Indeed, Kocher urges against operation when the goitre heart is fully developed.

Early excision is strongly urged in cancer, since a diagnosis cannot be postulated at the time it is most serviceable to the patient. The practice should be followed of operating at once on every rapidly growing goitre; thus these cases may be taken at the only time there is any prospect of ultimate cure.

It should not be forgotten that even after partial strumectomy, hypothyeosis may develop.

It is somewhat surprising in the light of Kocher's repeated publications upon his results in goitre, and results almost as favorable, though based on a smaller experience, reported by a score of others, that the extirpation of goitre should be regarded by the profession at large as an especially dangerous operation. In simple cases it is, in the hands of a practical surgeon, completed with a risk of life no greater than that, for instance, which now attends the operation of appendectomy. If simple cases were operated upon early it is certain that malignant cases would disappear, and probably that many instances of Basedow's disease. would be prevented. The almost uniform failure of medical treatment, and the fact that injections make the operation difficult and are often followed by sinuses, should cause goitre to be referred to the surgeon before they have attained such large size as to make their removal difficult, or have produced pressure symptoms or a toxemia so severe as to profoundly alter the vitality of the heart muscle.-Therapeutic Gazette.

APPENDICITIS, EARLY DIAGNOSIS OF SEVERE.

In every case of appendicitis, differentiation should be made between simple appendicitis and destructive appendicitis. The most positive manifestation of destructive appendicitis is painful abdominal rigidity. This demands immediate operation. When this sign is completely absent and no other manifestations are present which awaken anxiety, it may be assumed that simple appendicitis is present. A pulse-rate increased to 100 or above is a sure indication of destructive appendicitis, demanding opera

tion. A low pulse-rate, however, does not necessarily indicate a mild form of disease. Repeated attacks of vomiting and severe pain, which persists in spite of the use of the ice-bag, indicates a severe form of appendicitis. Temperature is of no material importance in determining the severity of the attack. The increased frequency of respiration and the presence of costal breathing are always unfavorable symptoms. The presence of one positively unfavorable manifestation is to be considered of more importance than is the occurrence of several favorable ones. A diagnosis of destructive appendicitis having been made, operation should be performed within two hours.-Krecke (Munchener medizinische Wochenschrift, Nu. 15, 1906; New York State Journal of Medicine, July, 1906).

DRAINAGE OF THE INTESTINES IN ACUTE OBSTRUCTION.

Moynihan, in the Archives International de Chirurgie, Vol. III, Fascicule No. 1, says "it has long been recognized that the relief in cases of acute intestinal obstruction does not depend alone upon the setting free of an ensnared loop, the liberation of a strangled coil, or the unraveling of a twisted bowel, but equally, at least, in the evacuation of the engorged intestine, in the emptying from the gut above the obstructed point of the retained contents."

The mere release of the bowel from the entanglement is but a part of, and not always the most important part of the operation. An operation may be successfully completed apparently and yet the patient may die rapidly from toxæmia, due to the absorption of matter retained behind the block. Sir Frederick Treves rendered a great service by insisting upon the emptying of the intestine when released from its obstruction. Thereby the mortality from intestinal obstruction was lowered fifty per cent.

While it is generally recognized that the intestines should be emptied, all methods have involved the serious risk of contamination by escaping feces, and they are, too, open to the objection that they only empty a few feet of the gut.

Moynihan describes a method of his own, which he finds sim

ple, efficient and safe. It consists in emptying the bowel through a glass tube, eight or nine inches in length, which is passed upward within its lumen, the bowel being then drawn on to the tube gradually until six or seven feet are threaded.

The obstruction having been released, a loop of the bowel about a foot above the obstruction is drawn out on to the surface of the abdomen on a hot moist swab. A clamp is then put on at the lower end of the loop, the bowel is then milked for a distance above and another clamp put on, a three-quarter-inch incision is now made in this segment of emptied bowel along a line opposite the mesenteric attachment. Into this the glass tube (of special pattern) is inserted and pushed upward until the upper clamp is reached. The tube may now be fastened securely by drawing an elastic tube through the mesentery and tying it around the bowel. The upper clamp being removed the tube is pushed gently upward into the bowel as far as it will go. The bowel where the tube enters is surrounded with gauze and held firmly by the surgeon, while the bowel above is pulled over the tube until some six or seven feet of gut are pleated on the tube. A rubber tube connected with the glass tube conducts the intestinal contents safely away from the addomen. The bowel being emptied is pulled from the tube, wiped off gently and replaced within the abdomen. As the glass tube is about to be withdrawn from the opening in the bowel a clamp is put on above, the wound in the bowel is washed and sutured, the lower clamp removed and the abdomen closed.

The advantages of the method are apparent and it is well worthy of trial in all cases of intestinal obstruction where there is as much distention. The tubes are made in three sizes, 2, 34 and 1 inch in diameter, and 91⁄2 inches in length.-New Orleans Medical and Surgical Journal.

ADRENALIN IN MALIGNANT DISEASES.

Dr. J. E. Rhodes, of Chicago (Journal A. M. A., August 11, 1906), reports the case of a patient suffering with inoperable sarcoma of the nasopharynx, treated by injections of adrenalin

into the growth (from 1.5 to 5 milligrammes at each injection), together with local application by swabbing or spraying. The results were marked reduction of size of the tumor and temporary alleviation of pain, but the patient continued to fail and died in less than two months from the beginning of the treatment. While the effect of the treatment was only encouraging in this case, Rhodes thinks that it should be given a trial in other cases. Mahu's favorable experience is noted and the history of a case successfully treated by Berdier and Falabert is reproduced. Rhodes believes, however, that caution should be exercised in the use of the method. He believes that it merits trial, especially in cases of carcinomata and sarcomata of the nose and throat, in which an unfavorable prognosis is almost invariable, and that the earlier it can be resorted to the better. He thinks it safe to assert that it has at least a palliative effect and may replace morphine as an analgesic in these cases, though, as yet, evidence of its curative value is lacking. In operable cases, however, in which delay is dangerous, a resort to surgery should still be the rule.St Louis Medical Review.

MEDICAL

RECTAL IRRIGATION IN ENTERO-COLITIS OF CHILDREN.

BY CLARENCE G. CLARK, M.D., NEW YORK CITY.

When we consider that nearly one-half of all the children born die before reaching the age of one year and that by far the greater portion of these die from some form of intestinal indigestion, we realize what an immense field there is for the improvement of our technique in the treatment of these affections. Our infantile. mortality could undoubtedly be greatly decreased could all cases be seen and treated actively from the outset. Although a great many are cases of a violent character from the very outset, still there is a certain proportion of a more or less chronic nature, and it is this class of cases which greatly tax the ingenuity and patience of the physician. No medication by the mouth seems efficient to stop the progressive wasting. As soon as food is taken it is passed out without the child absorbing any of it. It is of one of these cases that I wish to present to the medical profession a report, hoping that the methods adopted will be found successful in other cases of a similar nature.

Baby D., age four months. History: Child was nursed by mother for one and a half months, but as her milk was of poor quality and the child did not thrive, she was advised by her attending physician to stop the breast and substitute bottle. This she did, feeding the child on a mixture of milk, cream, milk sugar and barley water in a 3-6-1 proportion. The baby thrived on this for about two months, but early in July it developed a diarrhoea. The mother gave it home remedies, but still continued the milk, feeding it even more frequently than before, as the child was fretful and apparently hungry. The stools averaged 7-8 a day and occasionally the child would vomit. This continued for two weeks when the mother became worried at the progressive emaciation and decided to call a physician. I first saw the case on July 16.

Examination: Baby extremely emaciated, lies on cot without