NEW YORK COUNTY MEDICAL ASSOCIATION. Stated Meeting, Held December 21, 1903. DR. FREDERICK HOLME WIGGIN presented several speci mens. A Case of Nephrectomy.-The first specimen was a kidney removed from a girl of eighteen at the City Hospital about two weeks ago. In September she was operated on for a pyosalpinx on the right side, and did well until October 24, when there was a rise of temperature to 104° F., associated with pain in the right lumbar region. The urine contained pus, and pus was obtained from each ureter by catheterization. A diagnosis of pyelonephritis was made. Chills, sweats, and fever continued. Methylene blue was administered, and was recovered from the left kidney in an hour and a half, but not at all from the right kidney, showing how extensively this organ was diseased. Accordingly, nephrectomy was done instead of nephrotomy. The operation wound healed by primary union. Two Specimens of Appendicitis.-The first of these two specimens had been removed from a girl of fifteen who, nine days before coming under observation, had been taken with severe abdominal pain accompanied by chills, nausea, and vomiting. The operation was done at night, and an abscess, holding about ten ounces of very foul pus, was exposed and evacuated. It was not adherent to the parietal peritoneum. The cæcum appeared to be gangrenous at several points, and, hence, it was thought to be safer to remove it rather than to attempt drainage. An interesting feature was the finding of several undissolved medicinal tablets free in the abdominal cavity. This suggested the possibility of these foreign bodies having been the original cause of the appendicitis. Three hours after the operation she was apparently doing well, but after about sixteen hours vomiting set in, and she died twenty-four hours after the operation. No autopsy was allowed, so that the exact cause of death was not known, s probably intestinal paresis. but it was number of the insane, and also in the proportion of the insane to the population. Thus, twelve years ago, there was one committed insane person to 374 of the population, while at present there was one to every 303 of the population. The average daily number of insane in the State hospitals was over 23,000, a number so large as to give considerable value to properly collated statistics. In New York State during the past year, 15.31 per cent. of the cases of insanity were ascribed to moral causes, 53.16 per cent. to physical causes, and in 31.51 per cent. the cause was not ascertained. Among the physical causes, intemperance occupied the first place; it caused insanity in over 14 per cent. of the cases admitted, and was a contributing factor in not less than 30 per cent. of all the cases received. Among the other physical causes might be mentioned pregnancy, lactation, the menopause, fevers, privation and overwork, epilepsy, epidemic influenza, sunstroke, trauma, and autointoxication. The statistics regarding the hereditary tendency to insanity were of some interest. Of over 1400 persons admitted, 17.71 per cent. gave evidence of having inherited insanity; in 50 per cent. heredity was denied, and in 31.67 per cent. it was impossible to ascertain the facts regarding its transmission. Of the 73,000 cases treated in the State hospitals since October, 1888, 22 per cent. inherited the insanity, and the percentage was higher in women than in men. The statistics forced us to the conclusion that melancholia was far more frequent than mania. Among the men 50 per cent. were single and 30 per cent. were married. Among the women 38 per cent. were single and 48 per cent. married. There were twice as many widowed women as widowed men received. It was well known that during the middle period of life alienation was the most frequent. According to the statistics of this State, the admissions between the ages of thirty and forty exceeded very largely those of any other decade, over 28 per cent. of all admissions occurring between these years. With regard to the comparative frequency of insanity in the two sexes, it should be remembered that there were special causes operating. in women, e.g. pregnancy, parturition, the menopause, and uterine and ovarian disease. On the other hand, the predisposing causes in men were intemperance, sexual excess, and the mental strain incident to a strenuous business life. At the end of the year there were 1298 more women than men in the State hospitals. The average duration of life in the hospitals for the insane was greater in women, and more men Of the 7619 admissions, only The second specimen of appendicitis was removed from a girl of twenty-two, who complained of pain only over the region of the gall-bladder at the time of the last attack, although there had been more or less general abdominal pain and some nausea for the past year. observation she had an attack of jaundice lasting three days. recovered than women. While under bladder was found to be normal. The stomach was some what lower than usual, and its pyloric end showed some evidence of peritonitis. The appendix was up behind the colon. There had been some tenderness over the cæcum, but the chief area of tenderness was over the gall-bladder. The patient was recovering. Epithelioma of the Larynx; Laryngectomy.—The larynx presented had been removed from a man, fifty-two years of age, whose knowledge of English was so limited that a satisfactory history could not be obtained. He came to the City Hospital from Bellevue Hospital wearing a tracheotomy tube. The larynx was removed without much difficulty, but the patient died forty-eight hours later with suppression of urine. The pathologist reported 112 led professional lives. Under hospital treatment it was found that there was a slightly better chance for ultimate recovery in acute mania than in melancholia. The recovery rate was 24.6 per cent., and the death rate a little over 5 per cent. Dr. JOSEPH COLLINS thought the majority of those not in asylum practice would not now classify cases as mania and melancholia, and that the apparent changes in the number of cases of melancholia and of insanity, and in the proportions of recoveries in these diseases were chiefly due to differences of classification rather than any actual change of type. The statistics regarding the social condition in its relation to insanity tallied quite closely with those bearing upon neurological disorders. The speaker that the tumor found in the larynx was an epithelioma. thought we could not yet congratulate ourselves in any At the autopsy the operation wound was found in good condition. There was considerable pulmonary tuberculosis, and in addition, fatty liver and chronic diffuse nephritis. way upon the progress made in dealing with the insane in this country. In this State alone there was one insane patient to every three hundred inhabitants, and yet the three hundred sane persons were making no adequate provision for the care of the insane. There was no place, he declared, in this State, or in this country, where the acutely insane were properly treated. There were many asylums, but in none of these was there any proper facilities for treatment, except the Shepard Asylum in Baltimore. There were fine buildings and fairly equipped laboratories, but no proper means for the treatment of the acutely insane. The reform that we, as physicians, were called upon With regard to the differentiation between insanity and delirium due to other causes, a topic brought up incidentally, Dr. Collins said that if there was no such thing as delirium grave, then the question became comparatively easy. We all knew that in certain of the acute infectious diseases, best represented by pneumonia, typhoid fever, erysipelas, ulcerative endocarditis, there supervened a delirium, which was by no means very characteristic of the special disease in connection with which it developed. Prior to the introduction of quinine in the treatment of malarial fever, this disease was one of the most common of those giving rise to delirium. There were comparatively few American psychiatrists who had seen much of delirium grave. Personally, he had never seen a pure example of it; the cases seen at the present time, which resembled it, were called acute hallucinatory mania, associated with profound confusion, and they did not often terminate fatally. As to the treatment of the various forms of delirium, Dr. Collins said, the only method which was of the slightest service was that by stimulation. In general, this method might be said to consist in giving nourishing and stimulating enemata, and if this was not sufficient, to resort to saline infusion. Of course, rest and sleep must be secured, and the body temperature must be kept within proper bounds. Dr. ALEXANDER LAMBERT called Dr. Collin's attention to the fact that the Baltimore asylum mentioned by him was not the only place in this country where the acutely insane might receive proper treatment, for there had been a psychopathic ward in operation for the past two years in the New York Infirmary for Women and Children, and this ward was open to physicians who desired to treat patients there. With regard to the scientific investigation of insanity, Dr. Lambert said that such an undertaking had been started by Dr. Macdonald in the Pathological Institute, but the Legislature, which voted millions for the hospitals for the insane, objected to spending $32,000 for the work of this institute, even though this modest sum included the cost of maintaining the New York City offices of the Commission in Lunȧcy. It was sad to think that the real death-blow to that institute had been inflicted by three medical gentlemen from other States. He wished to say that probably only by the study of the living brain in action-the true study of psychologywould our knowledge of insanity be materially augmented. It must be admitted that the State had made great advances, from a humanitarian point of view, for our insane were now given homes in which they could live with fair comfort for the rest of their lives. The next step. which must come in time, was the proper treatment of insanity in the acute stage. Dr. MABON closed the discussion. He said that the acutely insane were certainly scientifically treated in the McLean Hospital, in Massachusetts, in the Buffalo Hospital, in the Hudson River State Hospital, and in various other State hospitals, including the one at Ogdensburg, of which he had formerly been superintendent. He had been in the State hospital service for seventeen years, and was familiar with what had been accomplished, as well as with the shortcomings. It should not be forgotten that a very large proportion of those coming to the State hospitals were already chronic. An effort was being made to separate the acutely insane and concentrate the medical service in that department, with the object of giving adequate treatment. THE WESTERN SURGICAL AND GYNECO LOGICAL SOCIETY. Thirteenth Annual Meeting, Held at Denver, Col., December 28 and 29, 1903. THE association met at the Brown Palace Hotel, under the Col., read a paper on this subject in which he reported two cases, one of which recurred after an unusually long Pancreatic Cyst.-Dr. GRANT gave the clinical history of a case of pancreatic cyst. He spoke of the causes of pancreatic cyst, reviewed the literature of reported cases, which showed convincingly that the disease was essentially surgical, and that delay in operating was as dangerous and fatal as in appendicitis. The gangrenous cases could only be saved by promptly opening the abdomen and draining. Formerly and recently reported cases in the Annals of Surgery by Woolsey, which seemed unfavorable for operation, amply attested this. The suggestion in the treatment of the sac was to dissect it out if small, but in the case of a large sac this attempt was manifestly unsafe and dangerous. The extensive adhesions made it exceedingly difficult, and extravasation of pancreatic juice or septic material would probably destroy the patient; patients had died from this treatment. To attach the sac to the abdominal peritoneum, if not already adherent, and drain, was safe, and undoubtedly the best treatment of a large cyst. Pancreatic juice out of its normal channel produced fat necrosis. Pancreatic disease often simulated intestinal obstruction, and the statement might be safely accepted that if the surgeon opened the abdomen and did not find obstruction or perforation of the stomach, but observed fat necrosis, the pancreas was, in all probability, the source of the trouble. Dr. M. L. HARRIS of Chicago spoke of the great value of colonic distention of the intestines. In going over the literature of pancreatic cyst he found that in 95 per cent. of the cases the transverse colon took a distinct circle below the tumor and the stomach above. There was practically no other tumor or cyst in which this relation was found. Dr. Grant, in closing, said several writers had considered the differential diagnostic point mentioned by Dr. Harris, but when it was remembered that cases of pancreatic cyst were more frequent in very fat subjects, and that there was quite uniform distention of the intestines, the stomach not being so much distended because of the pressure of the tumor, or, if so, it was entirely out of its normal location, it was difficult, if not impossible, to isolate the transverse colon and the stomach. He had never succeeded in getting any benefit from artificial distention in other cases, although he did not try it in this case. Accidental Perforations of the Uterus.-Dr. D.'S. FAIRCHILD of Des Moines, Iowa, said that the use of the sound and the curette in gynecological practice was probably the most frequent cause of this accident in legitimate practice. The facility with which the sound could be used in exploring the interior of the uterus and in repositing a retrodisplaced organ was no doubt responsible for some of these accidents. The curette, however, was often used in an indiscriminate manner and as a routine treatment in a great variety of uterine difficulties that could be better treated by other means with a greater prospect of permanent results. He mentioned a case that came under his observation this year which illustrated the ease with which a perforation of an apparently healthy uterine wall could be accomplished, and what was needed in cases of this kind. Dr. DONALD MACREA of Council Bluffs, Iowa, mentioned a case in which the upper part of the cervix, not the fundus of the uterus, was perforated by a modified Goodell dilator by a young practitioner, and a portion of the intestine pulled through the opening and pulled off. Dr. C. H. WALLACE of St. Joseph, Mo., spoke of a case in which a young physician perforated the uterus posteriorly with a curette at about the internal os, producing sepsis and death. Dr. H. G. WETHERILL of Denver, Col., said the great dangers associated with the use of the curette were beginning to be appreciated both by the profession and laity, not only in the hands of the inexperienced, but in the hands of experts. He detailed a case which illustrated the ease with which the uterus could sometimes be perforated. He referred to the classic case of a woman who attempted to induce abortion by inserting an umbrella ring into the uterus, which went through the posterior vaginal wall, and, when discovered, it was found to have perforated the liver, the diaphragm, and was found in the right pleural cavity. Dr. W. L. BULLARD of Pawnee City, Neb., mentioned two cases of perforation of the uterus, one of which was produced by a crochet hook of the ordinary size. An attempt was made to find the hook, but without avail. The patient was left alone. Six months after this she became pregnant, and the crochet hook was discharged through the anterior abdominal wall. Two months later the product of conception was expelled in the natural way. Dr. Fairchild, in closing, said his object was not to relate unusual cases of perforation of the uterus, but simply to give expression to an opinion that he had held for some time, namely, that the curette was a more dan-. gerous instrument than it was generally thought to be by the general practitioner. Men of great experience would not use the curette indiscriminately or carelessly, but there were many general practitioners who thought it was so essential and felt they could not do their patients justice without employing it, consequently the instrument was very often used indiscriminately. come from an earlier recognition and better understanding Ulcer.-Dr. FRANK C. DAVIS of Des Moines, Iowa, said Perforating Gastric Ulcer.--Dr. ARCHIBALD MACLAREN of St. Paul, Minn., said that perforating gastric ulcer was fully as common as extrauterine gestation, and that when the eyes of physicians were opened to this fact, they would be able to see them, diagnose them early, and save many lives that were now lost. In this country he did not believe that the perforation cases reached the hospitals as often as they did abroad. His ex perience led him to believe that Dr. Richard Harte was correct when he said that rigidity or tension of the abdominal muscles was the keynote to the early recog nition of peritoneal perforation from whatever source. The pain might subside, the temperature might not be elevated, but the rigidity continued even up to the end. He believed that many cases could be correctly diagnosed, as was proven by a few cases which he reported, and by the many cases which were constantly being published Treatment of Gastric Ulcer.-Dr. H. D. NILES of Salt Lake City, Utah, in a paper on this subject, presented the following conclusions: (1) Post-mortem statistics, clinical experience, and recent operating-room observations all tend to confirm the belief that neither the frequency nor the grave importance of gastric ulcer is fully appreciated by the profession generally, and the majority of cases are not recognized as such in life. (2) An earlier and more positive diagnosis means greater alertness in our observation and interpretation of symptoms, and more frequent exploratory operations. (3) In the history of every benign or malignant ulceration situated in a safely in the journals. He reported three cases. The first accessible region, there is always a time when the pathology can priate mechanical means. (4) Up to the present time the recognized indications for operative procedures in gastric ulcer have been the symptoms produced by the remote as hemorrhage, perforation, pyloric be to make an earlier diagnosis, and by the timely applicaobstruction, cancer, etc., but our aim in the future should tion of a rational treatment prevent the occurrence of these later and more serious manifestations of ulcer. (5) Taking into stricter account the local etiological factors will undoubtedly aid us in the prevention, diagnosis, and treatment of gastric ulcer. (6) The causative pathology deserves more consideration in the surgical treatment of gastric ulcer than it has yet received. (7) Perforation interference. (8) hypodermically, without any benefit, and the patient was a perforating latent gastric ulcer on the anterior wall. Operation was done eleven hours after perforation had resultant pathology, Hemorrhage from gastric ulcer is best treated by gastrojejunostomy. (9) Open or cicatrized ulcers near the pylorus always indicate rest for the parts and a sufficient outlet for the stomach contents. (10) A posterior gastrojejunostomy with sutures accomplishes these objects with the minimum risk and the most satisfactory results, and hence should usually be the operation of choice. (11) Our future advancement in the treatment of gastric ulcer must occurred, with recovery of the patient. The second case was one of probable perforating gastric ulcer, fol lowed by death in twenty-nine hours, either without operation or post-mortem. The third was a case of subacute perforating gastric ulcer, which was operated on nine hours after perforation, with recovery. Dr. CHARLES W. OVIATT of Oshkosh, Wis., mentioned the case of a man, sixty-two years of age, a laborer, who had never complained of any symptoms of gastric ulcer. He had eaten a hearty meal, laid down on the lounge feeling perfectly well shortly after, but within an hour he rolled over on to the floor with agonizing pain. A physician was called, who gave large doses of morphine died within a few hours. Post-mortem examination revealed a perforating ulcer in the posterior wall of the stomach, which seemingly had attempted to heal. There was no blood in the stomach, but the abdominal cavity was filled with stomach contents. Dr. B. B. DAVIS of Omaha, Neb., referring to the etiology, said that stagnation accounted practically for a large proportion of cases of gastric ulcer, and with out it there was no ulcer. This stagnation might be due to a variety of causes which he pointed out. Dr. LEONARD FREEMAN of Denver, Col., reported a case he observed some time ago, in which perforation occurred early in the morning, but rigidity of the muscles of the abdomen did not follow until two o'clock in the afternoon. This led to a non-recognition of the case, and although operation was done, it was too late to do any good. No Dr. H. A. SIPTON of Milwaukee, Wis., mentioned five cases of gastric ulcer and one of duodenal ulcer. diagnosis was made in three of them. He had operated on but two cases, the diagnosis in these having been made within twelve hours, one of whom died, the other recovering. Dr. CHARLES H. MAYO of Rochester, Minn., said that after examining 1100 stomachs by test meals, laboratory testing and physical examination, anæmia was a very important factor; next, long-continued neurasthenia symptoms. He mentioned one authority who, in examining 2200 cases at autopsy, found that 20 per cent. of women showed signs of ulcer of the stomach, and only 2 per cent. of men. Welch, in an examination of 800 cases of gastric ulcer, found 60 per cent. in women, and 40 per cent. in men. The speaker and his brother had operated on approximately 400 cases, and of 1500 cases of stomachs examined, they had found that the proportion was about the same as that given by Welch. Welch also found in an examination of 788 cases of ulcer of the stomach that only twenty-eight occurred in the greater curvature, so that the greater proportion of them were found in the pyloric end of the stomach. Of cases of cancer of the stomach, Dr. Mayo had elicited a history of chronic ulcer covering a period of from one to fifteen years. His statistics showed 88 per cent. of gastric ulcer, and 12 per cent. of duodenal ulcer. The tendency was more and more to class the first two and a half inches of the duodenum as a part of the stomach. In thirtyone cases of acute perforation of the stomach and duodenum, eleven occurred in the duodenum in this first two and a half inches, and he had operated on twenty-six cases of ulcer of the duodenum. Dr. M. L. HARRIS of Chicago said the extensive experimental work of Fütterer showed it was impossible to produce gastric ulcer in an animal until the hæmoglobin of the blood had been reduced below a certain point; that all lesions of the mucosa produced in healthy animals readily healed. When the hæmoglobin was reduced below a certain point, producing a marked anæmia, then these lesions developed into typical ulcers. These observations showed the importance of an examination of the blood in these cases. Another point was the examination of the fæces for hæmatin crystals, as a means of diagnosis in obscure cases of gastric ulcer. The Treatment of Hæmatemesis by Gastroenterostomy. -Dr. F. GREGORY CONNELL of Leadville, Col., in a paper on this subject, classified the operative treatment of hæmatemesis into direct and indirect. Under direct he included (1) excision of the ulcer; (2) partial gastrectomy or pyloroplasty; (3) ligation of the principal artery; (4) cauterization or curettage of the ulcer; (5) ligation of the mucous membrane, and (6) ligation of all coats. Under the indirect he mentioned (1) gastroenterostomy; (2) pyloroplasty; and (3) gastrotomy. After considering the direct method as a whole, he stated that these were not in common use, because of such objectionable features as the difficulty of locating the ulcer, the fact that the lesion was frequently multiple, the presence of firm and complicating adhesions, and the indistinct limitations of the pathological tissue. The high mortality rate of some and the impracticability and unreliability of others had been the cause of a general turning to the indirect method, as exemplified by gastroenterostomy. The manner in which a gastroenterostomy allowed an ulcer to heal was well understood and practically settled, but as to this same opera tion acting as a hemostatic measure, no such substantial reasons as those advanced for the healing could be presented. While rest and drainage undoubtedly favored clotting and the cessation of hemorrhage from small bloodvessels, it was difficult to understand how they could arrest hemorrhage from a large artery with a lateral opening, as in the case reported. As one was unable to determine with any degree of accuracy the nature or the source of the hemorrhage, gastroenterostomy was indicated only after a thorough search for the bleeding point. The exact status of gastroenterostomy in hæmatemesis was not well defined, as was shown by numerous quotations. It had been said that a search for the bleeding point was futile, harmful and unnecessary, and that a gastroenterostomy would without doubt prevent recurrence of the hemorrhage. To show that gastroenterostomy would, without doubt, prevent recurrence of the hemorrhage, the author reported one case and cited others from the literature. Gastroenterostomy was indicated in hematemesis (1) after a thorough search had failed to reveal the source of the hemorrhage. (2) When the source of the bleeding was discovered, but in such condition as to make direct treatment impracticable or impossible. The conclusion, based upon a sad experience and a review of the literature, was an endeavor on the part of the author to discountenance the idea, which had become quite prevalent, that nothing was to be gained by searching for the bleeding point, as gastroenterostomy was all that would be necessary to prevent recurrence of the hemorrhage. Two Cases of Acute Hæmatemesis in Which Gastroenterostomy Was Performed.—Dr. LEONARD FREEMAN of Denver, Col., detailed a case in which he performed a posterior gastroenterostomy. A Murphy button was employed. having the end within the stomach smaller than that within the bowel. The stomach contained bloody fluid, Recovery was uninterrupted. The button was passed on the twenty-third day. There was no further hemorrhage. About seven months later this patient suddenly died from hæmatemesis, the hemorrhages having begun about three months after the operation, small quantities of blood being frequently vomited subsequently. In the second case a posterior gastroenterostomy was done, and a Murphy button used, the ends of which were of unequal size. The stomach showed no external sign of ulcer, and no internal exploration was attempted. The organ was markedly dilated with gas and fluid. Reaction from the operation was so satisfactory that hopes of recovery were entertained; but in spite of no recurrence of the hemorrhage, death occurred at the end of fifty hours, due apparently to the great loss of blood. Autopsy revealed an ulcer as large as a watermelon seed on the posterior wall, at the junction of the lower with the upper two-thirds of the stomach. A small atheromatous artery, plugged by a thrombus, could be seen in the floor of the ulcer. Dr. H. D. NILES believed that in cases of acute hæmatemesis any operative procedure would be attended with a high mortality. It was difficult to diagnose gastric ulcer from the external appearance of the stomach with sufficient accuracy to deal directly with it, at least to determine upon an operation. Gastroenterostomy was not, in his opinion, an infallible remedy for the treatment of gastric hemorrhage. Unless one knew positively the source of the hemorrhage before opening the stomach, he thought it was better to perform the operation before hemorrhage was dangerous. Dr. J. E. SUMMERS mentioned a case of hæmatemesis the result of acute alcoholism. He opened the abdomen widely and found that hemorrhage came from eight or ten small erosions. He used hot water, as hot as could be borne without irrigation, and controlled the hemorrhage for a time, but it subsequently recurred and the patient died. Dr. JAMES E. MOORE said the treatment of gastric hemorrhage by gastroenterostomy at the present time was more or less empirical. The profession had not arrived at that point when positive statements could be made as to its value. The past history of cases showed that a considerable proportion of them not only recovered from immediate hemorrhage, but permanently without operation. Dr. O. BEVERLY CAMPBELL of St. Joseph, Mo., said in regard to the closure of the opening made in gastroenterostomy by the suture method, he had performed sixteen experiments on dogs. In twelve he used the Kocher method of suturing, and in all of them he did an anterior gastroenterostomy. The opening in each instance was quite large. The dogs were reoperated at periods of from three to six months, and at the end of three months in six cases the opening was reduced to such an extent that the index-finger could not be passed through it without a little force. In six of the cases there was almost total obliteration of the opening at the end of six months. In four there was a slight opening through which only a small probe could be passed. A vicious circle was established in 40 per cent. of the cases. These experiments showed a tendency, where there was noʻobstruction at the pylorus, for the opening to close, whether it was made with the Murphy button or by the suture method. A larger opening was obtained if the Connell suture or the Kocher suture was used, and in every case the speaker made a rather large opening. Six dogs, in which a vicious circle was established, began to fail in flesh at the end of about two months, and at the end of the third month they were opened and a vicious circle found. In every instance there was more or less narrowing of the opening. Dr. CHARLES H. MAYO reported a case in which gastroenterostomy failed to arrest hemorrhage. During the past year he operated upon a man forty years of age, who gave a history extending over a few years of occasional search for the ulcers; and if he found them, he could deal with them accordingly. The other class was illustrated by the two examples cited in the paper. The Correction of Retrodisplacements of the Uterus.— Dr. CHARLES W. OVIATT of Oshkosh, Wis., in a paper on this subject, referred to the many operations devised for correcting uterine retrodisplacements. He stated that whatever the operation selected, it should permit of thorough intrapelvic work and should be one that restored the normal axis of the uterus, at the same time leaving it free to adapt itself to its normal range of motion. The operation he described as meeting these requirements was that devised by Dr. Geo. H. Noble of Atlanta, Ga. A description of the Noble operation could be found in medical literature. During the last year the author had made this operation twenty-three times. In all but three there were intrapelvic or other complications. In ten the appendix vermiformis was removed either because of a history of definite recurring attacks of appendicitis, or because from its appearance it was deemed wise to remove it. In one case a broad ligament cyst was removed, and in several diseased appendages were taken out. These were mentioned to show that there was no difficulty in doing any necessary intrapelvic work through the transverse incision and separation of the recti muscles. In all the cases, local office treatment by means of tampons or pessaries had been resorted to without relief. Most of the cases were in women who were obliged to work and who preferred to undergo an operation rather than submit to further treatment. The three uncomplicated cases were marked neurasthenics with dysmenorrhoea. While the displacement remained corrected, there had as yet been no improvement in the dysmenorrhoea, and little or none in their general condition. There were no deaths or serious complications following these operations. The stomach disturbance and vomiting of blood. By the advantages of the operation were: Through the one inci laboratory test a little blood was found in the stomach. At the operation, in examining the stomach, he did not ind any external evidence of the ulceration. The stomach was dilated. He did a gastroenterostomy, but there was more hemorrhage after it than before, and the man died at the end of four days. He was very anæmic at the time of operation. At the autopsy the intestines were found filled with blood. The gastroenterostomy was a posterior one, after the Mikulicz method, and the line of suturing was perfect. There were no large ulcers in the stomach, but there were two or three points of erosion. Dr. D. S. FAIRCHILD said a distinction should be made between chronic gastric ulcers which bled and fissure ulcers which sometimes gave rise to profuse hemorrhage. The chronic ulcers could be treated by gastroenterostomy, but in fissure ulcers, where the hemorrhage was considerable, gastroenterostomy was not sufficient, and it became necessary to dissect the ulcer out. A case was narrated in point.. Dr. CONNELL had had recently three cases of acute hæmetemesis under observation. One bled very profuseOperation was advised, but refused, and it was thought the patient would die. There were no signs of ulcer. But she recovered. sion any pelvic complication might be treated. The operation utilized the strongest part of the round ligament instead of its distal end. The normal mobility of the uterus was not disturbed, and it was left in the pelvis where it belonged. It caused no bladder irritation and no dragging because the traction on the ligaments was in the direction of their natural course. The writer then quoted Dr. Noble, as follows: "The anchorage is superior in permanency to all peritoneal attachments; the uterine portion of the ligament will not stretch away. There are no sutures in the fundus to irritate the uterus. The fixa quent adhesions to abdominal viscera. The peritoneal tion is extraperitoneal. No irritated point invites subseinvestment of the ligament is not drawn into the abdominal walls, producing funnel-shaped depressions and invit ing hernia. It does not interfere with the physiological development of the uterus during pregnancy." The Surgical Treatment of Goiter.-Dr. CHARLES H. MAYO of Rochester, Minn., in discussing this subject, said that the respect American surgeons held as to the ability of Continental surgeons was to a considerable extent due of the capsule of the thyroid were due many of the sympto their statistics on goiter. To the peculiar formation toms occasioned by enlargement. Closely investigating the gland, it divided posteriorly and also enclosed the trachea, œsophagus, and part of the pharynx. Accessory glands were not uncommon in the lines of inversion from the pharynx in the original formation of the organ. It of a child, four years of age, who had acute hæmatemesis. Operation was refused, and the child died. The third case he operated on, having in mind Monihan's advice, that it was unnecessary to search for the bleeding point, as gastroenterostomy would cause a cessation of the hemorrhage. He operated, but the patient died. From the post-mortem examination in this case he felt confident explain some factors in the etiology of diseases of this that had he made a careful examination of the stomach with the object of finding the bleeding point, he would have found it, and had the ulcer been dissected out, in all probability the patient would have recovered. Dr. Freeman, in closing the discussion, said there were two kinds of cases upon which the surgeon had to operate: First, those in which the surgeon could take time and was probable that the lymphatic system acted as its duct, and a study of the function of the lymphatics would body. In young people at the age of sexual activity, parenchymatous goiters were quite common, but, as a rule, readily responded to treatment. Reverdin, in an analysis of 3408 cases, placed the mortality from total extirpa tion at 19 per cent.; partial, 3 per cent.; from intraglandular enucleation, at .78 per cent.; from resection at 6.6 per cent. The writer's experience was derived from 108 operations upon thyroid tumors. Of these, there were 34 |