sensibilities down to the spinal canal. The only pain complained of was when the needle struck the periosteum. Dr. Beverley Robinson had recently called his attention to an article that appeared in the British Medical Journal last October in which the writer recommended the use of this procedure in cases of well-developed uræmic coma, basing his recommendation on the old theory that the symptoms were due to pressure, as indicated by the preceling headache. The writer reported two cases in which he tapped the spinal canal after the usual methods of depletion had failed to give any relief. He withdrew something less than an ounce of fluid in each case, and in both the symptoms cleared up immediately. In one of them--a case of acute Bright's-the man was practically well when he left the hospital. Since reading this article, Dr. Peabody said, he had had an opportunity to try the method in two cases of uræmic coma, one a boy of twentytwo, who had been operated on unsuccessfully years before for an empyema. A sinus persisted for which he had been operated on four or five times. When Dr. Peabody saw him there was considerable deformity of the left chest, and a deep sinus, which still drained pus. Subsequently, albumin and casts appeared in the urine, pointing to an amyloid kidney, and without warning the patient had a series of convulsions in quick succession. He was first given urethane, under the influence of which the convulsions diminished in frequency but did not cease. The spinal canal was then tapped and six drachms of fluid withdrawn. The convulsion ceased and the following day patient was perfectly clear and bright. The second case was one of chronic nephritis, with high arterial tension. The urine was of low specific gravity; it contained many casts and a trace of albumin. The patient was becoming comatose and an ounce and one-half of fluid was with

drawn by spinal puncture. The arterial tension was markedly diminished, but otherwise there was no improvement. The somnolence gradually increased and a fatal outcome was expected. Dr. Peabody said he was inclined to look upon the improvement after lumbar puncture in his first case as a coincidence. He had never seen any harmful result follow the operation, but he knew of an instance in which the needle was broken and had to be dissected out.

Dr. JOSEPH D. BRYANT said that the plugging of the needle which Dr. Dana had encountered in some of his cases of lumbar puncture was probably due to the fact that he used an ordinary aspirating needle, which had an inner cutting edge. If a needle were employed with the inner edge dulled or entirely removed, especially at the throat of the implement, he believed that less difficulty would be encountered.

Dr. W. GILMAN THOMPSON said that Dr. Dana's paper was an exceedingly valuable contribution to a subject which was still in its infancy. The value of the clinical conclusions of the method was still in doubt, and rightly so, because deductions based upon the numerical preponderance of a certain kind of white blood cell were apt to be misleading. Similar investigations in connection with pleuritic exudates had thus far proven of questionable value. This field of research was one which should not be too strictly criticised at present, but it certainly should be investigated further. It was a curious fact that so many different diseases could produce these numerical differences in the white blood cells.

Dr. Peabody said that in doing spinal puncture he had found that the easiest method was to have the patient lie down on his side, bowing the back and flexing the thighs on the abdomen. This widened the space between the vertebræ, and the needle readily entered the spinal canal, although it was not unusual to have it impinge upon the iamine several times before it finally passed between them.

Dr. Bryant said the widest space was between the fourth and fifth lumbar vertebræ, and by bending the

back, as suggested by Dr. Peabody, the needle could be readily introduced and there was less danger of injuring nerve tissue than by puncturing between the lamina further up.

Dr. BEVERLEY ROBINSON said that about two weeks ago he saw in consultation a case of uremic dyspnoea which soon terminated fatally. In such a case, with pupillary contraction and rapidly developing œdema, the suggestion made by Dr. D. C. McVail in the British Medical Journal, October 24, 1903, to puncture the spinal canal might prove of considerable value.

Dr. JOSEPH FRAENKEL said the method discussed in Dr. Dana's paper was a very recent one. From 1900 until recently it had been practised exclusively in France. The French observers (Widal, Sicard, Ravot, Marie, Guillaine, Déjerine, Babinski, Nageotte) were somewhat enthusiastic in their views regarding its value. Marie believed the lymphocytosis of the cerebrospinal fluid to be of equal diagnostic value as the pupillary and reflex phenomena, particularly in cases of tabes and general paresis. Widal formulated the following rules for the interpretation of cytodiagnostic findings: (1) Increase of lymphocytes (mononuclear), denoted tuberculous disease; (2) increase of lymphocytes (polynuclear), denoted acute infectious disease; (3) increase of epithelial cells denoted the mechanical origin of the disease. Dr. Fraenkel said that forty-four examinations of the cerebrospinal fluid made by him gave the following results: Fourteen times he obtained no fluid; this occurred at the beginning of his investigations and was apparently due to defective technique. The thirty cases in which the cerebrospinal fluid was obtained were divided thus: Seven cases of tabes; three cases of general paresis; seven cases of multiple sclerosis; two cases of brain tumor; three cases of syphilis of the nervous system; four cases of paralysis agitans; one case of poliomyelitis; three cases of neurosis. Generally, he was able to corroborate the statements made by the French observers that there was an increase of the lymphocytes in the cerebrospinal fluid in cases of syphilitic and metasyphilitic disease of the central nervous system and in cases of multiple sclerosis. Confirmatory results were also obtained by Schoenborn in his examinations made at Erb's clinic in Heidelberg. The speaker said that the untoward symptoms of lumbar puncture observed in the course of his investigations were headache and nausea lasting from one hour to three days after the operation. This occurred only in four instances and was considerably ameliorated by saline injections. In one case of suspected disease of the posterior fossa of the skull, and in which no fluid was obtained, the mere introduction of the cannula brought on a rather serious condition of collapse.

Dr. Dana, in closing, said that Babinski had recently reported the cure of a number of obstinate cases of tinnitus aurium, combined at times with vertigo, by tapping the spinal canal. Dr. Dana advised that more attention be paid to the technique of lumbar puncture; as ordinarily done, it was painful and disagreeable.

Spondylosis Rhizomelia.-Dr. DANA exhibited the spine of a case of spondylosis rhizomelia, or chronic stiffness of the spinal column. A history of the case from which the specimen was obtained appeared in the Medical News, November 25, 1899.

About two years after this report of the case, the patient died from an intercurrent affection. The vertebral column was removed and preserved as a separate specimen. It showed ankylosis mainly of the lamina of the vertebræ, and, to a much less extent, of the bodies. The spine was perfectly rigid, like a single piece of bone, but was not deformed. There appeared to be a simple proliferation of bony tissue fastening together the processes, but without producing any great amount of bony hypertrophy or bony protuberances.

many

of the extreme cases left alone, the author thought the mortality should not be more than 5 per cent. in the hands of experienced surgeons. It was fair to conclude that the earlier an operation was performed in these cases, the less would be the fatality, and the greater the benefits.

Multiple Loose Bodies in the Knee-joint.--Dr. JOHN P. LORD of Omaha, Neb., reported the case of a middle-aged man who had suffered from recurrent attacks of arthritis, the result of loose bodies in the knee-joint. The attacks of inflammation and the frequent incapacity resulting therefrom had driven the patient to seek operative relief. Loose bodies in the posterior part of the joint were the chief offenders, and it was thought that no ordinary incision would permit of their successful removal. The writer's attention having been called to the use of the Volkmann incision by the Mayo brothers for suppurating knee joint, it was determined that this method of attack would be required in this case. Transverse division of the patella and the incision of the lateral and crucial ligaments were therefore done, as in an operation for resection. This permitted full command of the articulation. Great difficulty was encountered in removing two of the bodies beated behind the condyles. The patella was wired. The capsular ligaments were sutured with chromicized gut. Drainage was instituted and an interrupted plaster dressing applied. Union was primary, and a good result secured, although notion was limited. After two months the degree of flexion amounted to about 30 per cent. Attention was called to the necessity of delaying maniplation after this procedure for fear of retearing of the immature union of the ligaments, thus rekindling the arthritis. After a period of two months, however, active eforts were made to restore function, with greater success, although it was probable that full function could not be regained after such extensive surgical trauma of disarticulation. No precedent in literature was found for so radical an operation for this condition. There were ten of these loose bodies of large size, and so distributed that the ordinary incisions recommended would have been ineffective in securing the bodies, part of which were attached by pedicles. Less radical means would have defeated the object of the operation, and the patient's relief would not have been complete.

Chronic Adhesive Sclerosing Peritonitis.-Dr. H. G. WETHERILL of Denver read a paper on this subject, in which, after reporting an interesting case at great length, he presented the following points: (1) The rareness of the disease. (2) Failure to recognize it generally and to describe it fully on this continent, though it had been long well-known abroad. (3) The pathognomonic sign, namely inability to unite the shrinking peritoneum when once divided during the course of the operation, which, so far as the writer was aware, he was the first to observe and describe. (4) The essential chronicity of the disease, as indicated by long-standing symptoms, otherwise unexplained, and by the shrinking and retraction of the peritoneum at the first operation, sixteen months prior to the patient's death, which proved the previous existence of the malady, and that it was not directly or indirectly the result of the operation. (5) The great importance of covering all denuded surfaces when, before or during the operation, chronic adhesive sclerosing peritonitis was diagnosed. (6) The characteristic subperitoneal connective tissue hyperplasia which was the pathological feature of the disease. (7) The shrinking or contraction of the peritoneum caused by it, the clinical feature. (8) The possible significance of a somewhat similar pathological process taking place in the skin, coincident with unusual gastrotestinal symptoms otherwise unaccounted for. (9) The danger of serious sequelae incident to its surgical treatment. (10) The possibility of accomplishing much through medicinal measures when the etiology of the disease was better understood. Potassium iodide and inunctions of

mercury were worthy of careful consideration and trial in any suspected case of plastic peritoneal sclerosis.

Median Perineal Prostatectomy.-Dr. GEORGE E. GOODFELLOW of San Francisco, Cal., had operated by the median perineal route in cases of hypertrophy of the prostate approximately seventy-three times, without any immediate mortality, so far as he was aware. He described the technique of the operation in detail. All of these operations were done under spinal anesthesia. Recently he had modified the operation a little. Instead of making an incision, as he had previously described in his papers. from the base of the scrotum to the margin of the anus, he now made an incision an inch in length above the perineal center, and through this opening he could enucleate the prostate with his forefinger. If it was necessary to enlarge the opening, he did so in the usual way. But through an ordinary incision he had enucleated a prostate weighing 7 ounces. In no case had he failed to secure anesthesia when he had entered the canal. The needle was inserted between the second and third lumbar vertebræ.

Complications and Sequelæ of Prostatectomy.-Dr. JAMES E. MOORE of Minneapolis stated that no single operator had had sufficient experience to enable him to speak authoritatively upon the subject, and such extremes of experience had been reported that it was difficult to estimate the real dangers and difficulties of prostatectomy. It was altogether too grave an operation to be resorted to as a routine treatment for enlarged prostate, and was only applicable to properly selected cases. There would always be a place for palliative measures in neglected cases of prostatic enlargement. The most frequent cause of death following this operation was uræmia, consequently the most important preliminary examinations were those of the kidneys. The next greatest danger was sepsis, and in the presence of an infected bladder it was an ever-present one. The most positive indication for operation was very often a complicating cystitis, and it was for the relief of this complication that the various palliative measures were most frequently employed. The only satisfactory treatment for this complication was drainage, and this was best brought about by perineal prostatectomy. Stone was a frequent complication of enlarged prostate, and should always be sought for and removed during the operation. The incision for a prostatectomy, when too extensive, caused various complications. Hemorrhage was an occasional complication, but its dangers had doubtless been overestimated. A serious objection to the suprapubic operation was the extensive injury done to the bladder; while the most difficult problem connected with the perineal operation was how to avoid injury to the rectum. As sequelæ of prostatectomy, he mentioned impotence and incontinence or dribbling. A communication between the urethra and the rectum was one of the sequels met with occasionally. Epididymitis was quite a common sequel of prostatectomy, sometimes becoming so troublesome as to require the removal of the epididymis. Because the writer had dwelt briefly upon possible, as well as probable, complications and sequele of prostatectomy, he did not wish to be classified as a pessimist. Some failures were bound to follow this important operation, as they did every operation of like magnitude. But notwithstanding this fact, it was destined to be one of the greatest boons modern surgery had to offer suffering mankind.

Dr. ALEXANDER HUGH FERGUSON Congratulated Dr. Goodfellow upon his remarkable success, but thought he would yet encounter cases that would terminate fatally. Personally, the speaker had operated upon thirty-one or thirty-two patients without a death, without complications or sequelae, but since then in operating in these cases a death would occur after every few cases. He had had four deaths, so far as he could determine, after having operated in forty cases. In only one of these was death due to the operation per se.

The Use of Silver Foil to Prevent Adhesions in Brain Surgery. Dr. M. L. HARRIS of Chicago said the general principle of the introduction of some foreign substance had been tried in a sufficient number of cases of brain surgery to prevent adhesions, and with results which seemed to justify a belief in its efficacy. Of the materials thus far proposed, the author believed the thin foils were the best, and of these he preferred the silver foil. It was thin, soft, and smooth. It conformed to all irregularities of the surface on which it was laid. As many layers might be applied as necessary to secure a smooth, unbroken surface. It was not only tolerated very kindly by the tissues, but exerted a beneficial influence on granulating or healing surfaces. The foil might be placed directly in contact with the brain tissue between the pia and dura, or wherever it might be necessary to accomplish the purpose desired. The author had used the silver foil in a number of cases of brain surgery, and urged its inore frequent use. He cited a case which illustrated the application of the principle.

Resection of Arteries and End-to-end Union.-Dr. O. BEVERLY CAMPBELL of St. Joseph, Mo., detailed forty experiments on animals, in which different methods of operating were adopted. The author stated that from a recognition of the probably correct theory of the coagulation of the blood, and considering the experiments that had been made and the results obtained, eliminating the process of infection, there still remained factors in the production of thrombosis in the suture of arteries yet to be met and overcome before it could be hoped to reëstablish permanently the circulation of the blood following end-to-end union of arteries. The possibilities of permanently reestablishing the circulation of the blood in arteries following end-to-end union, or resection, was in the author's opinion yet to be demonstrated. In the experiments of Murphy, as well as the writer's, it was observed that where thrombosis did not occur, in the majority of cases an obliterating endarteritis occurred. Murphy observed: After suture of a vessel there is a tendency to endarteritis obliterans." As this process was one of slow formation, it was one of minor importance as to the ultimate result of arterial suture. While the endarteritis was occluding the vessel, collateral circulation was being established, and the danger of death of the part obviated. The following were his conclusions-(1) The death of the endothelial cells following injury to arteries and the addition of ceil death incident to the trauma inflicted from operative measures for the repair of the injury probably furnished the necessary nucleoalbumin needed for the production of the chemical process of coagulation of the blood. (2) That in the resection of arteries and in their suture in continuity, the suture should not penetrate the intima, as the additional death of endothelial cells incident to passing the suture and surrounding it from pressure necrosis might contribute to the coagulation of blood. (3) That the most rigid aseptic technique should be followed in surgical work upon the arteries.

Surgical Treatment of Pulmonary Abscess.-Dr. VAN BUREN KNOTT of Sioux City, Iowa, stated that in two cases which he had seen, although the patients presented all symptoms common to pulmonary abscess, and the physician in attendance, as well as himself, were satisfied of its existence, they were only able to locate it in one case at the autopsy, and in the other suffered the indignity of having the diagnosis confirmed and failure to locate the abscess accentuated by its rupture into the pleural cavity, with empyema as the penalty. While in many quarters attempts to locate the abscess by aspiration had been denounced as unsafe, and injudicious, his limited experience had taught him the inadvisability of attempting to open an abscess of the lung without the aspirator as a guide. The physical signs common to this condition in many cases were alone not sufficient to render its exact localization possible, and while one might be satisfied in a given case that the lung contained an abscess,

and from the usual methods of examination had decided as to its location, this point should be corroborated by the aspirator before proceeding with the operation. Two cases of pulmonary abscess were reported. As to the treatment of these cases by other than surgical methods, the author said it promised little, and as the complications of gangrene, empyema, and bronchiectasis so seriously increased the mortality, even in the hands of the best operators, it would appear that a plea made for early operative relief of patients suffering with pulmonary abscess was not inconsistent with the facts.

The Anatomy and Physiology of the Peritoneum and Their Relation to the Treatment of Peritonitis.- Dr. ARTHUR E. HERTZLER of Kansas City, Mo., said the stomata were declared to be artefacts, for the reason that they occurred only when the peritoneum was treated with a silver nitrate solution. They did not appear when dilute solutions were injected into the peritoneal cavity of the living animal. Other reasons had been given in a previous paper. Attention was called to the fact that the universal reference to the deposit produced when a serous membrane was treated with silver as an albuminate of silver was an error. No such substance existed. What was formed was in all probability a silver chloride produced by the action of the chloride in the fluid with the silver. In the silver solution, producing the stable silver chloride. The peritoneum was covered by a layer of fat cells resting on a layer of elastic tissue. Below this were the blood and lymph vessels. Both systems always formed complete channels and the lymph vessels never formed a connection with the peritoneal cavity. In the process of absorption from the peritoneal cavity the fluid must pass between the endothelial cells lining the peritoneal cavity, through the elastic layer, and between the cells lining the blood-vessels. Whether the cells of each of these layers were united with the intercellular bridges could not be stated. The absorption of .7 per cent. NaCl. solution took place more rapidly than any other solution. Salt solutions of more than one per cent. were absorbed more slowly. Certain solutions caused a transudation instead of being absorbed. Chief among these was formalin. It was effective in a dilution of 1-10,000. Absorption was likewise lessened by the production of an artificial hydræmia. Saline solution might be used either by hypodermoclysis or per rectum, the former being the more rapid and certain. Applying these researches to the treatment of peritonitis, the fallacy of salt irrigations was insisted upon. By using this fluid the toxins were hurried into the circulation more rapidly. The logical treatment was to employ those means which retarded absorption. The production of an artificial hydræmia might be accomplished by the injection of the salt solution either under the skin or per rectum. Formalin in the strength indicated was safe, as had been previously determined by intravenous injections.

Cholecystitis, with Special Reference to Etiology and Diagnosis.-Dr. T. E. POTTER of St. Joseph, Mo., after reviewing the subject, said that the most probable cause of infection of the gall-bladder was not through the intestinal walls, nor through the hepatic tissue, nor from the duodenum through the hepatic ducts, but through the blood of the portal system; and from this source we not only had the catarrhal and parenchymatous inflammations, with occasional empyema, but sometimes malignancy caused by the presence of stones. Among the most prominent symptoms he mentioned tenderness immediately under the ninth intercostal cartilage, saying that this symptom was as valuable as tenderness in the region of McBurney's point in cases of appendicitis. This tenderness might extend down for two or three inches. To elicit it, one should press the fingers up under the ribs and require the patient to take a deep respiration. The patient would complain of pain, and if the fingers were held firmly, the act of inspiration was in

stantly stopped as though there had been a sudden attack of pleurisy.

Treatment of Posterior Perforations of the Fixed Portions of the Duodenum.-Dr. J. E. Summers, Jr., of Omaha, Neb., read a paper on this subject. Retroperitoneal perforations of the duodenum were of such infrequent occurrence that little attention had been directed toward their treatment. After a careful study, he had been unable to find anything written upon the subject that was at all satisfactory. After referring to the surgical work of Kocher, Villard, Jaboulay, Henle, Jeannel, and Mikulicz, the author reported a case of gunshot wound involving the anterior wall of the upper vertical portion of the duodenum and the posterior wall of the duodenum nearer the lower angle. A young man, in attempting to escape from a policeman, was shot in the back by a 38 calibre Colt's revolver, the ball entering one inch below the twelfth rib and through the outer edge of the erector spinæ muscles, coming out in front one and one-half inches below the juncture of the ninth right costal cartilage, with the right rectus muscle. One hour after the shooting the patient was etherized; the abdomen was opened by a vertical incision through the wound of exit. It was observed that the bullet had in its course from behind forward perforated the duodenum and gall-bladder. The wound in the anterior duodenal wall was sutured, likewise both holes in the gall-bladder. Because of the bad condition of the patient, it was decided not to attempt to expose the posterior duodenal wall from in front, but rather to rely temporarily upon an incision from behind, and the introduction of the gauze pack. In the carrying out of this latter procedure the writer discovered that the bullet had made a groove through the lower pole of the right kidney, another reason for the posterior incision. A liberal gauze pack drain was introduced down to the repaired duodenal wound of exit, and the wounds of the gall-bladder, and the abdomen closed so as to admit of the drainage. The patient died three days later, the post-mortem illustrating the cause of death to be a retroperitoneal phlegmonous inflammation without peritonitis. Had the man's condition permitted, the author would have sutured the wound in the posterior duodenal wall after freeing and rotating the duodenum to the left. In the light of to-day one should, in a like case, in addition to repairing the duodenal wound or wounds, occlude the pylorus by means of a purse-string stitch. Either at this same operation or as soon thereafter as reaction permitted, a gastroenterostomy should be made. None of the procedures which he had indicated required much time for handling of the intraabdominal contents. They were the only rational methods of treating a perforation of the posterior wall of the duodenum. It was almost impossible for a gunshot wound of either the stomach or duodenum, which perforated both walls, to be limited to those organs. Therefore, under such circumstances, in addition to the repair of any intraperitoneal organs involved. proper incisions must be made to provide for retroperitoneal drainage.

Election of Officers.-The following officers were elected: President, Dr. Charles H. Mayo, Rochester, Minn.; First Vice-President, Dr. H. D. Niles, Salt Lake City, Utah; Second Vice-President, Dr. L. L. McArthur, Chicago; Secretary-Treasurer, Dr. B. B. Davis. Omaha, Neb.

Milwaukee, Wis., was selected as the place for holding the next annual meeting; time December 27 and 28, 1904.

Scarlatina.-Tobeitz, to prevent or cure nephritis, injects 1 c.c. of oil of turpentine into the outer aspect of the thigh and two days later give 25 drops by the mouth in capsule or emulsion. In severe cases he repeats the cperation on opposite thighs on successive days.-Medical Times and Hospital Gazette.

New Instruments.

A MODIFIED ALLIS INHALER.* BY A. F. ERDMANN, A.B., M.D., BROOKLYN, N. Y.

THIS modification is an attempt to make still more serviceable an instrument whose value is most highly appreciated by American anesthetists. One wishes another inhaler were at hand only when it becomes necessary to turn the head of the patient from the vertical to a more or entirely horizontal plane, for it is decidedly inconvenient to drop ether upon an Allis inhaler when the head is turned far to one side. The Sim's was Skene's favorite position for most vaginal operations, and when I began my anæsthetic service with him I soon wanted either to put aside my Allis, or else modify it to fit my needs. It was in 1898 that I hit upon the idea since then so ex elle ly introduced in the Fowler inhaler, of making the inhaler to open on the side instead of at the top. As I have shown in an old model, this can easily be done by simply cutting out of the rubber cover a half-inch strip across its middle third about three and a half to four and a half inches from the lower edge, and shutting off the air supply from above by merely stuffing in a towel or laying over the metal frame a tight-fitting piece of rubber or sheet metal.

The inhaler can now be used in either way. A towel or bandage pinned around will close the lateral opening, leaving a plain Allis; the side slit can be quickly exposed and the top opening covered to adapt the inhaler for side positions. To be sure this new procedure greatly diminishes the open-air

The Modified Allis Inhaler.-A. B, metal frame. C, side plate pushed back to open fenestra; dotted outline shows it full size and shape closing the opening. D. top plate, with open knob, to fit snugly over metal frame.'

space, but not so much as to be of practical interference. Besides, more air, as much as is desired, can be admitted by tilting the upper plate or laying the towel in loosely. When the inhaler is entirely closed it is adapted for the exhibition of ethyl chloride by the German method, and for the use of the bromide of ethyl according to Fowler's directions.

*Presented before the semi-annual meeting of the Medical Society of the State of New York, held in New York October, 1903.