of urine at my office yesterday; not enough to get the specific gravity, but it was found loaded with albumen. I would like for the members to examine the stump, and will be glad for any suggestions they may have to offer.

Discussion. Dr. F. W. Samuel: This is a most interesting case, and the operation itself has proven that it is unwise in injuries of this class to try and save structures which have been more or less devitalized as a result of the injury. I believe railroad surgeons at present are almost unanimous in their advice to practice high amputation in these cases, getting well above crushed and badly lacerated structures. In this case I believe it would have been better to amputate through the thigh instead of attempting to save the crushed and devitalized tissues below the knee. I am unable to say what bearing the history detailed by Dr. Marshall may have had upon the condition as we now see it. I find, upon examination, that the end of the stump is exceedingly tender; he can not bear the slightest pressure upon it, especially over the end of the tibia. I believe that there is beginning bone destruction and a secondary amputation should be done; also it will give a good stump for an artificial leg. Joints should always be avoided except in extreme cases that are not able to procure an artificial leg.

Dr. J. M. Krim: I agree with what has been said by Dr. Samuel. I do not believe the end of the bone is healthy. It is almost positive from the conditions present that there exists some bone lesion, and secondary amputation above the knee will have to be resorted to in the near future.

Dr. T. P. Satterwhite: The case is interesting from several points of view. I think Dr. Marshall did the correct thing in trying to save as much of the limb as possible. His ingenuity was considerably taxed as a surgeon to provide flaps for covering the ends of the bones under the circumstances. At the time of the accident we can not always tell just how much injury the tissues have sustained in the way of compression, etc. Unquestionably there is now present bone disease; however, I would not advise amputation just at this time; he is comparatively healthy-looking; he is a young person, and I would give him the benefit of the hope that it will be possible to avoid the necessity of amputation above the knee. We all know the higher we get in amputation the greater the risk to life, and Dr. Marshall, in my opinion, did perfectly right in amputating where he did. It is impossible sometimes to determine whether or not the tissues have been so devitalized by the injury that repair will not take place. I have no doubt that the

bones where Dr. Marshall sawed through them were perfectly sound at the time he amputated, and whether it was the injury that produced the condition as we now see it, or whether it is in some way due to the specific trouble from which the patient has suffered, it is impossible for us to say. At any rate, I would put this boy upon active specific treatment, hoping that this may be the cause of the present trouble, and await further developments before resorting to amputation above the knee.

Dr. G. B. Young: A feature in the case which has not so far been mentioned in the discussion is the probable relation between the renal involvement and the edema. While it is true the appearance of the stump would indicate a commencing bone lesion, at the same time the fact that he has on two previous occasions had a more or less general edema which slowly disappeared would lead us to at least consider whether or not the local edema which is still present may not be the remains of a general edema caused by renal insufficiency, its persistency here being due to the fact that the tissues about the stump are not normal in character. I would be disposed to put this boy upon treatment directed toward removing the edema, improving the action of the kidneys, etc., before I undertook to form a decided opinion as to the basis of the condition present.

Dr. Ewing Marshall: I am obliged to the gentlemen for their consideration of the case and the discussion also. I am strongly impressed with the idea that this boy has a granular kidney, due possibly to some degeneration. That he has had syphilis is certain, and I believe the combination of these two conditions is the underlying cause of the edema which has manifested itself. It is possible, of course, that a secondary amputation will have to be performed later. I did not see the patient in either attack of general edema; I only saw him recently, and as I wanted him to appear before the Society to-night, nothing absolutely has been done in the way of treatment. My idea is to put him on antisyphilitic treatment, with the addition of such remedies as will improve the kidney action.

Intussusception. Dr. F. W. Samuel: The following notes of a case of intussusception were given me by the family physician, Dr. F. L. Koontz: "D., female, aged twenty-one months; was attacked with a spell of vomiting at 5 o'clock in the evening of Saturday, March 15, 1902. The vomitus consisted of a large quantity of undigested banana. A physician was called, who administered essence of pepsin and fol

lowed that with a dose of castor oil. At 2 o'clock the next morning the child had an attack of colic, but the physician was not summoned until 5 o'clock. He then repeated the oil and applied hot flannels to the abdomen, and the child seemed to be relieved. He was summoned again at 8 o'clock to find the child in convulsions. Consultation was then asked for. There had been no action from the bowels; temperature 102° F., pulse 108, pupils widely dilated, uniform, and no reaction to light. The convulsive twitching was confined to the right side exclusively, the left seemingly paralyzed. This convulsion lasted for eight hours, during which time the temperature went up to 106° F. The abdomen became distended and stercoraceous vomiting appeared, which established the diagnosis of intestinal obstruction. Inflation of the lower bowel with water was tried, with the patient in an inverted position. An abdominal binder was placed on the child and a stiff rubber catheter was inserted into the colon; to this was attached a piston syringe and the piston withdrawn slowly and very gradually; at the same time the binder was tightened one pin at a time from above downward. By this means the distention was considerably relieved. A glass tube was then inserted through the sphincters and gas began to come away. The distention was entirely relieved by this means. The bowels moved, the temperature came down to 102° F., the abdomen became soft, stercoraceous vomiting ceased, consciousness was partially regained, convulsive movements ceased, and the patient's condition was apparently much improved. By the next morning the bowels had moved several times. The pulse was now very fast, but responded slightly to stimulants; the bowels did not act any more that day, and by noon Monday the patient was pulseless at the wrist; she sank into a comatose condition, and died at 8 o'clock. The specimen will show the result of the autopsy. All of the invaginations, six in number, were involved in an inflammatory process, and all of them agglutinated.

I present the specimens for your examination. All of these invaginations occurred in the lower two thirds of the jejunum, which makes the case far more interesting, because invagination or telescoping of the bowel is much more rare in this part of the intestine than in the ileum or even the large bowel. The common site of intussusception, in the child as well as the adult, is in the small intestine, about the ileo-cecal valve.

The number of invaginations are also interesting, together with the great amount of bowel which is invaginated in each instance. As I

incise one of the invaginated portions you observe that the intussusceptum and intussuscipiens are firmly agglutinated, and that the intestine is largely denuded of its peritoneal coat. I did not see this patient during life, and the only information I have concerning it comes from the family physician. I have performed post-mortems in two cases where about the same conditions were noted, both cases occurring at the ileo-cecal junction.

Discussion. Dr. P. F. Barbour: The pathological specimens shown by Dr. Samuel are the most interesting ones that have been presented before this Society for a long time. I agree perfectly with Dr. Samuel that the proper treatment of intussusception is surgical intervention, but I am conservative enough to say that I think it is wise to try an enema of water, using pressure obtained from an elevation of three or four feet. When this method is tried, however, I would have a surgeon present, so if I do not succeed he can proceed to operate at once. Twenty-four hours is as long as it is safe for an intussusception to exist without operative measures for its relief. Beyond that time operation would probably not be successful if reduction was accomplished. Pediatricians to-day are almost a unit as to the advisability of early operative intervention in these cases.

Dr. Carl Weidner: When the doctor reported the history of the case the diagnosis of intussusception was quite clear in my mind. I would like to emphasize the point he has made-an important point in the differentiation between intussusception and obstruction of the bowel from other causes, namely, frequent passages from the bowel or frequent desire to go to stool, with the passage of mucoid and bloody material. Again, localized swelling or tumor on one side of the abdomen and extreme tympany on the other are points of importance. The invaginations in this case occurred higher up in the intestinal tract than is usual, which makes the case more interesting. When the intussusception occurs in the large bowel we can frequently detect it by introducing a finger into the rectum, as I have done in two cases.

As to the indication for treatment, we ought not to wait long. When the symptoms are such as to make it apparent that obstruction of the bowels has taken place operation should be resorted to promptly. I have had cases similar to the one reported by Dr. Samuel, which terminated in the same manner. They might not have so terminated had prompt surgical intervention been resorted to. In exceptional cases

adhesions may occur; the invaginated bowel may slough, and the patient will thereby be relieved, but we should not run these risks, therefore the indication is for prompt surgical measures.

Dr. T. P. Satterwhite: Unquestionably the prognosis is death in the great majority of cases of intussusception without prompt operation. With the symptoms that the child manifested in the case reported there was a possibility that life might have been saved by surgical means. We all know that surgical operations upon very young children are attended with considerable mortality, yet there is always a chance of life being preserved by early surgical intervention in cases such as the one reported. Exploratory operation, even in the child, is not extremely serious, and even if intussusception is not absolutely certain from the manifestations present—as we know the dangers attending such a condition-I am clearly of the opinion that prompt surgical intervention or exploratory operation should be resorted to in order to form a proper diagnosis, and to relieve the condition if possible.

Dr. F. W. Samuel: The subject of intestinal obstruction is so large that its limited discussion is extremely difficult. I want to emphasize what Drs. Barbour and Weidner have said. The diagnosis of intussusception in the child is usually arrived at early, by the fact that there is always straining at stool, the passage of small quantities of feces streaked with mucus and blood; frequently there is a tumor; in fact, a tumor is present in a large percentage of cases in the iliac fossa, which can be readily made out-the so-called sausage-shaped tumorand examination per rectum reveals a mass where the intussusceptum has entered the intussuscipiens when it is low down in the tract. In rare instances it has been noted that nature has cured these conditions by adhesion and sloughing.

I want to again refer to the rarity of intussusception in this part of the bowel. I have looked through such literature as I have at my command on this subject and am unable to find the report of a single case where intussusception occurred in this particular location in children, therefore I regard it as exceedingly rare. Whether or not this case could have been relieved by operation I do not know, but we do know this much, that intestinal obstruction is a most serious condition, and the delay that usually occurs is responsible for many of the deaths following late operations.

The first paper that I ever read before this Society was a report of eight cases of intestinal obstruction, with eight deaths. I felt rather