jections to it are the difficulty in intro- | that it would give relief when the ducing and retaining the tube, the symptoms became urgent, could do no liability to produce ulcerations, and the harm if did no good, was painless, inability to clear the trachea and parts bloodless, etc., and it might save her below.' life. With this explanation he consented. The patient grew worse slowly but surely until 3 o'clock the next day, when I telephoned Dr. Jos. Eichberg, who at 4 o'clock introduced a tube. On the second day she coughed the tube. out. With the assistance of Dr. G. W. Row, of Bellevue, Ky., I reintroduced it. On the morning of the fifth day the tube became obstructed and was coughed out again, after which she made an uneventful recovery. In view of such reports, it is not strange that those who have not had any practical experience with intubation should decide to follow in the old rut, and depend entirely upon medical treatment, and finally, when the family saw there was no chance of life, would perform tracheotomy, with the usual results. If the subject of this paper was "Diphtheritic Croup and its Treatment," I should have reported my experience in that disease by inhalation, medication, tracheotomy, etc., that you might make comparison of the various methods of treatment, but I can sum it all up in three words: Every one died. Before reporting my first case of intubation, I wish to report the last case of diphtheritic croup which I treated before I resorted to intubation. CASE I. Sidney V., aged five years, had recovered from a slight attack of pharyngeal diphtheria. I was called to see him October 26, 1891, at 5 p.m. Mother stated he had been hoarse for thirty-six hours. I found slight membrane in the fauces, complete aphonia, and violent dysphonia. I at once informed the mother that he must die unless we performed tracheotomy. She would not consent until her husband arrived, which he did at 7 o'clock, and he gave the usual answer, that he would rather prefer the child should die a natural death than that he should be butchered. Child died at 10 o'clock, five hours CASE III. Jos. B., aged six years, was convalescing from scarlet fever and diphtheria; was anæmic and weak. I was called November 9, 1891, at 9 a.m., and found extensive diphtheritic membrane in the fauces, slight aphonia. Gave treatment for pharyngeal diphtheria. November 10, 9 a.m., aphonia was complete, with slight dysphonia. I told the father that if he continued to grow worse it would be necessary to introduce a tube. November 11, 9 a.m., dysphonia urgent. At 10 o'clock, with the assistance of Dr. C. B. Schoolfield, I introduced the tube, which I allowed to remain five days. Recovery complete. CASE IV. Baby A., female, aged three years. I was called in consultation by Dr. Barker, of Bellevue, Ky. The patient was cyanotic. I proposed intubation, was too late. although I thought it There was extensive membrane in the pharynx and nares; parotid and submaxillary glands greatly swollen. I introduced a tube without any difficulty, letting it remain four and a half days. Recovery complete. CASE V. Raymond M., aged nineteen months. I had treated him for diphtheria two weeks previously. Was called to see him November 29, and found complete aphonia and marked dysphonia. November 30, morning, slight improve. ment, breathing easier; at 6 p.m., dys phonia urgent, and with the assistance of Dr. G. W. Row, I introduced a tube at 7 o'clock. Everything seemed to be progressing favorably for the first twenty-four hours, when respiration. began again to be labored. I removed the tube, thinking, perhaps, it had become obstructed, but found it clear. The child grew worse. I reintroduced the tube, which gave slight relief. I proposed tracheotomy, but the parents objected. The child died at 5 o'clock, a.m., December 2, thirty-four hours after the intubation of the tube. CASE VI. Helen H., aged four years. I was called to see her December 3, 9 a m. Found aphonia not quite complete, slight dysphonia and diphtheritic exudation in the pharynx. At 10 p.m. found the child sleeping naturally and breath ing easily. I cautioned the parents to notify me if respiration became embarassed. I was summoned at 6 o'clock the following morning, and found considerable dysphonia, which became urgent by 10 o'clock, when, with the assistance of Dr. G. W. Row, I introduced a tube. Patient has rested well ever since. Temperature is about 990, pulse about 100, and this evening I left her in splendid condition. I will remove the tube to-morrow morning, and have now not the slightest doubt but that she will make a perfect recovery. (') [FOR DISCUSSION SEE P. 12]. 1 DECEMBER 19, 1891.-In regard to case No. VI, will say further that I removed the tube on December 9, but was compelled to replace it immediately. Removed it again on the 12th with the same result, the child becoming cyanotic immediately upon its removal. Removed it again on the 15th. It remained out for about an hour, when I was compelled to introduce it the fourth time. I made arrangements to introduce a tracheotomy tube on the 17th if I was unsuccessful in keeping the intubation tube out, but upon its removal on the morning of the 17th there was no further difficulty, and at present writing the patient is convalescing nicely. The tube in this case remained in situ thirteen days, during which I supported the patient with enemas of peptonized milk, whiskey and quinine, and sprayed the throat with peroxide of hydrogen and 1:2000 solution of bichloride, alternately, every two hours.-W. D. RICHARDS. There is very little to be said which is really new about this subject; much that is old. I do not know the exact number of times in which I have made a perineorraphy or colporrhapy, or both, for I have not kept exact records of cases, but it must be up into the hundreds. Of course, I do not include in this estimate the cases of primary perineorraphy, which I always make at once, if the perineal tear is greater than to the first degree. Primal tears do not occur with me in private or hospital practice as frequently as in years past. My impression is that many of the perineal lacerations are owing to too rapid delivery at the end of the second stage of labor, or to a misdirected perineal support. But we are talking about secondary perineorraphy. The number of operations devised for the secondary repair of the perineum is very large— almost as large in number as the number of vaginal pessaries, or vaginal specula, or rectal specula. There is, for instance, that of Baker Brown, Hegar, Simon, Bischoff, Winchel, Savage, Lawson Tait, Emmett, Godell, and a great many others. Some of these are very good and some not so good. The Baker Brown operation of many years since, is now totally and discarded. properly A skin perineum is not any pelvic support. Great improvements have been made in these operations in recent pears. A just recognition of the anatomical structure of the perineal body, in its pyramidal shape, is the essential feature underly- | flap operation than any person to whom ing all anatomical reconstruction. The I have ever listened. I never ignore mucous denudation must extend fairly the slit-flap principle in any operaup into the vagina. Necessarily, the surface denuded must vary in length, width, and also in depth, varying the shape of the area denudation, according to the local morbid conditions to be corrected, as vaginal prolapse, rectocele, cystole, and uterine displacement. I have had no personal practical experience with the flat-splitting operations. Several years since I wrote a paper for the Cincinnati Obstetrical Society, recommending the Hegar operation, or some modification thereof, for all cases. I still adhere to the conviction that this operation, modified in area denudation, by length, width, depth, direction and shape, is the best. Of course, then, the area of denudation is modified for the case, with its site and direction of injury, and secondary results. Of sutures, I have abandoned the use of silver wire, or any metallic substance, now using only catgut, silk worm, or silk, for all vaginal operations, using, however, silver wire for operations on the cervix uteri. I have seen Dr. Zinke use, and have used myself, catgut, to coapt the bottom of the triangular denudation. But months before I had used, or seen used by Dr. Zinke, the catgut in this way, I witnessed its use by Dr. McMonigle, of San Francisco, the successor of Dr. Scott in the California Woman's Hospital in San Francisco. Where the triangular denudation is broad, some underlying catgut seems, and is needful, to secure a thorough coaptation. Transverse vaginal sutures I always employ. These are sometimes interrupted; again, at times I use them continuous, and extend the same down to, and including, the skin of the perineal pyramidal base. Aristol I now always employ over the sutured tract, instead of iodoform formerly used; no vaginal injections, unless profuse discharge, which is not apt to occur. DR. C. A. L. REED: I am gratified at Dr. Zinke's paper, and I am particularly pleased with his mannikin demonstrations. He has come nearer explaining the Tait siit tion that I do for repair of the perineum, although I sometimes deviate from the hard and fast rules laid down by Mr. Tait for this procedure. Thus, Mr. Tait never passes any of his sutures through the skin; I have found that this leaves a fissure in the perineum after healing, and consequently I pass some of the stitches through the integument. Mr. Tait gives no attention to the pouched margins of the flaps as they protrude into the vagina after approximation; I endeavor to correct this by passing a "reef-stitch" through the entire margin from one side to the other. This closes the upper edge of the wound and prevents the gravitation of secretions from the vagina into it. There is one stitch, however, that should always be passed beneath the skin, and that is the one that dips down after the retracted ends of the torn sphincter. This modification of technique, however, does not militate against the principle of the slit-flap operation-the most important addition which Mr. Tait has ever made to plastic surgery. DR. A. W. JOHNSTONE: I thank Dr. Zinke for the very able way in which he has presented this subject as well as the very excellent method by which he has demonstrated the Tait operation. The greatest objection ever urged against Mr. Tait's operation was, that as sometimes done, it did not deal with a rectocele. This is obviated by pushing your dissection of the rectovaginal septum to its crest. A rectocele is a true hernia, due to a submucus rent which makes a real hernia ring. As to using the three encircling stitches, I come nearer using a dozen. Never stop to count the number of stitches, but do your work well and neatly. We have no right to cut away any tissue. If we narrow the vaginal tract we will have the same accident again. I have now been doing this operation for six years. Where there is merely a torn perineum and no rectocele Mr. Tait's method is the best that can be done, and by a higher dissec tion than some of his imitators have | fied terms denounced the removal of done I find it applicable to all forms of perineal damage. DR. THAD. A. REAMY: I have been interested and instructed by the paper. I was somewhat amused at the author including Reamy's operation in his enumeration of the various operations devised by various authors. I appreciate the compliment thus paid me by Dr. Zinke, but am quite certain that he founds this statement upon clinical observations made during his student days, when he was quite accustomed to seeing me operate. If he could have followed me the last six or seven years, in my clinical work, he would have found that I now repudiate any special operation. The object of an operation is, so far as possible, to restore the parts to original conditions. Each case must therefore be a law unto itself, each case demanding a special operation. The operator therefore who follows a special plan cannot, in my judgment, be successful in all cases. Thorough knowledge of the anatomy of the parts, a well-trained mechanical eye, which enables the operator to take in at a glance the special character of the injury and the resulting deformity, are essentials to success. Quickness of perception and accuracy of judgment in arriving at conclusions, with regard to the direction and extent of denudation, the number and direction of sutures necessary to most thoroughly restore that special case to its original conditions. It must be constantly remembered that the approach to a triangular body, known as the perineal, occupies the space between the integument below, and the diverging rectum and vagina before and behind; that this body is composed of the union of muscular tendons, fibrous elastic tissue, etc. Now the extent and direction to which the muscles and other structures composing this body may be destroyed and displaced, are by no means regular. The operator must be able to discern the direction of displacement, and therefore reason backwards to the character of the injury, and operate accordingly. Dr. Zinke has in the most unquali any portion of the flap after denudation. In this, I regard him in error. Take an injury, for example, which has resulted in an extensive rectocele (which is a hernia), associated, as it is usually, with extensive subinvolution of the vagina. In such a case, I would inquire, of what value would the flapsplitting operation be? None whatever. I have seen it tried in such cases by a skillful operator, Dr. Johnstone, even with his improvement of carrying the split further up than Mr. Tait does, and yet the results were unsatisfactory. The parts were by no means restored to original conditions. I have myself tried the operation in such cases with similar unsatisfactory results. The facts are, that in most cases of injury to the perineum, associated with subinvolution of the vagina, the removal of redundant tissue, including mucous membrane of course, is one of the important factors in the cure of the subinvolution, as well as an essential in the mechanical restoration. Probably the author of the paper this evening, has in his mind when he condemns the removal of the flap made by denudation, as done by myself and others, the removal of the posterior vaginal wall instead of the mucous membrane simply. If he will recog nize that ordinarily the denudation, when properly done, simply includes the vaginal epithelium, he will not regard it as such a bugbear. There are many cases of injury to the perineum, so called, which consist simply in the vagina having been pushed in front of the child's head and torn loose from the fascia and muscular structure connecting it with the anal sphincter and the deep fascia. It is pushed forward like the lining of a coat sleeve would be by the fist in attempting to draw the sleeve on violently. In these cases, after a year or two, the appearances are as though the vagina were torn loose, posteriorly, and retracted up toward the uterus. In such cases there is always great redundancy of tissue, and the best operation is to denude the cicatrix in front of the tear, dissect up deeply a flap, cut away the redundancy of tissue and fore-shorten | and urethra, but could not make out In many other cases the tear in the vagina has been on one side simply, extending up the lateral sulcus, separating everything from the deep fascia. Of what value is the flap-splitting operation in such a case? Or of what value is the operation, described by the author of the paper to-night, in such cases? None whatever. Here the parts can only be restored by making a path of denudation over the line of the tear, up the sulcus, then separating the parts deeply on either side, bringing the flaps together by deep stitches, which unite the edges on the two respective sides of the sulcus, and at the same time fastening them to the deep fascia. In conclusion, I will state that I regard the flap-splitting operation as valuable in special cases. I have in one or two instances avoided the objection referred to by several speakers to-night, of a small path of non-union along the line of suturing in the flap-splitting operation, by using catgut for all the deep sutures, cutting it short to the knots, and then covering it over by the integumentary flaps, brought edge to edge, and held by fine silk sutures. These last sutures are all that it is necessary to remove. Meeting of November 9, 1891. M.D., in the Chair. T. V. FITZPATRICK, M.D., Secretary. DR. C. S. EVANS reported a case of Calculus in an Infant. membraneous portion of the urethra. The catheter was passed on into the bladder and the urine allowed to escape. I show here the instrument; its chief peculiarity is the sharp curve similar to that found in a catheter for cases of enlargement of the prostate. Here the high position of the infantile bladder necessitates the same curve as does the enlarged prostate. The next day the mother called my attention to a swelling at the penoscrotal angle which was distinctly outlined. I left it alone, expecting it to pass down to the meatus. But it did not. I removed it by passing a curved probe around it and drawing it forward to the meatus, where it was easily removed by slitting up the meatus. The calculus is round, the size of a buck-shot, and is composed of uric acid. Dr. Evans's report is certainly very interesting on account of the age of the patient. I have never seen a stone in a child so young. I had a case analagous to the case reported, a child three years old, in which the stone caused reten tion, and was excised from the urethra at the peno-scrotal angle. I have frequently seen small stones passed by children. The catheter exhibited by Dr. Evans looks as though it was too small, but never having had occasion to use an instrument on so young a child my idea is only theoretical. DR. TINGLEY: Patient, a male child one year of age. The parents stated that the child had not urinated for twenty-four hours, which I doubted, but recalling the fact that the parents could tell positively I wish to refer to the fact that I by the child's wearing apparel whether catheterized a female child two and a or not it had passed urine in a given half years of age with a soft rubber time. I was more disposed to give catheter without any difficulty. In refcredit to their statements. On exami-erence to stone in the bladder in chilnation I found the bladder above the umbilicus. I then palpated the penis dren, I am reminded of a case that came under my observation recently. A lady |