The body was examined thirty-six hours after death by Mr. Ward. On the completion of the abdominal incision through the linea alba, a large quantity of thick purulent fluid escaped. The abdominal perietal peritoneum was adherent to the viscera by plastic exudation, that had been more copiously deposited in the region of the right iliac fossa than elsewhere. The free and contiguous surfaces of the small and large intestine were similarly invested, and the folds of the small were quite adherent; the peritonitis had been most intense over the cæcum and lower part of ileum. On turning aside the former by detaching the peritoneal reflection to the abdominal wall on the right side, a small abscess was exposed between it and the loose tissue in the iliac fossa. Protruding through that part of the wall of the small abscess in relation to the cæcum was a small, worn-down bristle, about one third of an inch long, that apparently had belonged to an old tooth brush. This, on further examination, was found to have ulcerated through the vermiform appendix, at the juncture of its distal one-fourth with the proximate threefourths. A probe passed through the appendix came out where the bristle was, in the centre of the abscess. Beyond this, for a quarter of an inch, the coats of the vermiform appendix were sloughy, and nearly disintegrated. The vermiform appendix was directed upwards and backwards, the whole being behind the cæcum and adherent to it by inflammatory products.

Dr. Silverthorn showed specimens of ulceration of rectum and recto-vaginal fistula.

Some discussion took place as to the character of the ulcers, whether stercoral or syphilitic, Dr. Cameron, Anderson and others. taking part.

TUBERCULAR KNEE.

Presented by Geo. A. Peters, F.R.C.S. Eng.

J. McC., æt. i7 Admitted to Toronto General Hospital under my care Sept. 5th, 1898.

Family history is good. There is no tubercle in the family so far as known.

Personal history. Habits good; worked as deck hand on the upper lakes.

Present illness.

Two years ago he was struck on the knee by an iron bar. No abrasion of skin was caused. He says that about twenty minutes after the accident the cords of the knee contracted, and he was unable to straighten the leg for two days. This injury laid him off work for about three weeks. When he returned to

work a little stiffness and swelling remained. In the latter part of 1897 he became much worse, the pain being very severe in the knee, especially if he stumbled or wrenched the limb in any way.

In February, 1898, he entered the Huntsville Hospital, where he remained for twenty-eight weeks. The treatment was to paint the part with iodine, and apply linseed poultices. About June an abscess formed under the patella, and was lanced on the inner side of the knee. Subsequently another abscess formed and broke about an inch below this.

At the time of his admission his condition was as follows: He was pale, with hectic fever. Tongue coated; appetite poor; bowels constipated. His face indicated great suffering, and the least movement of the bed or limb caused him great suffering.

The knee joint was found to be greatly distended with pus, which escaped in small quantities through the sinuses at the inner side of the joint. Drainage, however, was quite inadequate. The patella floated, and the serous membrane pouted in all directions. It had evidently ruptured superiorly, as a very large fluctuating abscess occupied the front of the thigh under the quadriceps extensor as high as its middle. This abscess had further ruptured through the vastus externus, so as to point under the skin a short distance above the knee.

On Sept. 14th an attempt was made to reduce the size of the abscess by free drainage. It was pretty clear that the disease was so extensive and of so septic a character that an exsection of the joint was out of the question, and to do an amputation with a large septic abscess occupying the front of the thigh as high as its middle would involve a great loss of bone, as well as greatly endanger the patient's life. Four free incisions were accordingly made into the extensive abscess cavity, and drainage tubes of large calibre inserted. The result was an immediate fall of the temperature, with a general improvement in the patient's condition. The internal lateral ligaments of the joint were found to be entirely disintegrated, and the surface cartilages of the femur and tibia were widely eroded.

Oct. 14th. The abscess above the patella having now contracted to the dimensions of a sinus, an amputation was performed in such a way that this sinus came between the flaps. The whole sinus was then freely dissected out. The wound healed kindly, and the patient's general health immediately became satisfactory.

Condition of parts found. The articular cartilage of the internal condyle of the femur was found to be widely eroded, though the bone beneath did not seem to be greatly softened. The cor

responding surface of the external tuberosity of the tibia was similarly eroded, as was also the under surface of the patella.

The structures at the inner side of the joint seemed less eroded, probably from the circumstance that the disintegration of the internal lateral ligament prevented close friction at that part. The whole space of the joint was filled by the soft, pulpy granulations of the synovial membrane, and this condition also extended widely through the ligaments and under the quadriceps muscle. The sawn surface of the femur showed an atrophic condition of the compact layer of bone, with a softened and porous state of the spongy portion.

The epiphyseal cartilages were wholly unaffected.

A large pocket of pus (unsuspected) was found in the calf of the leg.

Discussion by Drs. Primrose, Cameron, and Oldright.

A CASE OF ENLARGED GLANDS IN THE NECK.

Presented by G. A. Peters, F.R.C.S.

Query: Hodgkin's disease on Tubercular Adenitis.
M.A. Male. Age fifteen.

Admitted under my care in Toronto General Hospital in October, 1898. The family history shows consumption on the father's side, two sisters dying of consumption; and also on the mother's side, one sister dying of consumption. Seven brothers of his mother also died in infancy, the oldest reaching the age of four years. Father and mother are both living and healthy. The patient has one sister living and healthy at the age of thirteen. During childhood the patient suffered several attacks of remitting fever, extending over a period of two years, then he had a severe affection of the eye which kept him in a dark room the whole of one winter season (probably phlyctenular ulceration). In his eleventh year he was five weeks in bed with malarial fever. Since then he has been comparatively well until the present condition manifested itself. Nine months ago he first noticed a lump growing under his ear, which kept getting larger. About this time. he had some growth removed from his throat; probably enlarged tonsils or adenoids. When admitted to the Hospital he had the appearance of a fairly well nourished lad of fifteen with a series of tumors in the left side of his neck. The highest one was situated between the angle of the jaw and the mastoid process, and was about the size of a walnut. It was evidently a gland, and could be moved with tolerable freedom beneath the sterno-mastoid muscle. Another small gland as large as an almond was felt in front of this

and extending down to the region of the carotid vessels, and a series of smaller glands could be felt extending down in front, be neath and behind the sterno-mastoid muscle, and extending as low as the clavicle. These glands were tolerably discrete and quite freely movable, and did not seem to be closely matted together. In none of them could any softening be felt. The spleen was not enlarged, and no other groups of glands in the body showed any enlargement. The blood count showed in each c.m.m. from ten to twelve thousand white, and about six million five hundred thousand red, corpuscles. The hæmoglobin is normal in amount.

Clinically, in this case the diagnosis lay between tubercular enlargement of glands and Hodgkin's disease, or malignant lymphoma. In favor of Hodgkin's disease may be mentioned the fact that the groups of glands were those of the anterier and posterior cervical triangle, which are those most usually affected in Hodgkin's disease, tubercular adenitis affecting the submaxillary group of glands by preference.

Again, the glands seemed to be discrete and tolerably freely movable, not being matted together. There was no softening found even in the largest one, which was just under the ear, such as one would expect to find in so large a tubercular gland. The blood count did not seem to offer any considerable help in diagnosis. Moreover, the boy had not the appearance of a tuberculous patient. On the contrary, the absence of any enlargement of other groups of glands in any other part of the body might be looked upon as being in favor of tuberculous adenitis.

At the time of operation, however, it was found that there was much more fusion between the groups of glands than was expected, and that some of them contained spots apparently in process of caseation. According to Osler, caseation is not common in Hodgkin's disease, but a condition of necrosis very like it sometimes was present. There were no evidences, however, of suppurative process in any of the glands. One small calcareous mass was found.

Under the microscope it is seen that the disease is undoubtedly tubercular, but the caseation has an unusual degree of consistence, as if occurring very slowly. Giant cells and epithelioid cells are found in great numbers, but no tubercular bacilli were detected. Discussed by Drs. Cameron, McPhedran, Primrose and Graham.

(Continued in next issue.)

Book Reviews.

THE ESSENTIALS OF HISTOLOGY. By Edward A. Schafer, F.R.S., Professor of Physiology in University College, London. New (5th) edition. Revised and enlarged. Octavo, 350 pages, with 325 illustrations. Cloth, $3.00, net. Lea Brothers & Co., Publishers, Philadelphia and New York.

This book is written with the object of supplying the student with directions for the microscopical examinations of the tissues, and is divided into forty-six lessons preceded by a short but comprehensive introduction and followed by an appendix on methods of preserving, cutting, and staining.

The essentials of histology are here got out in such a manner as to enable the student to easily grasp them, beginning with cells, going through the various tissues, and ending in the complex organs. The illustrations, 392 in number, are good, up to date, profuse, and to the point.

Discussion of theories is aptly worded and only generally accepted views expressed.

PRACTICAL URANALYSIS AND URINARY DIAGNOSIS.-A manual for the use of physicians, surgeons and students, by Charles W. Purdy, M.D., LL.D., Queen's University; Fellow of the Royal College of Physicians and Surgeons, Kingston. Professor of Clinical Medicine at the Chicago Post Graduate Medical School; author of "Bright's Disease and Allied Affections of the Kidneys," also of "Diabetes,its Causes, Symptoms and Treatment." Fourth revised edition, with numerous illustrations, including photographic engravings and colored plates. The F. A. Davis Company, Philadelphia, New York, 'Chicago, publishers, 1898.

We have referred to some of the excellent features of former edittions of this admirable book. It is somewhat remarkable that three large editions have been exhausted within three years. The work has been adopted as a text-book in upwards of sixty medical colleges of the United States. Many chapters have been so thoroughly revised and changed as to be practically new. The book is an excellent one from all points of view and well-worthy of the author, a Canadian, and a graduate of Queen's University, Kingston, who has so highly distinguished himself in Chicago.