manent and excessive excitability of a certain number of vasomotor and sensory centers in the medulla oblongata, manifesting itself on one or the other half of the head, and often exaggerated by illness, cachexia, gout, etc. His radical treatment consists, in the first place, of a vegetable and milk diet, carried on for a period of years, early rising and plenty of sleep; no tobacco. Every day or two there should be galvanization of the cranium in an ascending direction. Hydrotherapy is a valuable adjunct. Bromide of sodium should be administered with interruptions of the treatment at intervals, for a period of two years, in doses of not less than two grams a day, associated with the tincture of strophanthus, and with cocaine.-Tablettes Médicales Mobiles, June 16, 1903.

Bacteriuria. Luigi Ferrannini examined the urine of a rabbit and of six dogs under various conditions. Microorganisms were found in all the specimens. Sixteen different species of bacteria were isolated, one, Micrococcus candidus, having been found in two cases. The one pathogenic microorganism (Micrococcus tetragenus) was found in a dog whose urine had the greatest number of species, and which had been reduced to the death point by injections made to induce glycosuria. None of the animals had cystitis. Some of the dogs had urethritis, but their urine did not show a greater number of bacteria than that of the other animals. It is therefore evident that microorganisms are to be found normally in the bladder. As to whether they originate in the urethra, the kidneys or the blood, that will have to be determined by further experimentation.—La Riforma Medica, June 10,

1903.

Adrenal Extract.-G. A. Weill advises the use of adrenal extract with cocaine (1 to 200 or 100 solution of cocaine to a 1 to 2,000 or 1,000 solution of adrenal extract) in minor surgery, giving it hypodermically. The action of the cocaine is greatly increased while the condition of ischemia induced by the adrenalin extract permits of a dry operation. The adrenal preparation also prevents absorption of the cocaine. A solution of adrenal extract, I to 1,000, is suitable for application on mucous surfaces. It arrests hemorrhage and to a great extent reduces hypertrophy of the tissues. As a general therapeutic agent its indications are limited to accidents due to chloroform, and to certain deeply-seated hemorrhages due to a morbid condition of the hæmatopoietic organs. It is better to administer it intramuscularly than through the stomach. Should the drug cause syncope the patient must be placed in a recumbent position, with loosened garments. Should more serious accidents follow, subcutaneous injections of ether are to be administered, and energetic friction of the body.-Revue de Thérapeutique, June 15, 1903.

The Association of Appendicitis and Cholecystitis.G. Dieulafoy bases his remarks upon the study of about thirty cases in which these two affections occurred. The question is, are they really simply simultaneous in appearance, occurring from some one cause, or does one affection induce the other, and if so, which is the first to occur? The author's conclusion, after reviewing the evidence, is that the infection is not an ascending, but a descending one, and that the cholecystitis is the cause of the appendicitis. In twenty-five out of the thirty cases the symptoms of the biliary lesion were the first to appear, those of appendicitis being secondary, and coming on in a few days, weeks or even months. A new chapter is thus added to both diseases, and the physician must be continually on the watch in case of cholecystitis, lest while he is taking his time to treat this affection, the far more dangerous one may be insidiously making its appearance, and suddenly complicate matters by its toxi-infectious accidents, compromising the life of the patient and calling for prompt surgical interference.-La Presse Médicale, June 17, 1903.

0.05

The Use of Vanadic Acid, More Especially in Gynecology.-M. Le Blond and Ch. David have found that chemically pure vanadic acid is a medicine which deserves high rank among medicaments. While antiseptic in its action, it has the quality of assisting cicatrization to a marked extent, which renders it superior to all other dressings in the treatment of cutaneous wounds. gm. to a liter of water is the proper proportion for this purpose. It gives good results when used topically in gynecology, and while it cannot be said that it is superior to all other known substances in use, it should be given the preference because of its absence of odor, and because it is better tolerated. The best solution for this use is obtained by adding to a volume of oxydasine (the commercial name of the 0.5 solution used by the author), two volumes of glycerin, this corresponding to a solution containing gm. 0.17 of the active agent per liter. In general practice, this substance is a valuable adjuvant in

the treatment of pulmonary tuberculosis, the dose consisting of two tablespoonfuls a day of a solution containing gr. 0.015 to the liter.-Bulletin Général, June 15,

1903.

Respiratory Insufficiency in Pulmonary Tuberculosis.— M. Mendel has for several years treated tuberculosis by tracheal injections of the essential oils (essence of thyme, of eucalyptus, etc., in a solution of olive oil, preference being given to eucalyptus). A study of the results of this treatment has convinced the author that the irruption of the medicament in the respiratory passages of a tuberculous patient has for its immediate result a considerable enlargement of the thoracic respiratory area. This dilatation, under continued treatment, becomes permanent. In some cases this result is not obtained; the sensation of the patients themselves may serve as guide, for in the cases which are likely to receive benefit from the treatment, there is a speedy sense of well-being, and a power of larger breathing capacity, and of exercising without breathlessness. The cases treated by the author were all in Paris, not in any mountain or sea resort. The air of a large city is all-sufficient for these invalids, providing that the respiratory apparatus is in fit condition to receive and use it. It stands to reason that the best results obtained are in cases which are subjected to treatment before too large an area of pulmonary tissue has become involved.-Archives Générales de Médecine, June 16, 1903.

Annals of Surgery, May, 1903.

All

Contribution to the Literature of Old Irreducible Dislocations of the Shoulder-joint.-Seven cases are detailed by A. F. Jonas. His plan of treatment consisted chiefly of, first, manipulation. Using the forearm as a lever, rotating outward and inward, abduction and adduction, never forgetting for a moment a possible accident to the axillary vessels and nerves, and the possibility of fracturing the humerus. If this plan failed, second, through incision the capsule and all cicatricial tissue were extirpated. muscular attachments that offered a restraint were severed, the axillary vessels were protected with a broad, flat retractor, and the head of the bone was brought into place by means of an elevator assisted by manipulation and traction. To avoid infecting the wound in this last manœuvre, it is advisable to firmly wrap the entire arm and hand with wet sublimate towels. Dry towels are liable to slip and become displaced, making it possible for the operator's hands to become infected. If the head cannot be replaced, then, third, the head of the humerus should be resected. This is an operation to be avoided when possible, on account of the resultant flail-like condition of the arm, and yet must be done (a) when the humeral head and neck become too extensively stripped of their attachments, experience having shown that necrosis may occur in 16 per cent. of the cases; (b) when osseous union has occurred between the head and the ribs; (c) when, after a division of all the restraining, soft parts, the head rests against the point of the acromion process.

Hepatic Syphilis from a Surgical Standpoint.-C. G. Cumston discusses the symptomatology and differential diagnosis of this affection and says that before surgical intervention should be seriously considered, the medical treatment should be thorough. The patient should use one gram of the ointment and take three or four grams of the iodide daily. When this treatment remains unsuccessful, even if we are in the presence of a gumma tous liver, it is because the gummata are so old and the tissues have become so changed that medical treatment is without avail, and under these circumstances the question of surgical interference may very properly be considered. It is hardly necessary to say that not all gummatous tumors of the liver which have resisted all treatment can be removed by operation, because, in order to be able to extirpate them, the tumor must form a single mass, and numerous deposits scattered here and there in the liver substance would render it impossible to remove them all. Besides this, the location of the tumor in an accessible point is nesessary-that is to say, either in the left lobe or on the convexity of the right lobe. What is particularly essential is that the tumor be not profoundly situated in the hepatic parenchyma, because in this case its removal would necessitate such a destruction of the organ that the patient's life might be in danger. But in those cases in which the gumma is only covered by a thin layer of parenchyma, resection is without danger, and relatively an easy matter. In cases of pedunculated gumma the operation is fairly easy when the growth has sprung from under the surface of the liver, for little or no injury is done to the hepatic tissue, and consequently with a good ligature there is practically no danger of hemorrhage. Several illustrative cases are given.

Book Reviews.

DE

MUCOMEMBRANOUS ENTEROCOLITIS. BY MAURICE LANGENHAGEN, M.D., London: J. & A. Churchill, 1903. THE present monograph deals with membranous enteritis, a disease which is not very rare and in which the author seems to have had vast experience. According to Langenhagen, gingival aphthous manifestations are particularly frequent in membranous enteritis. When the malady is very serious, gingivitis is almost a permanent symptom: when the malady progresses-as it generally does--by fits and starts, each renewed attack of the complaint is accompanied by a corresponding attack of gingivitis. And this is so constant that I am almost tempted to say that, if the lingual mucous membrane is the mirror of the stomach, the bucco-gingival mucous membrane is the mirr of its congener, the intestine. With reference to treatment Langenhagen lays much stress on a very rigorous bland diet, forbidding fruits and vegetables. Occasionally he keeps his patients principally on milk. In this respect the writer of the book is not in accord with many modern clinicians, as, for instance, von Noorden, Ewald, Einhorn, and Boas, who permit a very liberal diet. A SYSTEM OF PHYSIOLOGIC THERAPEUTICS, A Practical Exposition of the Methods Other than Drug giving Useful for the Prevention of Disease and in the Treatment of the Sick. Edited by SOLOMON SOLIS COHEN, A.M., M.D., Senior Assistant Professor of Clinical Medicin in Jefferson Medical College; Physician to Jefferson Medical College Hospital. Volume X. PNEUMOTHERAPY, Including Aerotherapy and Inhalation Methods and Therapy. By Dr. PAUL LOUIS TISSIER, One-time Interne of the Paris Hospitals; Assistant Consulting Physician to Laennec_and Lariboisiere Hospitals; Chief-of-linic in the Faculty of Medicine of the University of Paris. Philadelphia: P. Blakiston's Sons & Co., 1903.

PNEUMOTHERAPY is a branch of physical and physiologi

cal treatment which has not received much attention in this country. For this reason more space is devoted to the history of its development in the opening chapters than one finds similarly utilized in the volumes which have preceded. Divergent views are stated and discussed in relation to many subjects connected with pneumatic cabinet treatment, the effects of high altitudes, and often a quasi-judicial decision of the merits of a controverted subject is given. Inhalation methods in connection with certain aspects of pharmacology are carefully considered, showing a desire not to antagonize, by the methods proposed, valuable and discriminating treatment by drugs. The greater portion of the chapter has to do with conditions under which inhalations prove valuable and methods of preparing and administering the varied inhalants. It requires 478 pages to put before the reader what Tissier deems necessary for him to know concerning these matters. There is much of great interest in pneumotherapy and aerotherapy, and the mind of any practitioner will be broadened and strengthened by reading what the author has to say.

THE PRACTICAL APPLICATION OF THE RÖNTGEN RAYS IN THERAPEUTICS AND DIAGNOSIS. By WILLIAM ALLEN PUSEY, A.M., M.D., Professor of Dermatology in the University of Illinois; Member of the American_Dermatological Association, and EUGENE WILSON CALDWELL, B.S., Director in the Edward N. Gibbs Laboratory, University and Bellevue Hospital Medical College, New York; Member of the Röntgen Society of London; Associate Member of the American Institute of Electrical Engineers. Philadelphia: W. B. Saunders & Company, 1903.

THIS work is divided into two parts; the first containing 215, the second 355 pages. The first, after an introduction, presents chapters on the essentials of an x-ray equipment; x-ray tubes; induction coils, interrupters and their management; static machines and their management. Fluoroscopy; radiography; the photographic materials and their manipulation; the choice of an x-ray outfit. While the apparatus is described with a master-hand, one feels a slight disappointment in the text relating to the use to which it is all put. The application to diagnosis is dwelt upon to a greater extent than the means of employment of the different forms of apparatus for the cure of disease In part second many interesting questions are discussed. "The causes of the phenomena observed in tissues after exposure to x-rays,' "What is the property in x-rays that affects tissues!' How far should x-ray effects be carried," "Indications for the therapeutic use of x-rays," all this and many other topics are carefully considered. The author then gives his personal experience. The histories of numerous cases are given and the general conclusions to be drawn from them. The authors have conjointly added not a little to the literature of the subject,

and as the contributions of each represent a certain proportion of actual original work done their words are entitled to an attentive audience.

INTERNATIONAL CLINICS. A Quarterly of Illustrated Clinical Lectures and Especially Prepared Original Articles. By leading members of the medical profession throughout the world. Edited by A. O. J. KELLY, A.M., M.D., with the aid of various collaborators. Vol. I. Thirteenth Series. Philadelphia: J. B. Lippincott Company, 1903.

ON glancing over the contributors one sees that the same well-known men continue to work in the interest of thi serial-Keen, Osler, Ballantyne, Finger, Wilcox, Satterthwaite are among the number. A review of the progress of medicine for the year by E. W. Watson presents the advances in a concise manner.

The special articles are by King on "Functional Reversion and Its Import in Medical Practice;" and by Ballantyne on "The General Principles of Embryology."

There are the usual number of illustrations, some showing interesting features of blastomyces and the dermatites it produces. The clinical reports, both medical and surgical, contain much new matter of practical interest and are well presented.

TRAVAUX DE CHIRURGIE. Anatomoclinique par HENRI HARTMANN, Professeur agrégé de la Faculté de Médecine avec la collaboration de: CUNEO, ROger, Soupault, LUYS, LECÈNE, LEBOY, PRAT et DELAAGE. Voies Uri naires-Estomac. Paris: Georges Steinheils, 1903. THIS is a collection of works whose scope is indicated by the title, emanating from the hospital service and laboratory, with clinical and statistical data, illustrated with one hundred and thirteen figures and cuts.

The first portion dealing with hospital arrangement and equipment will interest all hospital workers. Those interested in pathology will find many important reports. The surgeon will find well-illustrated methods of procedure, and he who looks for end results will find reports extending from the ward through the dead-house to the microscopical laboratory-but also reports of cures traced long after discharge of the patient. It is an unbound volume of 360 pages, on good paper. The contributors to both the genito-urinary part and to that dealing with stomach affections are to be congratulated on this result of their labors.

TRANSACTIONS OF THE AMERICAN RÖNTGEN RAY SOCIETY. Third Annual Meeting, Chicago, December 10 and 11, 1902. Louisville Courier-Journal Printing Co., 1903. THERE are fourteen papers all on subjects of interest connected with radiography or radiotherapy. A list of about 250 members is given. The discussions are of much interest and many new points in the rapidly developing lightscience are brought out.

PRACTICAL HANDBOOK OF THE PATHOLOGY OF THE SKIN. An Introduction to the Histology, Pathology, and Bacteriology of the Skin, with Special Reference to Technique. By J. M. H. MACLEOD, M.A., M.D., M.R.C.P., Assistant in the Dermatological Department, Charing Cross Hospital, Physician to the Skin Department Victoria Hospital for Children. With eight colored plates and thirty-two black and white plates. Philadelphia: J. Blakiston's Son & Co., 1903.

THIS is intended as a working book for students, and is based upon work and demonstrations in the laboratory. Not only will the student here find the patholigo-histology or the histopathology, but the flora of the skin, and the rules for obtaining results in individual investigation. The word "introduction" in the sub-title is well chosen, for it is not the intention to offer here a substitute for any complete work on skin pathology-did one exist. The book stands by itself and fills the place it occupies. Elementary anatomy is sufficiently entered upon to prepare a basis for the comprehension of subsequent chapters. If this should prove a stepping-stone to an anatomicopathological nomenclature the work, done upon it will have been well spent. The author deserves praise for producing such a work, and all interested in the skin should become familiar with its subject matter. THE CARE OF THE BABY: A Manual for Mothers and Nurses. By J. P. CROZIER GRIFFITH, M.D. Third edition. Philadelphia: W. B. Saunders & Co., 1993.. ACCORDING to the author, endeavor has been made in this volume to furnish a reliable guide for mothers anxious to inform themselves as to the best way of caring for their children in sickness and in health. The hygiene of pregnancy is first discussed, followed by a description of the characteristics of a healthy baby, together with the growth of its body and mind. Toilet, clothes, sleep, and feeding are all considered, much attention being naturally given to feeding. Under the head of sickness are considered such subjects as colic, prolapse of the bowel, hernia, worms, jaundice, croup, pneumonia, con

vulsions, various deformities, and the infectious dis

eases.

MANUAL OF BACTERIOLOGY. By ROBERT MUIR, M A., M.D., F.R.C.P.Ed., Professor of Pathology, University of Glasgow, and JAMES RITCHIE, M.A., M.D., B.Sc., Reader in Pathology, University of Oxford. American Edition from the third English Edition by Normana Mac Leod Harris, M.B. (Tor.), Associate in Bacteriology, the Johns Hopkins University, Baltimore. New York: The MacMillan Company, 1903.

THE American edition of this well-known manual is perhaps one of the best and most comprehensive, up-to-date handbooks for the student published in the English language. The treatment of the doubtful questions is to be commended. The investigations of each observer and the conclusions are stated with as little bias as possible. Where conclusions are not justified the facts are stated without advancing to a conclusion. Due prominence is also given to the recognition of the facts which tend to show that many of the pathogenic organisms are members of a closely related group of bacteria. Several new illustrations and subjects have been added to this edition. These include a new chapter on the bacteriology of air, soil, and water. The chapter on immunity has been modified and extended, and consists now of a judicious statement of the experimentally ascertained data on this subject; the different abstruse conceptions of the nature and mechanism of this subject are skilfully handled, and unwarranted deductions from the many theories of immunity are avoided. An appendix furnishes a compact outline of the principal literature on the different subjects. This outline deals chiefly with the original works found in the foreign languages. Suzor's compilation on hydrophobia and a number of other references of value to the student who is not familiar with the foreign languages are omitted. The alterations and additions to the chapter on media, filtration of cultures and the miscellaneous methods, such as the use of the celloidin sacs for the study of the action of microorganisms when within the body, are very useful. The chapters on diagnosis, animal noculations, the bacilli of the typhoid-colon group, and tetanus, also contain notable additions.

LE TRAITEMENT RATIONNEL DU DIABÈTE. Par M. le DOCTEUR A. LORAND, Médecin consultant aux eaux de Carlsbad. Paris: C. Naud, Éditeur, 1903. THE Various measures for the treatment of diabetes mellitus advocated in this attractively written essay are more or less those propounded by the modern German school. The author, a médecin consultant aux eaux de Carlbad, of course, gives preference to the mineral-water treatment at the spa, maintaining that it may not only favorably influence the pathological substratum of the disease, but also eventual complications, such as hepatic diseases, gastrointestinal catarrhs, etc. The author opines that as long as we do not know the real cause of diabetes, the mineral waters afford its most rational treatment. THE AMERICAN YEAR-BOOK OF MEDICINE AND SURGERY. By GEORGE M. GOULD, M.D., and others. Volume on Medicine. 691 pages. Philadelphia, New York, London: W. B. Saunders & Company, 1903.

It is not surprising that it has been found advantageous to continue the experiment of publishing this work in two volumes, a medical and a surgical, and of selling these separately. The ponderous tomes of former years were cumbersome and annoying to the reader, while those who were interested exclusively in either medicine or surgery naturally objected to the amount of space devoted to subjects which they did not care to study. The union of the departments of laryngology and otology under the editorship of Dr. D. Braden Kyle and Dr. George Fetterolf will be appreciated by many. In the department of general medicine, which occupies 248 pages, the infectious diseases, the conditions affecting the constitution of the blood and the diseases of the stomach are treated in a satisfactory manner. The next largest division, that of pathology and bacteriology, deals with numerous topics of importance, among the most interesting of which are intoxications, immunity, hæmolysis, the etiology of carcinoma and the general pathology of tumors. In the department of dermatology the novel and, for the present at least, absorbing topic of the therapeutic use of the x-ray and of the Finsen light receives due attention.

CHRONIC HEADACHE AND ITS TREATMENT BY MASSAGE.

By GUSTAV NORSTROM, M.D., of the Faculty of Stockholm. New York and London: G. E. Steichert, 1903. THE writer of this essay has had considerable experience in treating cases of migraine by massage, and his results have induced him to place his methods before the profession. Although we cannot accept without reserve his theoretical explanations of the causes of this obstinate

malady, still the results which he has obtained compel attention to his method of treatment. To avoid misunderstanding of the classes of headache which have been cured, the author appends case-records and careful descriptions together with the outcome.

A SYSTEM OF CLINICAL MEDICINE, Dealing with the Diagnosis, Prognosis, and Treatment of Disease. For Students and Practitioners. By THOMAS D. SAVILL, M.D., London. Physician to the West End Hospital for Diseases of the Nervous System; Physician to St. John's Hospital for Diseases of the Skin, London; Formerly Medical Superintendent of the Paddington Infirmary; Medical Officer of the Paddington WorkHouse, and Post-Graduate Lecturer to the London Post-Graduate Association; Assistant Physician and Pathologist to the West London Hospital; Examiner in Medicine and Clinical Medicine in the University of Glasgow, and Medical Officer to the Royal Commission on Vaccination. Vol. I.: Local Diseases and Microbic Disorders. London: J. & A. Churchill, 7 Great Marlborough Street. Philadelphia: P. Blakiston's Son & Co., 1903.

THE first volume of this system, which will soon be completed by a second, approaches the subject of diagnosis by the way of symptomatology; in other words, the author means to help the student or the practitioner in his efforts to interpret the evidences of disordered health; and starting with some signs and symptoms, he may refer to this work and obtain valuable hints for further search. In addition to this index of symptoms a brief account of separate diseases, is added with their prognosis and treatment. We regret to notice, however, that no mention is made of the Brand bath in the treatment of typhoid fever, this being the accepted method in America, where a mortality of 10 per cent. in unselected hospital cases compares very favorably with the 15 to 20 per cent. which he quotes. However, the work accomplishes its purpose in being a friend in need when puzzling symptoms present themselves. It is a work quite unlike the usual textbook in teaching the reader to weigh his evidence for or against a certain diagnosis. Useful and practical charts and illustrations add to a text in itself well worth reading.

THE RÖNTGEN RAYS IN MEDICINE AND SURGERY. As an Aid in Diagnosis and as a Therapeutic Agent. By FRANCIS H. WILLIAMS, M.D. (Harv.), graduate of the Massachusetts Institute of Technology, Visiting Phycian to the Boston City Hospital, etc. With 428 illustrations. Third edition, with enlarged appendix. New York: The Macmil ian Company, 1903.

THE first edition was reviewed in these columns in 1901the second in 1902, and now it becomes our pleasure to look over a rewritten appendix in which is recorded 150 of the author's personal cases with a discussion of the therapeutic value of the Röntgen method. There are also twelve pages of bibliography, bringing the whole number of pages up to 757, or an addition of over 50 pages. To say that there has been advances made in the development of x-ray science is to put it mildlyboth in the fields of diagnosis and therapy, as well as in apparatus and technique, improvements are constantly being made, and, to keep pace with them, necessitates frequent reconsideration. Professor Williams continues to reflect in his added pages the great amount of personal work and research of which his first edition gave abundant evidence, although nearly the whole of the new matter relates to the way as a therapeutic agent. Still the subject is of such growing importance that one feels that still more could be written upon it. Little or no change has been made in the body of the work. UTERINE AND TUBAL GESTATION. BY SAMUEL WYLLIS BANDLER, M.D. New York: William Wood & Co.,

1903.

THE modern views concerning the processes antedating uterine gestation, the embedding of the ovum and the development of the embryo, are here presented in a clear and interesting manner, great prominence being given to the trophic influence of the ovary and the part played by its internal secretion in governing the development of the uterus, genitalia, and breasts, and in regulating menstruation. The origin of the syncitium is discussed at considerable length, and attention is called to the probability of the placenta being a gland possessed of great potentiality by reason of its secretion. The portion dealing with the etiology, histology, and usual course of ectopic gestation has already appeared in the American Journal of Obstetrics. The concluding chapter describes chorioma, perhaps better known under the name of deciduoma malignum. All of the subjects covered are admirably presented, and in this the author has been materially aided by the introduction of ninety-three illustrations.

Society Reports.

NEW YORK ACADEMY OF MEDICINE.

SECTION ON SURGERY.

Stated Meeting, Held May 11, 1903.

ROBERT T. MORRIS, M.D., CHAIRMAN.

A Consideration of General Anæsthesia, with a Presentation of Instruments.-Dr. FREDERIC GRIFFITH presented this paper. He said that anesthesia was produced by a direct action upon the cerebrospinal nerve centers. The indications for an anæsthetic were to relieve the pain of an operation or of childbirth; to overcome the general spasm of strychnine poisoning, traumatic tetanus, puerperal infection and uræmic convulsions; the muscular spasm in fractures and dislocations, and the passage of gallstones and renal calculi.

Selection. In selecting anæsthetic, the ether should be the one of choice when the administrator was inexperienced; also in atheroma and organic heart disease. As a rule, loud cardiac murmurs denoted power in the cardiac muscle, and were, therefore, of better omen than low murmurs, which pointed rather to poor compensation. Chloroform should be selected for brain and eye surgery upon persons having either lung or kidney disease. Nitrous oxide was useful as a preliminary to other general anæsthetics in cases of athercma or aneurysm, and when it was desired to restore motion in ankylosed joints. Bromide of ethyl was very prompt in its action, and did not depress the heart.

Administration. It should be remembered that no two individuals took an anesthetic alike, and that the skilful anesthetist was one who recognized this fact and acted accordingly. Ether might be more carelessly given than chloroform without ill effect. The anesthetist was often more important than the operator, and at all times the operator should keep him well informed as to the progress of his work. Twenty-four hours before the administration of an anesthetic the patient's bowels should be flushed out by giving calomel, one-fourth of a grain, every twenty minutes until two grains had been taken, and following this by a dose of Epsom salts. A high soap-and-water enema should be given on the morning of the day fixed for the operation. Of course, the patient's heart, lung, and urine should be carefully examined. At the time of the operation all superfluous garments should be removed, remembering, however, carefully to conserve the body heat by blanketing. Anything loose in the mouth should be removed, and note should be taken of the dental work. The patient's eyes should be protected by gauze or a towel, and, following the suggestion of Bodine, he should be instructed to listen to the anesthetist's voice and keep the hands tightly clasped. There should be no conversation or other noise in the room while giving the anæsthetic to induce narcosis. Besides the inhaler, the anesthetist should have a wooden screw, a mouthgag, tongue forceps, curved needle, swabs on sticks or forceps, and a sterile hypodermic syringe. When a hypodermic injection was required the application of tincture of iodine would sterilize the skin for the puncture. The speaker said that he personally made use of a single-ear stethoscope, placed over the precordium, in order to keep informed of the condition of the heart. Strychnine, morphine, and atropine should also be near at hand. The collection of mucus in the throat was not necessarily due to poor anæsthetization. Because of the complications liable to arise from psychical erotism it should be the rule never to anæsthetize a female when unattended. Vomiting in an early stage was often due to the use of too little ether, but later on was usually caused by giving too much ether. When the latter was the case, the ether should be stopped, the patient's head turned to one side, the tongue and jaw brought forward

and the mouth cleaned out. When using ether with the bag inhaler, the addition of fresh ether often caused vomiting; the remedy was to have a sufficient supply of ether. More ether was required in summer than in winter because of the greater evaporation.

Poisoning.-Poisoning due to idiosyncrasy was rare, and an overdose of ether was likewise rare. Lividity and pallor of the face, dark blood and a thready pulse indicated that the ether should be stopped, and the patient be given more air, or perhaps stimulated by the application of wet towels to the chest or by the use of artificial respiration, rubbing with ether, or the inhalation of ammonia or oxygen. For hypodermic use one should give of a grain of strychnine or of a grain to 1 of a grain of atropine sulphate. The author was of the opinion that nitrite of amyl was useless.

By

A New Inhaler.-Dr. GRIFFITH then presented his inhaler. This was designed to meet the demand for a single instrument for the safe combination of anæsthetics. It consisted of a metallic face piece which would not collapse during respiration, and which fitted closely to the patient's face by means of a pneumatic cushion. means of a single valve the gas was delivered in increasing proportions until, without a struggle or any sign of apparent discomfort, the patient was thoroughly anæsthetized in a period of time varying from thirty seconds to three minutes. A supply of fresh air was constantly admitted to the mixing chamber in any desired quantity by means of slide openings at the top of the receptacle for liquid. Although ether was commonly used in combination with nitrous oxide gas, chloroform could be just as readily employed. Should the supply of gas run short before the patient was completely anesthetized, re-breathing was provided for by the use of a stopcock fitted to the reservoir gas-bag.

Modification of Esmarch's Chloroform Dropper Aimed to Secure Reliable Dropping.-Dr. VICTOR C. PEDERSEN read this paper. He said that he wished to deal with chlorofrom narcosis without claiming any advantage of one anæsthetic over another, but rather the right use of all. Chloroform was the immediate cause of death in a great number of cases, but ether killed nearly as many by producing kidney disease or pneumonia. Chloroform and ether were classed with the stimulants and depressants, the action of one or the other depending upon the dosage. In administering chloroform several points had to be borne in mind. In the first place, a proper mask must be used, for in giving chloroform it was necessary to give it with 95 to 97 per cent. of air. For practical purposes any metal frame would answer, but it should be covered with from two to four thicknesses of gauze, the redundant edges of the latter being turned into the hollow of the mask. In the next place, a suitable chloroform dropper was very important. The ordinary Esmarch dropper acted well when the glass stopper was well ground, but when this was not the case two or more drops would flow out just when they should not. By having the opening at the mouth of the dropper at a right angle to the tube this excessive dropping would be prevented. The diameter of the chloroform tube should be so proportioned as to allow half air and half chloroform. Chloroform should be literally given drop by drop, and in case coughing occurred it should be stopped momentarily. The administration of chloroform should not be hurried, and at least five minutes should be taken to induce narcosis. No stertorous breathing should occur. The pulse should be from 75 to 80 per minute, compressible and slightly increased. If the pulse rate rose to go he would personally change from chloroform to ether. The condition of the capillary circulation constituted one of the most valuable indications as to the reaction of the nervous system, though the condition of the heart and the color of the blood were important. Feeble breathing was not always a sign of great danger. Pallor of the face and

Stated Meeting, Held May 18, 1903.

ALEXANDER LAMBERT, M.D., President. Carcinoma of the Rectum and Uterus.-Dr. FREDERICK HOLME WIGGIN presented several specimens. The first one had been removed from a woman, fifty years of age, who had ceased menstruating three years before. Three months before coming under observation the menstrual flow had apparently returned. The attending physician thought the mass projecting from the cervix was a polypus, and could not be a cancer because it was so soft. After operation the specimen was submitted to the pathologist, Dr. F. M. Jeffries, who reported that it was a peculiarly malignant type of carcinoma. The specimen was presented in order to emphasize the fact that the absence of induration did not necessarily exclude malignancy.

A New Nitrous Oxide and Ether Inhaler.-Dr. NATHAN W. GREEN presented this inhaler. He said there was a tendency at the present time to make use of the combination of nitrous oxide and ether, and with this inhaler the comfort of the patient was increased while the time of anesthetization was reduced. The apparatus was simple and compact, and could be held in one hand and worked with the fingers of the same hand. It consisted of a metallic cone with three valves on one side, one valve for the air, another for the nitrous oxide, and a third for the ether. These valves were arranged and operated after the manner of the stops of a cornet, and without any motion which would attract the patient's attention.

Dr. J. T. GWATHMEY exhibited another inhaler in which the upper chamber of the Bennett inhaler had been discarded, and that instrument further simplified.

Dr. MARTIN W. WARE, referring to ether pneumonia, so-called, said that at the last meeting of the British Association of Anesthetists the consensus of opinion was in favor of considering this an aspiration pneumonia. The fatalities from nitrous oxide gas had been more numerous during the last ten years than in the two decades and a half preceding. He had used nitrous oxide gas anesthesia in operations of minor surgery, and had given it five thousand times before witnessing a crisis or fatality; then, in connection with an operation for the incision of a bubo, the patient became cyanosed, but was rallied after stopping the gas. One reason nitrous oxide gas was not more generally used by the profession was the large quantity of the gas required, and the expensiveness of the inhaler. Dr. Ware said he had used ethyl chloride anæsthesia from 1,000 to 1,200 times, and it possessed certain advantages over nitrous oxide. The expense was not much below that of the latter, and it was not quite so safe, but the patient was more relaxed and never became cyanosed. A special mask was necessary for its administration. Its mortality was said to be one in twenty thousand. Ethyl chloride was superior to ethyl bromide because with the latter cyanosis was marked, and the mortality was greater.

Dr. PEDERSEN closed the discussion. He said that up to the present time he had not had any cases of ether pneumonia, and this good record he attributed to the fact that the ether mask was always boiled and the patient's mouth washed out with peroxide of hydrogen or some other antiseptic solution. This precaution seemed a proper one when bacteriologists told us of the frequent presence of pneumococci and other organisms in the mouth. He had only used ethyl chloride once, in a vigorous colored person, but as the patient became rigid and cyanotic, and presented a somewhat alarming condition, he had not felt inclined to give this agent a further trial.

The second specimen had been removed by operation from a woman who had been operated upon about six months previously for a scirrhus of the breast. She died shortly after operation with evidences of acute suppression of the urine. The pathologist reported the tumor to be a carcinoma invading the body of the uterus.

The third specimen was a carcinoma of the rectum involving the posterior vaginal wall and the vulva, and more than one-half of the labium majus on each side. The disease was removed by operation with a very satisfactory result.

Sarcoma of the Neck.-The next specimen was a large mixed-cell sarcoma of the neck. At the operation it was found that the external carotid artery was involved in the growth, but after ligating the common carotid it was comparatively easy to extirpate it. The operation had been done a week before, and in spite of the apparently desperate nature of the case at the time of the operation the patient was doing well. When the patient had sufficiently recovered he would be advised to submit to a course of x-ray treatment.

Large Mass of Varicose Veins.—The last specimen presented was a very large mass of varicose veins, which had extended from the ankle to above the knee, and which had been successfully removed by operation.

Etiology, Serum Diagnosis, and Serumtherapy of Dysentery. Dr. W. H. PARK presented this paper. The speaker said that for many years amœbæ had been found in the stools of tropical and chronic dysenteries, and these stools produced in animals symptoms resembling those of dysentery. It was almost certain that tropical dysentery and some of the dysentery occurring here in temperate regions were partly at least dependent upon the presence of these amœbæ. Until the work of Shiga very little had been added to our knowledge of this disease. Some observers were of the opinion that many forms of dysentery were due to colon bacilli of special virulence, and this seemed to be perfectly possible. In 1897 and 1898 Shiga, working in Kitasato's laboratory, thought he would not only examine the stools but would apply a serum test. He found in practically every case examined a bacillus, which up to that time had not been clearly defined. These bacilli for practical purposes might be considered as belonging to the colon group, although they differed in certain important particulars. These bacilli were found from the first days of the disease up to convalescence in all of the acute cases, and they were not present in the normal stools of children and adults except here and there in localities in which an epidemic was raging, and then just prior to the onset of the disease in these individuals. Subsequently a number of investigators went from the Johns Hopkins University to Manila to study dysentery. They found that although in a great number of the worst cases the ambæ appeared to be the cause, there were many other cases of acute dysentery, and some of subacute or chronic dysentery in which no amoeba were found They then examined for the Shiga bacillus, and thought they found this bacillus in many of the cases in