THE TECHNIQUE IN APPENDICITIS OPERATIONS.- Dr. W. P. Carr, of Washington, D. C., said that in this disease it was apparent that no one method of operating will suit all cases. Surgeons must modify the technique to suit the case and the strength of the patient. In his first 100 cases he had 8 deaths. In his last 72 cases he has had but 2 deaths, and he believes the improvement in mortality is due to a fuller knowledge of the condition of the patients, and a suitable adjustment of the technique to those conditions.

As to the incision, it should always be either the gridiron or through the rectus muscle; otherwise hernia is very liable to follow. There is but one objection to the gridiron incision, namely, it cannot be greatly enlarged without cutting across the fibers of the internal oblique and transversalis muscles. This, he thinks, should never be done. It is better to close the wound and open again through the rectus muscle, if a very large opening becomes necessary. However, if this incision is well placed, it may be stretched with the fingers, and a fairly large opening made through which any uncomplicated operation may be done. The stretching should never be excessive, as paralysis of the stretched muscle fibers may result, and hernia follow.

NEGLECTED APPENDICITIS.- Dr. Charles M. Rosser, of Dallas, Tex., concedes the safety of an acutely inflamed appendix, if the pathology is limited to the structures of that viscus; but the serious mortality following cases not so treated justifies a classification of those passing the initial stage as being neglected, whether the delay is due to indifference, ignorance, or cowardice, and whether the responsibility is upon the family, patient, or medical adviser. The safe time limit varies with the character of the attack, the skill of the operator, and the resistance of the individual.

The author considered the question of whether to operate settled affirmatively; that the question of when to operate is agreed to, if early; but he proposes the question of, who shall operate, and what operation shall be done?

While appendectomies are occasionally simple of performance, yet they are prospectively delicate, and the patient is entitled to the most skilful service available in each instance, and he thinks the geographical distribution of competent surgeons is sufficiently general that there is hardly an excuse for an emergency operation by the attending physician if he is not so equipped.

He advises incision in all cases at all stages; except those already moribund, and in which added insult to vitality will be immediately hazardous, and a class having reached adhesive protection in which a relaxed rectal orifice indicates early rupture and discharge by that route. After incision the surgeon must decide whether to remove the appendix alone, removal and drainage, or whether drainage alone should be the operation of election. But as exploration can best determine an otherwise indefinite pathological progress, the patient should be given the benefit of the doubt.

LATE RESULTS IN THE TREATMENT OF INOPERABLE SARCOMA WITH THE MIXED TOXINS OF ERYSIPELAS AND BACILLUS PRODIGIOSUS.- Dr. W. B. Coley, of New York City, gave a brief history of the development of the method, stating that he has used the mixed toxins of erysipelas and bacillus prodigiosus since 1892. Up to the present time he has advocated the treatment practically only in cases of inoperable sarcoma, but in view of the experience thus far gained from his own cases, as well as the successful cases in the hands of other surgeons, he believes it wise to use the injections in all cases after primary operation for sarcoma as a prophylactic against recurrence. In these cases, however, the dose should be much smaller, just sufficient to produce a very slight reaction, and the treatment should be continued for two or three months. He also believes it wise, in practically all cases of sarcoma of the extremities, to give the patient the benefit of a trial with the mixed toxins before sacrificing the limb by amputation. This opinion is based upon 12 cases of sarcoma of the extremities in which the treatment has been so tried, with the result that the tumor disappeared, and in 8 of the 12 cases the patients were alive and well from three to six years afterwards; two were well at the time of the last

observation, at the end of one year; the other two were recent cases. Three of these twelve cases were personal cases. Eight of them were of the round-celled variety; 2 spindle-celled, and in 2 no microscopic examination was made, although amputation was advised by prominent surgeons; five were sarcoma of the tibia; one of the fibula; two of the femur; one of the forearm ; one of the humerus; one of the thigh, involving the periosteum; one of the calf of the leg. In all of these cases amputation had been seriously considered, but it seemed justifiable to give the toxins a trial before resorting to operation.

As to the final results of personal cases, of 34 which may be fairly classed as successful, in that the tumor disappeared under the injections with the mixed toxins, the type of the neoplasm is as follows: 12 round-celled, 16 spindle-celled, 2 mixed celled, I epithelioma, 3 no microscopical examination made, but the clinical appearance together with a history of recurrence left practically no room for doubt as to the diagnosis.

The results in these cases thus far have been as follows: 4 were well less than a year; 3 were well for one to two years; 3 were well from two to three years; 3 were well from three to five years; 23 were well from five to thirteen years. In five cases a recurrence took place and finally proved fatal. In one of these recurrent cases the patient had remained well for eight years; in one three and a quarter years; in one two and a half years; in one seven months; in one six months.

These five cases of recurrence, the author argued, are important in that they furnish absolute proof of the correctness of the diagnosis and refute the statements formerly often made in regard to the successful cases, namely, that there must have been an error in the diagnosis.

The writer states that he has been able to collect 56 cases of complete or partial success obtained by other men; of which 17 were round-celled sarcoma; 14 spindle-celled; 2 mixed celled; 3 endothelioma; 2 epithelioma; and in 18 no microscopical examination was made, or it was not recorded; but in all of these cases the clinical diagnosis was confirmed by a number of surgeons, and the patients were considered hopeless from an operat

ive standpoint. The results in these cases were as follows: 13 were observed less than one year; in 6 the tumor disappeared and the patient remained well from one to two years; in 9 the tumor disappeared and the patient remained well from two to three years; in 12 the tumor disappeared and the patient remained well from three to five years; in 9 the tumor disappeared and the patient remained well from five to eleven years; in 5 cases recurrence took place six months to two years later; two died during the treatment, one of pyemia due to staphylococcus infection, the other of septic absorption, the tumor being a large intraabdominal sarcoma which had completely degenerated.

Dr. R. E. Fort, of Nashville, Tenn., followed with a paper on LAMINECTOMY, in which he reported a case that he had successfully operated upon, with recovery of the patient.

The following papers were read by title: "END Results in APPENDICITIS WORK," by Dr. Edward E. Balloch, Washington, D. C.; "Two CASES OF VAGINAL CESAREAN SECTION FOR ECLAMPSIA," by Dr. John F. Moran, Washington, D. C., " CESAREAN SECTION NECESSITATED BY OBSTRUCTION OF PELVIS BY RIGHT HALF OF BICORNUATE UTERUS," by Dr. Geo. S. Brown, Birmingham, Ala.; "PENETRATING WOUNDS OF THE ABDOMEN. WITH REPORT OF CASES, INCLUDING A CASE OF TRAUMATIC RUPTURE OF CONGENITAL CYSTIC KIDNEY," by Dr. C. E. Caldwell, Cincinnati, Ohio; "THE VICIOUS CIRCLE AFTER GASTROENTEROSTOMY," by Dr. John B. Deaver, Philadelphia, Pa.; "SOME OF THE USES OF PELVIC MASSAGE," by Dr. Joseph Taber Johnson, Washington, D. C.; "RECENT PROGRESS IN THE SURGERY OF THE VASCULAR SYSTEM," by Dr. Rudolph Matas, New Orleans, La.

OFFICERS:- The following officers were elected for the ensuing year: President, Dr. George H. Noble, Atlanta, Ga.: Vice-Presidents, Dr. Stuart McGuire, Richmond, Va., and Dr. E. Denegre Martin, New Orleans, La.; Secretary, Dr. W. D. Haggard, Nashville, Tenn., re-elected; Treasurer, Dr. Chas. M. Rosser, Dallas, Texas, re-elected.

Baltimore, Maryland, was selected as the place for holding the next annual meeting.

Records, Begollections and Bęminiscences.

COMPOUND COMMINUTED FRACTURE OF THE THIGH A TRIUMPH OF ENFORCED

CONSERVATISM.

BY A. A. LYON, M. D., SURGEON C. S. A., OF NASHVILLE, TENN.

It was on the bright Sunday morning following the historical flanking movement of the wonderful Stonewall Jackson at Chancellorsville, after he had rolled up as a scroll the legions of General Hooker, on the late afternoon of May 2, 1863, that my regiment, the 48th Mississippi, became engaged with the Federal Army immediately in front of the famous Chancellor house. In this conflict the losses in my command were very heavy, and perhaps I may be permitted to say, that in my ambulance corps the per cent. of casualties far exceeded the losses in the fighting line, due to a notion of my ambulance sergeant, an intrepid Jew named Newman, who rigidly construed his duty to take care of the wounded to mean that he and the other litter bearers should keep within a hundred feet, more or less, of the fighting line, and that, too, standing upright and ready for instant action. The result was that he lost that morning about half of his corps. This, however, is parenthetical; and what I especially desire to present is a compound comminuted fracture of the femur in the person of Frank C., a private in the line.

He was a young man of twenty or twenty-one years of age, dark complexion, hair, and eyes, not especially robust but in good health. He was struck by a minie or Enfield ball nearly in front of the left thigh, about the middle of the upper third, and just below the trochanter major. The wound externally was, as usual, insignificant in appearance, but produced a comminuted fracture of the bone extending up to the hip-joint presumably, and, as I thought at the time, possibly into the