Cases. Hypertrophie prostatique fausse route a la partie anterieure du canal infiltration urineuse pyleonephrite degenerescenco calcaire du trefle aponevrotique du diaphragme. Bull. soc. anzt. de Nantes, 1879, Paris, 1880, 12-14.

Macleoid, G. H. B. Hypertrophy of the Prostate Gland and its Treatment. Glasgow Med. Journal, 1880, xiv, 1-14.

Guelliott, O. Hypertrophie de la prostate, valvule vesicale et replis semilunaries de la muqueuse urethrale fausses routes ponction de la vessie. Bull. soc. anat., Paris, 1880, iv, 130–132.

Boursier. A. Hypertrophie de la prostate infection urineuse. Jour. de med. de Bordeaux, 1880-81, x, 346.

Clark, A. A. A Case of Prostatitis Accompanied by the Discharge of Hyaline Casts. Tr. Clin. Soc., London, 1880, xix, 95-98.

Gross, S. W. Chronic Catarrh of the Prostate Gland: A Clinical Lecture. Med. Gaz., New York. 1880, vii, 665.

Castelo. Prostato cistitis. Ann. acad. de med., Madrid, 1880, ii, 1893-198.

Foot. Myoma of the Prostate Gland-Pyelonephritis Parasitica (Klebs). Dublin Journal Medical Science, 1880, lxx, 67.

Campenon et Julien. Prostate. N. dict. de med. et chir., prat., Paris, 1880, xxix, 583-766.

Coulson, W. On Disease of the Bladder and Prostate Gland. Second edition, London, 1840; same, London, 1852; same, sixth edition, London, 1857; same, sixth edition, New York, 1881.

Ueber acute eitrige prostatitis. Ibid., 1881, N. F. i, 129–146.

Tefft, J. E. A Clinical Lecture on Senile Hypertrophy of the Prostate. St. Louis Med. and Surg. Journal, 1881, xl, 650 656.

Furbringer, P. Ueber spermatorrhea und

prostatotorrhea. In Sammlklin, vortr., Lpz.,

1881, No. (Inn. med.), No. 69, 1835-1860.

Guiard, F. P. Hypertrophie de la prostate saillie du lobe moyen retention d'urine cellule vesicale cystite purelente nephrite. Bull. soc. anat., Paris, 1881, lvi, 268 271.

Vance, R. A. The Hygiene of Old Age, with Special Reference to Prostatic Hypertrophy and Secondary Disease of the Bladder. Med. and Surg. Reporter, Philadelphia, 1881, xliv, 424427.

Casi (di un) di ematuria da ipertrofia prostatica con atonia vesicale sua cura proposta di una sciringa a curva variabile ed apertura terminale e di un mezzo per tenere il catetere a permanenza aperto di contimio. Medicina e la chir., Roma, 1881-2, iii, 90–93.

Werner. Verlegung des orificium intermum polypose wucherung. Ztschr. f. wundarzte u. geburtsh., Winnenden, 1882, xxxiii, 155 159.

Prentiss, D. W. Case of Double Hydenoprhosis with Dilatation of the Bladder and Ureters, Due to Disease of the Prostate Gland. Maryland Med. Journal, Baltimore, 1832-3, ix, 588-591.

Lowy, L. Prostatitis gonorrheica. Wien. med. presse, 1882, xxiii, 1166, 1198.

Black, D. C. Remarks on

Lancet, London, 1882, ii, 617.

Prostatorrhea.

Society Proceedings.

THE ACADEMY OF MEDICINE OF CINCINNATI.

Meeting of December 22, 1902. THE PRESIDENT, A. B. ISHAM, M.D., IN THE CHAIR.

STEPHEN E. CONE, M.D., SECRETARY.

Tracheotomy Tube Retained Three Years and Four Months.

DR. JOHN A. THOMPSON: The early history of this case I shall give in the words of the original operator, Dr. J. M. Leslie, of Chillicothe.

"You ask me for the early history of the case; it was dramatic in the extreme. Dr. J. W. Lash had charge of the case and sent for us to operate in the night, April 8, 1899. It was a drive of about five miles in the country. When about half-way we were run into by a drunken driver and our buggy broken. This not only delayed us, but got us into a nervous condition not to be desired.

"On reaching our destination we found our little patient (then nineteen months old) suffering desperately from dyspnea, cyanosed and tossing. He had been sick for several days with diphtheritic croup. A table had been prepared for us by placing a lap-board on the top of a small square table. As there was no time to lose, the child was placed on this at once and the operation begun, Dr. E. J. Galbraith giving the chloroform. Antiseptic precautions, so far as possible, were observed. As usual in these cases, the veins were very much congested and hemorrhage free. The windpipe was reached and opened with difficulty. Just as my knife. passed through the cartilaginous rings the lapboard tilted and the child went head foremost between the chloroformer's knees and on to the floor. My instruments, which were on the table by the side of the patient, rattled about our feet; the lightholder turned his back to the fray and kept the light steadily in front of him; everything was confusion, and pandemonium reigned. When the table was again righted, the instruments collected and the light turned on, life was almost extinct. My cut in the trachea could not be found and I was compelled to make another

through which the tube was at length inserted. Some help was necessary to start the breathing, but the vigorous use of a feather instituted coughing, which cleared out the trachea. Respiration became regular, and we ourselves breathed. The dyspnea gradually lessened, the cyanosis passed off and the child slept. The feather had to be used and the inner tube cleaned quite often at first, and I felt that my be was too small. About four hours after the operation the tube slipped from the trachea and dyspnea was profound. at once inserted a larger and longer one and we had no further trouble from that source. From this time on the progress was not eventful, except that he could not breathe without the tube.

I

"I never before in tracheotomy cases for croup had to keep the tube in for more than ten days, usually about seven. thought in little Herman's case I had a case of paralysis of the vocal cords, and still think that was the case at first. I thought al-o the two cuts in the windpipe might have formed a flap, which, when the tube was inserted, made a valve. This idea was dispelled when he breathed without the tube for an entire half day. It is probable that granulation tissue played a very prominent part in the difficulty."

Dr. Leslie further said in his letter to me that in the first few months following the operation the tracheotomy-tube was frequently removed, but always had to be re-inserted in a very short time. In the fall of 1901 the child breathed without the tube for a half-day, but became cyanosed when put to bed and the tube had to be hurriedly inserted. Dr. Leslie occasionally removed granulation tissue from the track of the tube, but made no radical operation.

When I examined the boy at my office, August 17, 1902, little could be seen but a mass of exuberant granulations around the tracheotomy wound in the neck. From these gratulations, which were covered by a very offensive pus, protruded the end of a tracheotomy-tube. An attempt to examine the larynx was not satisfactory, as the child fought vigorously. I noticed that when the father removed the tube a number of granulations came with it, and that the child could breathe fairly well for a short time without the tube in position.

Operation was advised and was made.

August 19, at Christ Hospital, under chloroform anesthesia. I first dissected away the scar tissue around the wound so as to have a better chance for the union of the skin. Then with a sharp curette I scraped away a large amount of granulation tissue around all of the margins of the wound. These granulations extended down fully two inches on the anterior wall of the trachea, and were especially abundant at the point where the end of the tracheotomy tube touched the anterior wall. Bleeding was very free, and the constant coughing from the irritation of the instruments in the trachea made the operative work very difficult. Inspiration of this blood and consequent pneumonia were avoided by keeping the head and shoulders much lower than the other portions of the body. It was hard to maintain complete anesthesia, as the patient was getting air through both the normal passages and the old wound. The skin had grown down between the cut ends of the cricoid cartilage and this was dissected out, after the removal of the granulations, in the hope that it might be possible to get union of the cartilage. I put an intubation-tube into the larynx. It was not possible to introduce the fullsized tube, and the smaller one was promptly coughed out as soon as the child. began to recover from the chloroform. The exterior wound was not sutured, as we feared it might be necessary to re-open it in an emergency. It was covered with gauze and a bandage loosely applied.

The recovery from the anesthetic was uneventful. The child had two attacks of dyspnea in the next twelve hours from the accumulation of mucus and clotted blood in the trachea. This dyspnea was spontaneously relieved by coughing up the accumulated matter. The temperature rose to 102° the afternoon of the day on which he was operated. The next morning it was 100°, and never went above that point again. Convalescence was uneventful. The wound in the mucous membrane of the trachea closed the fifth day, and the skin wound the eighth day following the operation. operation. The patient left the hospital for his home on the tenth day, and so far there has been no recurrence of any trouble.

An examination of the larynx after the operation shows it to be small but perfecly formed. There is no notable impairment of the voice.

Report of a Case of Incarceration of the Vermiform Appendix in the Right Femoral Ring.

DR. RUFUS B. HALL: On October 3 I was asked to see Mrs. J., aged sixty years, in consultation with her physician, Dr. Joseph Eichberg. The patient was suffering from an irreducible right femoral hernia. She gave a history of having had a hernia for a year or more, but it could be easily reduced. It was reduced a week or ten days prior to this visit. She was directed to have a truss fitted and wear it. The truss was adjusted and she wore it a day or two, and then complained of its hurting her and laid it aside. The hernia gradually increased in size and became more painful and inflamed. At the time of my visit it was about the size of a hen's egg and was tense, smooth and elastic. It could not be reduced. The symptoms were such as to justify the belief that the contents of the hernial sac were acutely inflamed and the safest advice was immediate operation. The patient did not have intestinal obstruction, but the abdomen was distended with gas and she complained of frequent attacks of nausea.

She was prepared for operation and it was made on October 5. On exposing the sac it was found to contain about two or three ounces of straw-colored fluid. The sac contained nothing except the fluid and the point of the vermiform appendix, which protroded into the sac about threequarters of an inch. It was very markedly congested, a very dark red, and was firmly agglutinated to the hernial canal. The adhesions were broken up and the entire appendix was drawn throuuh the canal and removed. The stump was treated in the usual manner and the bowel reduced into the abdomen. The hernial canal was closed after the manner of Bassini and the wound closed tightly. The patient made an uninterrupted recovery.

I present the specimen here, with hernial sac. It is unusual to have a hernia of the appendix, and very unusal to have, only this in the hernial sac. It is probable that at the time the truss was adjusted the appendix was in the canal and the pressure caused its inflammation and agglutination in its new location. She really had appendicitis in the hernial sac. Report of a Case of Catarrhal Appendicitis. Miss S., aged nineteen, was operated

October 10, two months after her second attack of appendicitis, both attacks being quite severe. The first attack was six months before the second one. She was attended in both attacks by her physician, Dr. Solar, of this city. The appendix was agglutinated and obstructed near the colon. It did not contain a foreign body, but was distended with mucus. She made an uninterrupted recovery.

Appendicitis.

The third specimen is one of unusual interest, from Mr. S., aged thirty, of Richmond, Ind., a patient of Drs. Bulla and Kinsey. He was operated on at the Presbyterian Hospital, November 19. In the past six months he had suffered three attacks of appencicitis, the last one about four weeks previous to the operation. He was not alarmingly ill at any attack, and when he came for an examination on November 14 he did not consider himself sick enough to justify an operation. I advised an operation and he entered the hospital three days later for that purpose. There was pain on pressure over the region of the appendix and a small lump could be outlined. The operation revealed the appendix adherent and the omentum adherent over the head of the colon. This was liberated. The appendix was wound around the head of the colon something like the letter "U." and in this elbow was a small lump about as large as a black walnut and covered over with exudation. The parts were well walled off with gauze, for I suspected that this lump was a pocket of pus. This proved to be true. It contained about a half an ounce of thick, foul-smelling pus. This was removed and the parts thoroughly cleansed. The appennix was then removed and the wound closed without drainage. The patient made an uninterrupted recovery.

This case is interesting, as it illustrates what we may have present in these recurrent attacks of appendicitis, yet the symptoms did not justify our saying that there was pus present at this time. It is probable that the pus in this case was developed in his last attack. Rupture of this abscess would have caused general septic peritonitis, or would have necessitated an operation in the midst of the same, with all of its attendant dangers, as the following case illustrates:

On December 16 I was called to Ripley, Ohio, by Dr. Prine, to see a man who had been sick ten days in his third attack of appendicitis. He had general septic peritonitis, with an enormously distended abdomen and high temperature. He was perspiring freely at the time of my visit. He was bronze in color and was suffering from sepsis. An immediate operation was proposed and made. No dullness was present on percussion over the region of the appendix.

The abdomen was opened close to the anterior superior spine of the ileum and a coil of bowel at once protruded through the wound. This was returned into the abdomen. The finger was then introduced and a mass the size of the closed hand could be felt which corresponded to the head of the colon. The intestines were walled off with gauze and the head of the colon liberated for half an inch. About two or three ounces of foul-smelling pus was evacuated. There was no attempt made to remove the appendix and a rubber drainage tube was placed. To my surprise, the man is convalescing. Nothing promised relief in this case except an operation, and that very little. The first two attacks of appendicitis were so light that there was some doubt as to the diagnosis until the last attack came on.

Two Cases of Ectopic Gestation. DR. MAGNUS A. TATE: Mrs. R., aged thirty-one, Ripley, Ohio, referred to me by Dr. Dunlap. Came to Cincinnati to be operated upon for a supposed pelvic abscess, and gave the following history:

Three years ago gave birth to a child, and since that time has not been healthy. Eighteen months ago had a miscarriage at the third month, and has been bedridden most of the time since, and for the last three months has had pain throughout the entire pelvic region, especially marked upon defecation and urination.

Patient could hardly walk when brought to the office. Upon questioning her, I found that every evening she had fever, chills, and a fast pulse. Upon examination the posterior vaginal wall was bulging forward and out as large as a fetal head, semi-fluctuant, and filled up the whole of the vaginal canal. Upon rectal examination (which was very painful), as high up as the finger could reach, this semifluctuant mass was felt. Patient was re

moved to St. Mary's Hospital for operation. I fully concurred with the diagnosis as given by her family physician, that she was suffering from a pelvic ab

scess.

Operation. Upon making a transverse incision of Douglass' cul-de-sac, instead of getting pus, thick clotted blood welled out of opening, and I was dealing with an ectopic pregnancy instead of a pelvic abscess. Recovery was uninterrupted, and in six weeks patient left for home.

CASE II. Mrs. M., aged thirty-eight, mother of six children, last born ten years ago. She entered St. Mary's Hospital complaining of constant pain in lower right side, with a history of pain in that region for some years, and also a swelling in right ovarian region, gradually becoming larger the last six months. About two months before entering the hospital she fell and struck her right side, and since then pain has been very marked, and the swelling has increased in size, but not rapidly. Temperature 99°, pulse 90. Upon examining the abdomen a swelling was seen in the right lower region, and upon bimanual examination a distinct tumor the size of a cocoanut was felt in the lumbar region, the uterus pushed over to the left side and slightly enlarged. A positive diagnosis as to the nature of mass was not made.

Operation.-Upon opening the abdominal cavity the whole field was immediately filled with thick clotted blood. At least a quart and a half was taken from abdomen, and from the ruptured tube a large handful was removed and the tube ligated. Abdominal cavity_flushed out with hot saline solution. Cavity closed without drainage, and patient made an uninterrupted recovery, leaving the hospital in four weeks.

These two cases show conclusively how difficult it is to make positive diagnosis of abdominal tumors. In neither case was there the usual symptoms to guide us to diagnosing ectopic gestation. At no time was there the discharge of blood per vagina in the second case, and at no time was there a history of collapse or shock in either case. In the first case woman was an invalid for three years, with irregular menstruation, sometimes with stoppage of two or three months, with the presence of a large semi-fluctuant mass bulging out the vagina, increased pulse-rate, chills and

elevated temperature, just the symptoms which would point to pelvic abscess and not to ectopic pregnancy. In the second case mass on the right side felt like it might be that of a pus-tube, but no diagnostic sign or symptom of ectopic gestation was present.

Exhibition of Patient Upon Whom Operation for Floating Kidney Was Performed.

DR. MERRILL RICKETTS: On the 8th of September last I made an operation for floating kidney upon the gentleman before you. He had then been ill for about five years, and had taken as high as fifteen grains of morphine daily. His urine had been examined many times, and he had been examined by many men.

I present him to-night merely to show the incisions. The anterior incision was made to determine the presence of one or more kidneys and the condition present. The anterior incision was made to assist me in making. a posterior operation. The operation was completed in thirty-three or thirty-four minutes. The left kidney was found to be very much out of place. After the kidney was brought into position and the capsule sutured in place, the kidney was divided longitudinally. The urethra was examined, but nothing was found. The operation was done in the man's home in northern Ohio. On the sixth day following the operation he received one-eighth grain morphine, since which time he has not received any. He weighed at the time 127 pounds; to-day he weighs 151 pounds. He has no desire now for opium in any form, and has no special distress or pain. I am told by his family physician he has pus in his urine occasionally. On the tenth day following the operation he was allowed to sit up, and on the thirteenth day he walked out to the dinner table for dinner. If he had been under my jurisdiction in all probability I would not have consented to that. On about the fourteenth day he went out in the yard. I speak of this to show how well he has done.

Just now I have under consideration three cases of kidney trouble, three of them tubercular, and two of them floating.

Specimen of Double Pyosalpinx.

I present this specimen because of a statement which was made last week by one of our prominent gynecologists,

namely, that pyosalpinx should be opened through the vagina and drained. I want to show how impossible it is ordinarily to make a diagnosis of pyosalpinx and drain through the vagina without entering the peritoneal cavity. In the ordinary cases of pysalpinx one might select a few which should be drained through the vagina, but this is not usually the case.

Tubal Pregnancy.

Another specimen which I have is that of a tubal pregnancy which was operated upon in Portsmouth last Tuesday evening. The patient was twenty-two years of age. She had tenderness in the left side for three days before I saw her, but she had no temperature or tumefaction. An abdominal incision was made and a quart of clots removed from the abdominal cavity. The tube was removed, showing the specimen presented here.

Specimen of Foreign Body Removed From the Intestines, Supposed to be a Piece of Carbon.

Some eleven days ago Dr. Handley was called to see a man who had been sick

about seventy-two hours. When he saw him he found the abdomen greatly distended, pulse and temperature normal, and he was vomiting stercoraceous matter. This continued for another forty hours, when I saw him. He was in a state of collapse, and I advised that the abdomen be not opened. He ran along until the ninth day, and seemingly had vomited gallons of stercoraceous matter. His bowels during this time moved twice. An aspirator was inserted in his left side and about one pint of coffee-looking fluid was withdrawn. Operation was decided upon, and I made an incision on the right side and entered the abdominal cavity. Upon examination of the intestines I found an opening in the cecum about the size of a silver dollar. After this the man ceased to vomit, and a great deal of fluid and gas escaped. He did not experience much pain. Since the operation his temperature in the rectum has been as high as 104°. He is taking as much nourishment as is allowed him. Taking it all in all, the man is in an excellent condition. Today this specimen passed from the rectum. It was supposed at first to be a piece of rubber from the plate on which his false teeth were placed, but it proved