facial vein the induration was markedly increasing and very painful. The face was cyanotic.

7th day. Had had very little pain since the incision and application of the acid, from the relief given by taking one-half grain morphia during the night. Sol. carbolic acid had been kept constantly applied every quarter of an hour to the wound. There were ulcerations at two spots to which the nitric acid was gently applied. Ordered whiskey, one-half ounce every two hours, which stimulated the heart's action; nourishing beef extract, milk and eggs.

8th day. Doing very well; very little suppuration of the wound.

9th day A. M. Wound suppurating; sloughs thrown off.

P. M. Thought I could detect deep-seated fluctuation over the left antrum and facial vein, a point still remaining very painful. 10th day. Sloughs nearly all out; tumefaction of face diminishing.

11th day. No more sloughs; tumefaction over facial vein and antrum disappearing by absorption; general health indicated improvement.

12th day. Fluctuation point about the size of a dime detected, but absorption successfully encouraged to prevent a scar on the cheek.

13th day. Wound slowly healing.

14th day. Wound assuming the condition of indolent ulceration; stimulated by the gentle application of diluted nitric acid. 16th day. Doing well; gave

R.-Potass. iodidi, 3ij;

Fld. ex. sarza, co.,

Fld. ex. rumex crispi, aa f3iss. f3j ter in die.

18th day A. M. Wound much inflamed, and erysipelatous. blush for two inches on each side; directed a poultice of pulv. cortex ulmi to be applied.

P.M. Wound covered with thick diphtheritic exudate; the edges inflamed resembling the margin of a vaccination on the eighth day; discontinued the whiskey; ordered champagne, two ounces every two hours; the best nutritive diet continued. 19th day A. M. Erysipelatous inflammation diminishing and more confined to the wound.

9 P. M. Felt better; acid. tannic. c. vaseline applied to wound;

and lapis calaminaris dusted over inflamed skin; ung. zinci oxyd. benzoatum to margins.

21st day. Cleaned out the cavity, which was half an inch in depth, from pseudo-membrane; applied ung. bals. Peru to cavity and the tannate of vaseline to margins of the wound, while the irritation of the skin was relieved by the ung. bals. Peru. 22d day. Doing well.

23d day. Scarified cavity to hasten its healing from the base of the wound, which remains very deep; healing progressing rapidly round the edges.

25th day. Doing well. 28th day. Doing well.

30th day. Doing well.

32d day. All well; size of scar inch.

53d day. A deep-seated abscess on the opposite right cheek had appeared. Let out by incision half an ounce of very thick

green pus.

54th day. Doing well; no re-formation of pus on cheek; the induration over the left facial vein entirely disappearing by absorption.

56th day. Still improving; champagne now discontinued and patient sent out for a drive in Central Park; convalescence continued until restoration to health became complete.

ABDOMINAL SECTION IN THE TREATMENT OF ULCERATION AND PERFORATION OF THE CACUM AND THE APPENDIX VERMIFORMIS.

BY WILLIAM A. BYRD, M.D.,

ILLINOIS.

THE report that I have the honor to present to this Section to-day is offered as an appendix to the paper that I read before you in New York last summer. I will first show you a cæcum and vermiform appendix that I took from the body of Leon Vallet, who died in our city (Quincy) March 24, 1881. The appendix has a gangrenous patch on each side about an inch and a half long by half an inch wide. Through the centre of each patch is a ragged hole that will permit the passage of the tip of the little finger. He was taken sick the night of March 18th with great pain in the umbilical region, and sent for an irregular practitioner, who treated him until the morning of the 23d, when-instead of improving he was getting worse-he sent for Dr. M. F. Bassett, who found him cold, clammy, nearly pulseless, tympanitic, vomiting stercoraceous matter, and having extreme pain in the umbilical region. He diagnosed some form of abdominal obstruction and told him he had but little hope for him, that it was a case that required the intervention of a surgeon, if anything would do him good. That evening the doctor requested me to see the case for him. I found the case as described above, the tympanites being very great and the pain agonizing. As he had been given large doses of opium without much relief, I determined to use the aspirator. I passed the needle through the abdominal wall, but not into the intestines, as I supposed. There was withdrawn two pints of thin, brown fluid having a marked stercoraceous odor. This settled the diagnosis; proving it to be not only a case of obstruction but also one of perforation. The man being evidently in a state of collapse, and, it being nearly eleven o'clock at night,

I did not advocate nor believe that an operation would do any good. At three o'clock in the morning he died.

The 27th of March I was called in counsel with Drs. Wm. M. and D. M. Landon to see a patient near Adams, Illinois, who was suffering with obstruction of the bowels, having, by a strange coincidence, been seized the very same night that Vallet was. This case will perhaps be better described by Dr. D. M. Landon, whose letter I will now read.

"Mrs. Jonah Broyles, married, aged 39, mother of five children; family history good, so far as any predisposition to any of the diatheses is concerned. Several years ago she had Asiatic cholera. Her first husband died of an attack at the time she had the cholera. Menstruation regular. Says her right side has been lame and sore ever since the attack of cholera. Has been obstinately constipated most of the time during her married life, and, judging from her irregularity to attend to the calls of nature, one would suppose this condition had been brought about by a paresis of the muscular coats of the bowels; which paresis was due to over distension, from long retention of fecal matter. On March 18, 1881, she was seized with colicky pains in the bowels, in the region of the cæcum which lasted nearly all day. March 19. Soreness in right side, but she felt so little inconvenience from it that she went to Quincy, a distance of twelve miles, in a spring wagon. When she returned, was attacked with a violent colic, which lasted until she was relieved by morphia hypodermically, Sunday evening, March 20. Temperature had ranged from 984° F. to 101°; pulse 85 to 120. Before I was called she had taken a dose of antibilious physic, a quack nostrum of some kind, which was followed by copious evacuations from the bowels. When I saw her she was suffering from the most violent tenesmus I ever witnessed. Said she felt just as if she was going to be confined. Thinking there might be impaction of feces in the bowel, we gave copious injections of warm water, which were retained, no benefit being derived from them. Symptoms of obstruction became more aggravated, with stercoraceous vomiting, pain, tenderness, and induration over cæcal region. Slight elevation of temperature; frequency of pulse slightly increased. Extreme thirst, which was due probably to the morphine; loss of appetite. In a few days symptoms of suppurations, chilliness, and profuse sweating presented themselves. At this time, March 27, Dr. William A. Byrd, of Quincy, Illinois, was called in consultation. In the doctor's opinion, there were inflammation and obstruction of the bowel at the cæcum which should be relieved by abdominal section The patient feeling somewhat easier the operation was not then permitted, but the doctor was

recalled April 1, when he made an exploratory aspiration, getting an ounce or two of pus. Abdominal section was commenced at 2 P. M. After working nearly an hour, tearing up old adhesions, which matted. together several knuckles of bowel, the point of original disease was reached. The cæcum and appendix were one mass of diseased tissue, being inflamed and ulcerated throughout. The cæcum was perforated in three places, to the left and posteriorly. At one of the points of perforation the appendix was adherent to the cæcum and was perforated at the site of adherence and also at the opposite side. The perforations were evidently produced by the irritating action of some half dozen hard concretions found in the abscess cavity. These were nearly as hard as stone, and were about the size and shape of plum-seed. The perforations were all cut into one, making a single opening in the bowel instead of three, and the edges of this large opening were then stitched to the opening in the abdominal walls. The opening as presented to the outside was, when finished, about three inches in diameter. As there had been some of the contents of the bowel extravasated an opening was left at the inner side of the incision, between the bowel and the abdominal wound, large enough to admit the nozzle of a syringe to permit the washing out of the abdominal cavity, which was done every few hours during the treatment of the case, with a very weak solution of carbolic acid. Strict attention was paid to cleanliness. Morphine was given as the occasion required, hypodermically. Quinine and easily digested food were given and perfect quiet enjoined. The patient has been improving ever since the operation. Some suppuration yet, but no evidence whatever of inflammation. Rests well at night, appetite good, and, in my judgment, will be entirely well in a short time.

Very respectfully,

ADAMS, ILLINOIS, April 29, 1881."

DAVID M. LANDON, M.D.

The above letter was received after my arrival in Richmond, and will give you as good an account of the operation as I could have done, in fact better, as Dr. Landon is a very capable and observing physician, and had the case under observation from its inception.

For a long time I had the greatest dread of invading the peritoneal cavity, and would have thought that cases wherein there was not only an opening into that cavity, but also perforation of the bowel and extravasation, must of necessity be fatal, but I have now made abdominal section, opening also into the bowel four different times, all of the patients recovering from the