is worth a trial if it has for its purpose the alleviation of pain or the extension of human life, and if, by reason of those facts, this operation lessens pain and extends the period of human life it is worth a trial. But before resorting to an operation for the cure of a disease which is wholly secondary-not a primary affection-the surgeon, I think, should stop and consider what good is to be accomplished by an operation that can only for a short time afford relief; on the other hand, may he not by his operation leave behind some cicatrices or adhesions which will increase the suffering and pain rather than mitigate or cure them? All of these considerations should be taken into account before opening the abdomen in a case of tubercular peritonitis. In the next place, how is the surgeon to make an accurate diagnosis unless he has some stepping-stones, unless there is a previous history of tuberculosis, or some reason to believe that the patient has tuberculosis elsewhere when he has peritonitis? How is he going to diagnosticate tubercular peritonitis and exclude tubercular infection of the intestines or of other internal organs? It is almost impossible to make a correct diagnosis along this line. The surgeon may suspect tubercular peritonitis and be reasonably sure that such a thing does exist, but his suspicion is only aroused when it occurs as a secondary affection, not a primary one. Then, if you will study tuberculosis as it affects external parts of the body, the lungs, etc., you will find that the ultimate end is dissolution and death, and when the system becomes infiltrated with tubercles the removal of a section of the peritoneum, or even the entire peritoneum will not cure the disease. How are we going to state positively that the bacilli have not penetrated or infiltrated other organs? It is impossible to say. The most that can be said touching the question of diagnosis, which every skilled surgeon must make before he uses the knife, before he applies the antiphlogistic touch to the abdomen, is that he believes it to be a case of tubercular peritonitis. Take any patient who suffers from tubercular peritonitis, or from tuberculosis of any of the abdominal organs, and he has but a short time to live; you can not rid the system of the infection, therefore I hold that an operation for the cure of tubercular peritonitis, especially as it is always a secondary affection, must be a dismal failure. The statement of Dr. Wathen, "touch me not," should, I think, apply to all cases of tuberculosis affecting the intestine or peritoneum. It would be a good rule to follow to let the patient die as easily as possible. I do not see any better treatment in these cases, from the standpoint of the physician,

than euthanasia. Give them such remedies as will ease their pain and let them go on to death as easily, as quietly, as possible. Some of these patients will live a considerable time; others will die in a very short period. These cases should be turned over to the physician, whose duty it should be to administer such remedies as will relieve pain and let them die as easily as possible.

Dr. M. F. Coomes: The essayist stated that ulceration occurs most frequently in the neighborhood of Peyer's patches and in the colon. The probable reason for this is the fact that the colon is the receptacle of more solid fecal matter, and is therefore more liable to ulceration, thus affording a nidus for infection with tuberculous material. Again, there is a very rich blood-supply in these solitary glands, not only the ileum, but also the cecum and ascending colon. It is possible infection occurs in this way, and these glandular structures more frequently break down than other tissues.

Dr. Ewing Marshall: I have recently noticed some German statistics which show that in a collection of five hundred post-mortems ninetysix per cent were found to be the subject of tuberculosis, though the patients were accredited as dying from other causes; and the writer of the report ventures the opinion that probably if more care was observed in making post-mortems that almost one hundred per cent of tuberculosis would be found; that there would be found evidences of tubercular nodules dating back perhaps years prior to death.

I agree entirely with the speakers who have preceded me that tuberculosis is rarely circumscribed; that it is general. Further, I agree with Drs. Samuel and Irwin in regard to the use of the knife in tubercular peritonitis. My observation with tuberculous patients has been that there is a tendency, if they are well cared for, for them to improve temporarily; but if you injure them in any way they will go down hill very quickly, and I should think that surgery would be classed as an injury to these people, and would increase the trouble elsewhere even if there was temporary benefit in the abdominal cavity.

Dr. F. W. Samuel: In my previous remarks I referred only to tubercular peritonitis; my experience with this disease has been a very sad one, and I am only speaking of my own experience. One class of these cases is markedly benefited by operative intervention, and good results have been reported by men in whose statements we have every reason to have confidence. A number of cases have been reported as having gotten well, but the majority of them, I believe, have a sad ending.

Dr. W. H. Wathen: If the members understood me to take a sanguine view of the results of surgery in the treatment of tubercular peritonitis, when applied to any extensive number of cases, they have been mistaken. I simply desired to present to the Society the results of the work of surgeons of the world who have had the greatest experience in the surgical treatment of tubercular peritonitis and of tubercular disease of the intestines and other intra-abdominal and pelvic structures. It is as clearly demonstrated as it is possible to demonstrate any thing that tubercular peritonitis has, in many instances, been permanently cured following laparotomy, for these patients have died afterward of other troubles and in post-mortems the peritoneum was found in an apparently normal state, having been the seat of tubercular peritonitis when the laparotomy was performed. The only argument, therefore, that can be offered against laparotomy is whether these patients would have recovered just as well from tubercular peritonitis. under hygienic, sanitary, and medicinal treatment as they did under the surgical treatment.

From my remarks you will judge that the number of operable cases is limited, because operation is only indicated where you have diagnosticated the disease as primary and it has remained primary until the operation, or where the disease of some other part of the body is not so extensive as to in any sense destroy or seriously cripple the structures involved. In the early stages of tubercular peritonitis very little good can be expected from operative intervention, but in other stages great benefit is often derived and the patients' lives are prolonged. Sometimes in operating upon the tubes and ovaries tubercular disease is found confined to these structures, or to structures lying immediately in contact with them. Operations have been performed many times, removing these tuberculous organs, with permanent results. I think we can show clearly that operations have been performed for the removal of tuberculous kidneys, tuberculous uteri, etc., that have not. returned, and the patients have apparently been cured. Many operations have been performed where a tuberculous bowel had become stenosed, with no active condition of tuberculosis anywhere else, simply a tuberculous contraction, where the fecal matter could hardly pass through the stenosis; and certainly in such instances either an anastomosis, which can be easily done, or even a resection, if necessary,. would be indicated, because the patient can not live otherwise.

So while I do not believe that operative intervention is indicated in very many instances of tubercular involvement of the peritoneum or

intestines, I am equally sure that it is indicated in other instances; but there are distinguished surgeons who to-day believe that in a general way these patients with tubercular peritonitis will recover about as well under general hygienic and sanitary treatment as they will following an operation. But I do not believe there is any one who claims that a tuberculous bowel, kidney, uterus, ovary, tube, or genital organ in the male, should not be operated upon where there is no evidence of a general tuberculosis, the disease having resisted other treatment. P. F. BARBOUR, M. D., Secretary.

Reviews and Bibliography.

The Practical Medicine Series of Year Books. Comprising ten volumes on the year's progress in medicine and surgery. Issued monthly. Under the general editorial charge of GUSTAVUS P. HEAD, M. D., Professor of Laryngology and Rhinology, Chicago Post-Graduate School. Volume 1, General Medicine. Edited by Frank BILLINGS, M. S., M. D., Head of Medical Department and Dean of the Faculty of Rush Medical College, Chicago. With the collaboration of S. C. STANTON, M. D. October, 1901. The Year Book Publishers, Chicago.

This is one of the practical medicine series which is to be composed of ten volumes and to be issued monthly. It will be the effort of the editors of these volumes to give everything that is new, practical, and up-to-date in medicine and surgery. This work entails a great deal of labor as well as time in selecting from the various medical books and journals that are published. In short, each of these volumes is an epitomized statement concerning diseases of which they treat, and is well worthy of the price asked for it. The price of the volume is $1.50. The whole series will be $7.50.

A Manual of Clinical Laboratory Methods. By JOHN BENJAMIN NICHOLS, M. D., in charge of Clinical Laboratory, Garfield Hospital; Hematologist to Columbian University Hospital; Professor of Normal Histology in Medical Department of Columbian University, Washington, D. C. Illustrated. New York: William Wood & Co.

This is a book of some three hundred pages, and contains all of the most practical knowledge concerning laboratory methods employed in clinical medicine. It gives various methods of estimating the number of blood corpuscles by volume and by count. It gives the composition of the secretions and excretions in detail, and gives minute instructions as to all

procedures connected with the analysis of these fluids. The book is well indexed and well paragraphed. Important points connected with a subject are characterized by large type. It is one of the most valuable books of its kind it has been our good fortune to see.

Progressive Medicine. A Quarterly Digest of Advances, Discoveries, and Improvements in the Surgical and Medical Sciences. Edited by HOBART AMORY HARE, M. D., Professor of Therapeutics and Materia Medica in the Jefferson Medical College of Philadelphia; Physician to the Jefferson Medical College Hospital; Laureate of the Royal Academy of Medicine in Belgium, of the Medical Society of London; Corresponding Fellow of the Sociedad Espanola de Hygiene of Madrid; Member of the Association of American Physicians, etc. Assisted by H. R. M. LANDIS, M. D., Assistant to the Out-Patient Medical Department of the Jefferson Medical College Hospital. Philadelphia and New York: Lea Brothers & Co. 1901.

This volume contains diseases of digestive tract and allied organs; liver, pancreas, and peritoneum; genito-urinary diseases; anesthetics, fractures, dislocations, amputations, surgery of the extremities, and orthopedics; diseases of the kidneys; physiology; hygiene, and practical therapeutic referendum.

This volume, like all of its predecessors, is up-to-date in every particular. The report of spinal anesthesia by lumbar puncture is alone worth the price of the book. This book is rich in recent surgical literature, and it is difficult to see how any up-to-date surgeon can afford to be without it. No words of ours can add any thing to its value.

Typhoid and Typhus Fevers. By Dr. H. CURSCHMANN, of Leipzig. Edited, with additions, by WILLIAM OSLER, M. D., Professor of the Principles and Practice of Medicine, Johns Hopkins University. Handsome octavo of 646 pages, illustrated, including a number of valuable temperature charts and two full-page colored plates. Philadelphia and London: W. B. Saunders & Co. 1901. Cloth, $5.00 net; sheep or half morocco, $6.00 net.

The original German edition of this volume is universally recognized as the standard authority on the subjects of which it treats. The American edition, however, even surpasses the German, for, besides containing all the material of the original, extensive additions have been made to almost every chapter, thus incorporating into the work the very latest views on the subjects under discussion.

The chapter on bacteriology has been thoroughly revised and much new material added, giving prominent consideration to the distribution of the typhoid bacilli, especially in the urine, the rose-spots, and the blood.

To the chapter on pathology many minor additions have been made, incorporating the important work of Mallory. The literature on the localized lesions due to the bacillus has been carefully reviewed and made to conform to the most recent advances in that part of the subject. Thayer's exhaustive study of the state of the blood has been utilized, and the surgical aspects of typhoid fever have been fully revised with the aid of Keen's monograph.