movable organs to assist in their progress, or else traction, a result of adhesive contact must aid in the lifting or elevation of them upward in the abdominal cavity.

Dr. Stone reported two cases illustrating the variety he described in his paper. Both of these grew to very large proportions. In the first, the largest tumor was very high in the abdomen, and was entirely separate from all former uterine connection, including its blood supply. The presence of a large wedge-shaped middle portion is sufficient proof of the mode of development. It has forced other growths both upwards and downwards, acting as a wedge between the two. In the second case the central portion of the specimen is made up of many small tumors which have appeared to force the larger growths in opposite directions, as in the first case. The largest growth was highest, and was completely separated from the uterus and the tumors below, except by a small amount of connective tissue, and its anterior peritoneal cover. The pelvic tumors in both

of these cases were firmly impacted, and in the second case it was impossible to release the specimen without injury to deep and unseen vessels, which resulted in fatal hemorrhage. The first patient made a fairly satisfactory recovery, and was now able to attend to her duties as housekeeper.

GOITRE, WITH a Report of 182 OPERATIONS UPON THE THYROID:- Dr. Charles H. Mayo, of Rochester, Minn., said that surgery of the thyroid is increasing. These operations are as satisfactory as any made, giving relief with brief disability. In fifty years the mortality has fallen from 40 per cent. to less than 3 per cent., Kocher's percentage being 2. Accessory glands, like branchial cysts, are more often found in the lines of hypoblastic inversion. The lymphatics serve as ducts. Total extirpation is followed by cachexia in from fifty to seventy per cent. of cases. Graves' disease is probably due to an over- or perverted secretion, the glands showing a general or local condition of cell activity.

The great majority of enlargements in young people respond to medication. Part of the benefit obtained in the removal of the sympathetic is from cutting the lymph channels draining

the thyroid. During the past seventeen years the Mayos have operated upon 182 thyroids, with 9 deaths. Of these, 57 were cases of well-marked Graves' disease, with 7 deaths in all, and but I in the last 23. Of these cases, 50 per cent. made an early The rerecovery; 25 per cent. did so during several months. mainder were improved, but had occasional relapses of a temporary nature. Among the remaining 125 operations representing cysts, colloids, parenchymatous and malignant tumors, there were but 2 deaths, one from pneumonia, the other from tracheal collapse on the third day following extirpation of a carcinomatous goitre. Cocaine was used in 13 cases, but ether anesthesia preceded by morphia and atropine was the rule. The head was maintained in the high position. The incision is usually transverse. Parenchymatous enlargements and some colloids were extirpated; cysts and encapsulated growths were enucleated. Saline solution was freely given after operation.

THE DIAGNOSIS OF RENAL CALCULUS:- Dr. Guy LeRoy Hunner, of Baltimore, Md., took up this subject from the general relationships, first considering the various other maladies of the kidney from which nephrolithiasis must be differentiated, and then discussing the diseases of other organs which may mislead the diagnostician. The Roentgen ray and the wax-tipped bougie are considered invaluable aids in the diagnosis of renal calculus, but they both fail at times, and the importance of the urine examination in all suspected kidney cases was emphasized. Several cases were reported to illustrate the difficulties of diagnosis.

REQUIREMENTS AND QUALIFICATIONS FOR A SUCCESSFUL CAREER IN SURGERY: The President, Dr. Lewis C. Bosher, of Richmond, Va., said that to the recent graduate in medicine. no department of his chosen profession appeals with the same force as does surgery. While a student he had been impressed by the brilliancy of the results secured by his professors; at the meetings of the Alumni the clinics in surgery are crowded, while those in other branches are usually either slimly attended or else attended as a compliment to the individuals holding them, rather than from actual interest in the subjects. It is little wonder that so many young physicians decide to enter the allur

ing field of surgery, where they believe they will effect such marvelous results and brilliant cures, in abundant pecuniary reward, in the homage of their fellowmen, and, if moved by even higher motives, in the actual good they may do to suffering humanity.

President Bosher called attention to the importance of an academic education, saying that many a man has attained success in surgery without it, but we are dealing with the rule, not the exceptions. This academic education should be truly liberal, both in quantity and quality, and should include as much as possible, studies of a scientific nature, especially biology, physics, and chemistry. Of these three branches, he thinks physics will prove of the greatest use to the surgeon, while biology and chemistry are branches of more practical value to the general practitioner.

It is incumbent upon teachers and practitioners of surgery to make it plain to the public that there is a material difference between the trained surgeon and the novice. This education will enable the public to discriminate in a wholesome manner, and will ultimately have the effect of rendering it apparent to the candidate for surgical practice that he must properly equip himself before he can stand before the world as a representative of the great surgical art.

TRAUMATISM of the Ureter and PELVIS of the Kidney.— Dr. Rufus B. Hall, of Cincinnati, reported two cases. In these the ultimate results were satisfactory. The exact location of the injury was not determined in either case.

ANEURYSM TREATED BY SUTURE INSIDE THE SAC.- Dr. F. W. Parham, of New Orleans, read a paper in which he reported two cases treated after the method of Matas. One was an idiopathic aneurysm of the popliteal artery; the other, an aneurysm of the second and third portions of the left subclavian. The popliteal aneurysm was treated by suture of proximal and distal openings separately, inside the sac, and continuous suture of the groove of the artery intervening. In the subclavian case. only the proximal opening was sutured, the distal bleeding being controlled by ligatures. Both patients recovered.

The indications for this procedure are:

(1) The practicability of laying open and inspecting the interior of the sac. (2) The possibility of applying a constrictor, clamp, or temporary ligature to the proximal side of the tumor.

In the second case reported the suture was employed because the proximal ligature failed to stop the bleeding completely.

The operation of suture within the sac is to be preferred to ligature; because, first, every possible bit of artery is saved except that actually forming the sac of the aneurysm. Second, the suture accomplishes simple approximation of the intima, and does not cut through, as may happen with ligature of an atheromatous artery. Third, all collateral bleeding in the sac is stopped by direct suture of the vessel mouths within the sac. and packing of the sac becomes unnecessary. Fourth, there is no disruption of the outside vascular (collateral) connections of the sac wall, already much relieved by the emptying of the sac.

The reconstruction of the artery is to be attempted only in certain cases, as in aortic aneurysm; where suture of the proximal opening will, like ligature, probably be fatal, and in other aneurysms where from swelling and lymphangitis, as in Morris' case, the danger of gangrene is too great to risk any interference with the nutrient stream. In such case reconstruction of the artery may be preferred for two reasons: (1) Because even a temporary continuance of the main stream will be a great advantage until the subsidence of edema consequent upon the evacuation of the sac shall have somewhat relieved stress upon the collateral vessels; and (2) because, as remarked by Matas, and shown in Dana's case, it is feasible at a secondary operation to again open the sac and close the arterial opening.

In abdominal aneurysms the method of Matas offers some hope of cure.

VARICOSITY OF THE SAPHENOUS VEINS, WITH RESULTING VARICOSE ULCER.- Dr. Robert Carothers, of Cincinnati, mentioned the operations most commonly employed for the relief of this condition, and among them reference is made to the Schede operation, and the Trendelenburg; but, he said, complete exci

sion of the internal saphenous vein is undoubtedly the most satisfactory operation to be employed. Until the ingenious invention by Charles H. Mayo of two instruments which subcutaneously strip the vein, it was an operation which required a long incision, tedious dissection, and considerable time for its performance. This operation, as advised by Dr. Mayo, is, that after making a small incision in the upper third of the thigh over the saphenous vein, the vein is located, tied in two places, cut between the ligatures, and the distal end threaded into the enucleator, which is pushed under the skin along the course of the vein for about six to eight inches, where another small opening is made on to the instrument, the vein taken out, then the instrument drawn out from the first opening, rethreading the vein into the instrument, and again pushing it under the skin for another six or eight inches; another small incision on to the instrument allows the vein to be drawn out, which is again ligated and removed. The lateral branches are torn off, and, as a rule, close themselves. This operation is very quickly and easily done, but is not without danger from hemorrhage or sepsis. The author has twice performed this operation, and said the immediate results were satisfactory. His cases were too recent to say what would be the ultimate results. They were old cases with large, troublesome ulcers treated by skin grafting. The patients were able to leave the hospital in less than three weeks, wearing an elastic porous bandage for support, and are now, at the end of about eight weeks, both at work as housewives. In one case in which there was a troublesome eczema, after an effort for one week to relieve the same, he again followed the advice of Dr. Mayo, sealing the eczematous area with compound tincture of benzoin until the skin had healed.

THE DANGERS FROM SCOPOLAMIN-MORPHIN ANESTHESIA.— Dr. Horace J. Whitacre, of Cincinnati, Ohio, based his conclusions upon observations made in forty cases of anesthesia induced by this method, upon animal experimentation, and upon a review of all deaths that have been reported in the literature up to the present time. The author concludes (1) that scopolamin-morphin narcosis is not devoid of danger; (2) the use of scopolamin-mor