the statements made to you by Dr. Vance, a gentleman who is an authority on the subject of trusses. Every other speaker has indicated his want of confidence in the use of them, and a great many believe that statistics can be adduced to prove that trusses are of no value and that relief is not obtained; yet here is an authority who declares to you that he has succeeded in a number of instances, not only in children but in adults, in accomplishing a radical cure. It is merely an illustration of the fact that in the opinion of certain individuals certain measures accomplish satisfactory results which in the hands of other individuals utterly fail of any thing like success. This subject is too important for theory to guide us instead of practice, and this theory, based largely upon statistics, leads us I think into errors oftentimes. It is the experience of nearly every surgeon with whom I am acquainted, not only in Louisville but in other cities, that the term uninterrupted recovery means a different thing from an absolutely uneventful convalescence. It has been my experience in operations, both for strangulated hernia and in conditions in which the bowel was not strangulated, to have more or less trouble in the recovery of the patient. Even though I might think he had a practically uninterrupted recovery, still septic infection of not only the wound but of the mesentery occurs in the hands of the ablest surgeons. Within the last few months a paper has been written by Dr. Bull, of New York City, in which he reports a number of instances of infection of the omentum by the ligature. I have had two surgeons in Louisville tell me that the same accident has happened to them. All of these patients are regarded as having got well from the operation, but in many instances they have been subjected to a long and painful convalescence, with more or less localized peritonitis, with perhaps a discharge of pus. If we recommend to them without hesitation an operation for the radical cure, based upon the statistics that have been presented to you by the essayist, and the patients have only accepted the operation because of the rosy color we put upon it, and then an unfortunate result follows, or a tedious recovery obtains, we are very likely not only to get some reproach from the patient and family, but to feel that we ourselves have done unjustifiable damage. Therefore I would suggest, in the consideration of this subject, that we look at it from a practical rather than a theoretical standpoint, and the prognosis. should be looked upon as depending upon a considerable variety of conditions, and we should not be satisfied with any thing short of actual recovery. It occurs to me that there are certain conditions in which the operation for radical cure is to be done without hesitation. In some cases of strangulated hernia the patient is not in a condition to submit to any thing like a prolonged operation. Occasionally, after strangulated hernia, the patient is usually so depressed constitutionally as to render it unwise to subject him to long operative measures. But where he can bear it the operation should be done. In case of irreducible hernia the patient is subjected to the dangers of strangulation, which is infinitely more grave.

than the operation itself. An operation in these cases should only be done when the patient applies for it, or after the risks and dangers have been laid before him and he accepts and even insists upon it's being done. Those persons who are comfortable in wearing a truss, who have had no difficulty with it, who have not subjected themselves to an expert to cure them without an operation, should not be encouraged to undergo an operation unless there is some special reason for it, as going on a long journey, or their avocation is such as to expose them to risk. Aside from this I question whether it is just to recommend to the profession or laity that this operation should be done without careful consideration of all of its risks.

With respect to the transplantation of the testicle, it appears to me that the statements made by Dr. Dugan, who is in every respect competent to express an opinion upon both the anatomical and surgical parts of the subject, are not safe ones at the present day to recommend to the general public. Oftentimes an individual subjected to treatment of this kind, who perhaps safely and comfortably recovers, would reproach his surgeon, and in many instances the patient might suffer from serious depression because of the changed condition in his anatomy. It is occasionally necessary, it is perhaps often expedient; but in any thing like general practice it occurs to me it would be exceedingly unwise. It is only these two or three points that occurred to me as being worth while to present my views upon, as I have always looked upon conservative surgery as being simply a question for the welfare of the individual, but it should never be so limited as to interfere with the radical nature of an operation that is demanded by the condition. The surgeon should never be so rash as to rush boldly into an operation for the sake of doing it or of obtaining the reward that results from it.

Dr. Rodman (closing the discussion): Dr. Dugan has answered the first question asked by Dr. Foster, as to when to apply trusses after operation. I will say Dr. Kelly and most operators who are doing a great deal of work in this line do not use trusses at all after operation. I think myself that it is not a bad plan to use a light form of truss in the case of a man who has a good deal of heavy work to do. A good deal will depend upon the length of time the patient is kept in bed. Some are kept there for two weeks and use trusses after this; others are kept there six weeks. There is a difference of opinion on this question, but in general the tendency is to do away with trusses after the operation.

As to the radical cure for femoral hernia, while a great many operations have been done it has not been shown that they really improve the chances for radical cure. High ligation of the sac, then doing as I emphasized in my paper, was referred to by Dr. Dugan, and I will say it is my custom not only to ligate as high up as possible, but to even twist the sac. In that way we avoid the infundibulum in the internal ring.

Dr. Davis spoke of the use of silk-worm gut as a substitute for kangaroo tendon. Bassini uses silk altogether; he never uses tendon. The

use of the latter seems to be largely an American practice. In the country tendon can not be had.

Dr. Cowan has seen some of Halsted's old statistics. Only last week, in a discussion in New York at the meeting of the American Surgical Association, he was speaking on the subject of hernia. He reported 180 cases with 3 relapses, which would be 1.6 per cent. That was the most recent expression from him. As Dr. Dugan has said, Dr. Kelly has decided that question to the satisfaction of all, namely, that 85 per cent of all cases which recover do so within a year. If a patient passes a year the chances are he will remain cured, though some of course do remarkably well for five, ten, or twenty-five years. Dr. Cowan spoke of the great number of relapses following the radical cure operation. I took the position in my paper that we should follow our work for the last four or five years. It is well known that there were fifty per cent of recurrences following McBurney's operation, and it has been abandoned not only by operators in general but by McBurney himself. McBurney admitted in the discussion that the operation was not a good one, and he preferred Halsted's method to any other. Bull, who was pessimistic in 1890, is now optimistic, and is doing to-day more herniotomies than any man in America. I saw him (while I was in New York) do two herniotomies.

Dr. Dugan misunderstood me in regard to the number of children not cured. I said one third were uncured by trusses. Dr. Vance has treated that subject in a fair and scientific way, and his remarks are borne out by statistics. Macready has written a magnificent work on the subject of hernia; his results are drawn from the largest hernia clinic in the world, the London Truss Society. Children under one to two years of age are practically cured by trusses, but taking all children under ten years of age and 33 per cent remain uncured by mechanical means. If you can get the little children early, with intelligent mothers to watch the little fellows all the time, you will cure the vast majority of cases of inguinal hernia. Macready speaks pessimistically of femoral hernias, because practically none of them get well. I would like Dr. Vance to have spoken on this subject.

I am very glad to state here that Dr. Dugan practically advocated the same operation that goes by the name of Dawbarn in the Louisville Surgical Society. I am inclined to believe that it is to be the operation of the future, because when we know we can get rid of the testicle and cord as factors, we are certainly more likely to get better results. The older operators of the seventeenth century had the best results in operating for the radical cure of hernia, but they did it by castrating the patient, and performed the operation to such an extent that it was positively forbidden.

Abstracts and Selections.

RENAL DISEASE AND GENERAL PARALYSIS OF THE INSANE. In the last number of the Journal of Mental Science Dr. Hubert C. Bristowe recalls attention to a subject to which he has recently devoted considerable study. In a former paper he alluded to the high percentage of patients dying of general paralysis of the insane, who showed signs of chronic changes in the kidney. On considering the possible connection between the clinical condition of general paralysis and the changes found postmortem in the kidneys, the condition of the arteries seemed to furnish a connecting link. At all events, as was pointed out, a diseased condition of the cerebral arteries occurred in those dying of granular kidneys very similar to if not identical with what is found in those dying of general paralysis of the insane. In the present paper an attempt is made to supply the deficiencies in the first. Reference is first made to the statistics of Mr. Beadles and Dr. Bond. The former found that in 2,610 cases of insanity there were 1,128 cases of chronic renal disease, or 43.21 per cent. Dr. Bond, out of 154 cases, found 74 cases of renal disease, or 48 per cent. Dr. Bristowe's numbers are 532 necropsies, 327 cases of chronic renal disease, or 61.466 per cent. The exclusion of patients over sixty, in whom some chronic fibroid changes in the kidney might be present without much significance, reduces the percentage to 52.9, a reduction of 8 per cent. Excluding also general paralytics, a further reduction by 12 per cent is effected; and after making certain allowances Dr. Bristowe makes his percentage of chronic renal disease among the insane, excluding general paralytics, 44 per cent. Among general paralytics he finds the percentage of chronic renal disease to be 72.11, a sufficiently striking difference. Dr. Bristowe next takes the statistics of the Dorchester, Bristol, and Gloucester asylums with reference to renal changes in general paralysis. At Dorchester the total percentage of diseased kidneys in general paralysis was 71.875, at Bristol 54 per cent, and at Gloucester 74.157. To account for the differences several factors have to be taken account of, and not the least important is the personal factor of the observer. Dr. Bristowe now takes his own figures together with Mr. Beadles' and Dr. Bond's, a total of 3,446 cases of insanity. Of these patients 48.867 had renal disease. Reckoning 12 per cent of these as general paralytics and 4 per cent as over sixty, there is a percentage of renal disease among the insane under sixty, excluding general paralytics, of 32. Taking, on the other hand, the statistics of the Somerset, Gloucester, Dorchester, and Bristol asylums as regards general paralysis and renal disease, there are 266 cases, and of these 183, or about 68.8 per cent, had renal changes. As Dr. Bristowe remarks, from the statistics it seems justifiable

to conclude that in general paralysis renal changes are much more common than in other forms of insanity; that, in fact, they are usually found. Dr. Bristowe briefly considers the question of the cause of these changes, and is of opinion that they depend upon some toxic condition in the blood, possibly alcohol, possibly syphilis, perhaps both; and in concluding his paper asserts that he is still able to maintain, after a wider examination of material, that renal disease of some form is exceedingly common in general paralysis. At the same time, he remarks, it is not clear that the form of renal disease is always interstitial nephritis, and he inclines to the view of Gull and Sutton that there is such a disease as arterio-capillary fibrosis, in which the kidneys are commonly affected. Dr. Bristowe would also suggest that disease of the brain-that disease which manifests itself clinically as general paralysis of the insane-is under some circumstances another result. The Lancet.

ACUTE INFECTIOUS DISEASE WITH INTESTINAL LESIONS.-At a recent meeting of the New York Pathological Society Dr. James Ewing presented specimens. The patient was a plumber, seventeen years of age, who was admitted to the Roosevelt Hospital on February 7, 1895. He had a family history of phthisis. The present illness had begun on February 1st with general pains, moderate fever, and considerable prostration. On the second day there was abdominal pain, which was at first diffused, and he had three diarrheal movements and repeated vomiting. On the third day he developed a petechial eruption, most marked on the limbs. Following an enema he had a large, dark stool, and the next day, after a purge, a stool containing mucus and blood. Up to this time the case had been considered one of appendicitis. On February 12th the abdominal pain became much worse, and on the following day a new crop of petechial spots appeared on the exposed parts of the upper limbs. At the time of his admission to the hospital the urine had a specific gravity of 1.028, was acid in reaction, and was free from albumin. On February 16th its specific gravity was 1.013, the reaction was neutral, and there was a small quantity of albumin present. On February 18th the specific gravity was 1.015, and the urine contained thirty per cent of albumin. On February 20th the specific gravity was 1.022, there was sixty per cent of albumin, and some hyaline and epithelial casts. On February 23d there was sixty-five per cent of albumin, and a specific gravity of 1.025. His temperature rose to 104.6°, the pulse to 150, and the respirations to 42, and it was evident that there was a double pneumonia and a beginning peritonitis. On the next day the specific gravity of the urine was 1.017, and it contained seventy per cent of albumin and five per cent of sugar, with some waxy casts. He died on February 27, 1895.

The history, then, was that of an acute infectious disease of mild onset, with symptoms of moderately acute enteritis, associated with a petechial eruption, occurring in two distinct crops. Death was due to the pneumonia and the peritonitis. The autopsy showed pneumonia in both lower