the obstruction. The further away from the duodenum and the more gradual the strangulation, the more delayed the vomiting, absolute constipation and distention, and the more infrequent the paroxsyms of pain. Ascending meteorism in the left inguinal region, associated with paroxysms of pain and a pelvic mass, are more than suggestive of a sigmoid torsion. In cases of postoperative obstruction there will be a history leading to the true lesion. The danger of reducing a hernia en masse when taxis is resorted to, was pointed out in a recent monograph which appeared in the New York and Philadelphia Medical Journal. The diagnosis of intestinal obstruction rests upon the previous history, the absolute constipation, the findings ascertained by early auscultation, and later by noting the distended, changing contour of the abdomen, the anxious expression, the abdominal tenderness, the muscular rigidity, the agonizing, paroxysmal pain, and the findings obtained by palpation - especially rectal palpation. Sudden cessation of the excruciating pain may signify gangrene. The mere fact that distended coils of intestine can be seen to rise and fall with each paroxysm of pain is sufficient to convince even the tyro in medicine that an obstruction to the normal onflow exists. Every moment lost brings the patient nearer to the grave.

CHOLECYSTITIS.

In acute cholecystitis the excruciating pain may be complained of in the appendical region. The fact that a distended gallbladder may appear in the right inguinal region and be mistaken for an appendical abscess, must be remembered. The finding that the tumor moves with the respirations, and that a tympanitic area exists between the border of the liver and the tender, movable mass combined with a previous history of biliary colic should clear up the diagnosis.

In acute phlegmonous cholecystitis, the age of the patient, the previous history, the localization of the pain and the point tenderness as well as the muscular rigidity, in the region of the gall

bladder, the presence of a very tender tumor in the right quadrant which moves with the respirations, and the picture in general, should suffice to guide the medical attendant to the gallbladder.

Mr. Mayo Robson has frequently observed that partial obstruction of the cystic duct due to a gallstone may exist without causing jaundice. The excruciating pain of gallbladder perforation may be followed by a subsidence of the symptoms until the manifestations of an overwhelming peritonitis appear.

It is evident that whenever a patient complains of sudden, severe, persistent pain in the right inguinal region we must first determine the true significance of the appealing cry. Above all, we must never give morphin until we have made a routine examination, and until we are confident that the lesion does not require surgical intervention. Personally, I am confident that morphin kills more often than it saves.

In conclusion I desire to impress the following points:

1. Sudden, severe, persistent pain in the right inguinal region is a very important, and a most valuable symptom.

2. The true significance of excruciating pain in the right inguinal region can only be accurately determined by securing a complete previous history, a clear description of the mode of onset and course of the present attack, and by making a thorough, painstaking examination.

3. The effect of the pain upon the patient's mind, pulse, temperature and posture, as well as the accompanying changes that have taken place in the abdomen, as evidenced by point tenderness, muscular rigidity, distention, changeable contour, etc., must be carefully considered.

4. I can not too forcibly condemn the common practice of soothing the pain with morphin. It must be remembered that pain is the guide which is to direct the attention of the skilled practitioner to the seat of trouble.

5. In by far the greater proportion of the cases, sudden severe pain in the right iliac fossa with fever, point tenderness and localized rigidity, signify an infected appendix.

CLINICAL REPORTS.

REPORT OF THREE CASES OF REFRIGERATORY FACIAL PARALYSIS.

BY SELDEN SPENCER, A.B., M.D., ST. LOUIS, MO.

In the last number of the "Transactions of the American Otological Society" appears a paper of more than ordinary interest and value. It is entitled "The Relationship between Otitis Media (non-suppurative) and Facial Paralysis of the Refrigeratory Type," and was read before the society by Dr. H. O. Reik of Baltimore.

Recently I have had three cases of refrigeratory facial paralysis which, as bearing on this subject, I deem worthy of report. For the benefit of those who have not the opportunity of reading the publication above referred to, I shall endeavor to state briefly Dr. Reik's position on this subject.

The article is prefaced by the following declaration : "In the majority of cases, if not indeed all, of facial paralysis of the refrigeratory' or ' rheumatic' class, an acute or sub-acute otitis media is an intermediary condition between the exposure to cold and the appearance of the paresis." Dr. Reik explains this by saying that from some kind of exposure to cold the patient acquires an acute otitis which may be simply catarrhal with a swelling of the mucous membrane and may give rise to an exudate in the tympanic cavity. If there happens to be any dehiscency in the canal wall of the facial nerve of sufficient size to allow the entrance of bacteria or fluid, inflammation can extend directly to the nerve, or the effects of it can cause pressure on the nerve. Dr. Reik therefore concludes that in all facial paralysis of this type treatment should begin by giving attention to the

ear, and the longer such attention is delayed the worse will be the prognosis. He adds: " Paracentesis of the tympanum is certainly not a serious or difficult operation; it can do no harm and I assure you it may do a great deal of good, and do it promptly in these cases."

Another fact emphasized by the above article is the paucity of the literature on this subject. My recent diligent search had fully advised me that such was the case; hence the delight experienced on reading the above article. Dr. Reik truly says that in text-books on otology scarcely anything can be found and the subject as found in other works is treated very unsatisfactorily.

I regret that I can only mention Dr. Reik's position in this discussion; but I hope that all who are particularly interested may be able at some time to read Dr. Reik's article.

I herewith report three cases of facial paralysis of the refrigeratory type, and also mention a fourth case of facial paralysis, not of this type, which complicated an acute suppurative otitis or the purpose of showing how promptly it yielded to treatment and how it was entirely relieved with the disappearance of the otitis.

Case 1. About six months ago a young negress, aged seven, called at the Washington University Hospital of St. Louis, and on account of deafness, was referred to the ear clinic. It required but a glance to see that there was a marked facial paralysis of the right side of the face. On this side there was also marked deafness, and the examination revealed a clouded and slightly congested membrane. Fluid was present, but because pain and bulging were not marked, it was decided to try what inflation would do. The nasal cavities were cleansed and daily the ear well inflated by the Politzer method. iodid, in fifteen drop doses was prescribed. improvement, until after about three weeks completely disappeared. The child is still kept under observation, as the hearing in both ears was affected by a chronic non

The syr. ferri Every day brought

the paralysis had

suppurative condition.

in fact, almost normal.

But the hearing is noticeably improved;

Case 2. Miss T., aged 26, called at the office on December 8, 1904. Patient had a marked facial paralysis, having lost all muscular power on the right side of the face.

History: The patient had suffered the ordinary diseases of childhood, but had never experienced any serious illness; had had occasional attacks of acute otitis during early life. The hearing had been good up to the time of the attack which began eleven weeks prior to call on above date. First symptom was pain which patient described as neuralgic and limited to the right side of the head. Two days later the right ear seemed "stopped up" and patient experienced slight dizziness. This condition continued for three weeks at which time the patient was subjected to an unusual exposure. an unusual exposure. Two days later patient suffered increased dizziness and deafness, accompanied by severe pain in the head and nausea when attempting to arise. It was three weeks after this attack when the patient called at the office, having a marked facial paralysis which she stated was only three days old.

Examination of the ear showed a lusterless opaque membrane. The light spot was absent but no marked congestion or bulging present. The examination of the nose revealed a chronic hypertrophic rhinitis, but not in such a degree as to interfere to any great extent with nasal respiration; naso-pharynx in fair condition. Patient complained of no pain at this time but of dizziness and marked deafness of the right ear.

Hearing test showed following condition: