attributed the breaking up of the |