warm boracic lotion. The drug seems to destroy or neutralize the excretory products of the larvae, which often excite considerable local inflammation and high fever. It is fatal to most of the lower forms of life. A Case of Vesicular Mole of Unusual Size.---Thomas Slater Jones describes this case. The patient was aged forty-eight years and had had eight children. Five years before she passed a similar mole but much smaller. When the writer was called to see her, she was having strong labor pains. No foetus could be felt. Masses of the cysts presented themselves at the os. The patient was put under chloroform, and the writer introduced his hand into the uterus and got the whole mass of cysts away without much difficulty. He kept his hand well over the uterus and injected ergotin hypodermically and hemorrhage did not occur. The patient made an uneventful recovery. The mass weighed five pounds four ounces. The cysts looked somewhat like grapes, and contained a gelatinous material, slightly tinged with red. Some Deceptive Abdominal Conditions and the Question of Operation.-A. H. Tubby calls attention first to the condition of the pulse and temperature. He says that the conditions of gravity are two: First, a normal temperature with a pulse-rate of 100 or over; secondly, a more serious condition, a subnormal temperature with a rising pulse. If the abnormal ratio has been established for a day or longer, the prospects of surgical interference arc extremely unfavorable, because the altered ratio is signiicant of the absorption of septic products. It is important not only to ascertain the number of leucocytes but the ratio of polymorphonuclear cells. If these are increased from the normal rate of 65 per cent. to over 70-75 per cent, then pus formation is certainly present. Rigidity is a symptom to be carefully watched, particularly if it be persistent. Vomiting is a very variable sign. Distention is often absent in the early stages, but in the later stages of abdominal disease the fatal significance is only too well known. Diarrhoea occurring in the course of acute appendicitis is generally significant of septic absorption from a non-evacuated abscess. Local tenderness is always of value as a guiding point to the site of the lesion. The persistence of hæmatemesis and melæna after an injury or in association with a suspected gastric or duodenal ulcer, may be such as to determine the question of operation or otherwise. The presence or absence of increasing abdominal dulness is an important factor in doubtful cases of injury when it may be that a solid viscus has been ruptured, and blood is being poured out into the peritoneal cavity, or the dulness may be due to effusion of pus or fluid, or to matted intestine with adhesion, as in appendicitis. Effusion of blood beneath the abdominal walls is not a symptom to be relied upon and should be considered only with other symptoms. The association of pleurisy and perigastric abscess is well known, so also is the existence of subdiaphragmatic abscess secondary to appendicitis, and the presence of fluid at the right base. As to the chest symptoms, the point lies in their persistence preceded by a history of abdominal trouble. Berliner klinische Wochenschrift, February 1, 1904. Stimulating the Secretion in Nursing Women.-Zlocisti points out the necessity of encouraging nursing instead of bottle-feeding and reports the results he has had with a purified form of cotton seed used as a galactagogue. The observations of dairymen have established the value of the oil cake obtained as a by-product in the expression of the oil from cotton seed as a means of increasing the milk output of dairies and the author has employed a purified product deprived of its indigestible cellulose constituents for a similar purpose with nursing women. The results showed that the preparation was not found disagreeable to take by the women and that it did not seem to cause any undesirable effects. In all of the twelve cases in which it was given it seemed to cause a very marked stimulation of the milk flow, which became apparent on the third or fourth day, when twenty-five to thirty gm. of the substance had been administered. Cytodiagnosis of the Cerebrospinal Fluid.-Meyer abstracts the observations of the French school who have developed this method of diagnosis and appends the results of his own investigations. In thirty-five cases examined, lymphocytosis was found fourteen times, which comprised eleven cases of undoubted general paralysis and three in which the same diagnosis was probable. In four cases, viz., of paralysis, of chronic alcoholism suspected of paralysis, of multiple sclerosis and of katatonia an increase of small mononuclear leucocytes was observed. In the other seventeen cases, mostly functional in nature, but including one case of paralysis, no lymphocytosis was observed. These results are in harmony with those of the French authors, and show that in nearly all cases in which a condition of chronic meningeal irritation could be assumed, lymphocytosis of the cerebrospinal fluid is found. When this is present an organic lesion probably exists, and therefore the point may be of importance in differentiating functional and organic states. What the value of such examinations is in the differential diagnosis of various organic conditions remains to be seen. Münchener medizinische Wochenschrift, January 26, 1904. Severe Discoloration of the Skin Following the Injection of Adrenalin.-Schücking has used his preparation with good results in plastic operations on the vagina, but believes it increases the postoperative nausea. In one case after 134 c.c. of a 1-100 solution had been injected the patient's skin acquired a deep bluish black color resembling that of Addison's disease and lasting one-half hour. The pulse remained palpable, but respiration became shallow until artificial respiration was used. 2 A Rapid Gasometric Method for Determining the Sugar in Urine.-Riegler has devised a simple yet accurate method for determining the amount of glucose in diabetic urine which possesses the advantage of taking very little time. It depends on the decomposition of potassium permanganate by glucose into CÔ, and potassium carbonate. The amount of the latter is estimated by adding dilute sulphuric acid, and measuring the CO gas given off. On consulting a table the amount of glucose required to produce a corresponding amount of potassium carbonate is obtained, and the results are said to be more accurate than with the usual methods. A detailed description of the apparatus, working directions, correction tables, etc., is given. An Improved Azotometer for the Quantitative Determination of the Urea and Uric Acid in Urine.-Jolles has simplified the apparatus used in his method for determining urea and uric acid, and describes its perfected form. The method for urea consists in diluting the urine and adding phosphotungstic acid. A measured amount of this mixture is treated with sodium hypobromite solution in the apparatus, and the amount of liberated nitrogen read off. The same apparatus is used for the uric-acid determination. The urine is mixed with ammonium acetate and ammonia. The precipitate is washed with ammonium carbonate and boiled with magnesia to drive off all ammonia. The result is acidified and oxydized with potassium permanganate. fluid is then alkalized with sodium hydrate and decomposed with hypobromite solution in the apparatus. The amount of nitrogen corresponds to a uric acid content obtained by consulting a table. The The Origin of the Basophilic Granular Red Blood Cells. Naegeli reviews the arguments of those observers who consider these granules as degenerative, and of those who take the opposite view and hold that they are the result of response to a stimulus and are therefore regenerative in nature. Under the author's direction Lutoslawski made a series of observations in animals poisoned with lead. These corroborate the conclusions of Sabraze's, who found that acute poisoning fails to produce the granules, that if they have been formed as a result of chronic poisoning, a large increase in the dose of the lead causes them to disappear, and also that they disappear before death. This looks as if they were formed as regenerative bodies, but the author does not consider the question settled, though he says that it seems certain they cannot be degenerations. Whether they are the result of changes in the nucleus or in the cytoplasm is also still undecided. The Acute and Chronic Circumscribed Inflammations of the Colon.-Bittorf describes five cases in which, after a greater or less degree of constipation, a tender abdominal mass developed, usually in the region of the sigmoid, and there was an accompanying rise of temperature. One of the cases was remarkable for the development of a large exudative mass in the left iliac region, while under observation, together with a leucocyte count of 24,000. The mass was absorbed in about eight days and recovery followed. Castor oil was found the most efficient purgative in all the cases. Such conditions begin through the gradual accumulation of fecal particles in the haustra of the intestine. As the collections increase in size they become dry and irritating to the mucous membrane, so that by degrees the submucosa and peritoneum become inflamed and the clinical picture of the condition is produced. In the chronic cases there are moderate temperature, constipation, loss of appetite, malaise, nervous disturbances, and sometimes diffuse pains in the left iliac region, together with a sausage-shaped mass in the same situation. The treatment comprises laxatives, compresses to the abdomen, diet, rest in bed, and massage. Book Reviews. ASTHMA IN RELATION TO THE NOSE, with Notes of 402 Cases. By ALEXANDER FRANCIS, M.B., B.C. Cantab. London: Adlard & Son, 1903. THE author regards the ordinary classification of asthma as untenable and misleading. For him it is due to spasm of the bronchial muscles probably always induced by reflex action and not due to any mechanical obstruction of the air passages. The nose comparatively rarely supplies the immediate exciting cause of the asthmatic reflex, but in the asthmatic state a morbid connection exists between some parts of the nasal apparatus and the respiratory center whereby the stability of the latter is affected. In other words, some part of the nasal mucosa has a controlling influence on the respiratory center and that area is on the septum. He employs the usual measures of treatment, but his procedure par excellence is to cauterize the septum with the galvanocautery point from a spot opposite the middle turbinate forward and slightly downward. The results he brings forward are remarkable. We can only say that the same method in the hands of others has not been by any means so successful. A COMPEND OF PATHOLOGY, General and SPECIAL. A Student's Manual in One Volume. By ALFRED EDWARD THAYER, M.D., Professor of Pathology, University of Texas. Second Edition, containing 131 Illustrations. Philadelphia: P. Blakiston's Sons & Co., 1903. THE domain of pathology has received such important additions through the recent investigations in the fields of hemology, bacteriology, parasitology, etc., that constant changes are necessary to keep the textbooks representative of the present status of the science, while the subject of immunity has made such great advances that most of the older views as to the nature of disease have undergone important modifications. The present volume is thoroughly modern in its treatment of all of these topics and should be of interest to all who are anxious to follow the trend of thought which is molding the pathology of to-day. Most of the important recent contributions have been incorporated and the tabular arrangement adopted by the author in many instances, is most valuable in illustrating the philosophy of the various branches of the subject. The illustrations are excellent and, together with the admirable mechanical execution of the volume, combine to make it a most attractive handbook. Technik und DIAGNOSTIK AM SEKTIONSTISCH. Von Dr. RICHARD GRAUPNER, Assistenzarzt am Kinderkrankenhaus und Dr. FELIX ZIMMERMANN, Früher Volontärassistent am Pathologischen Institut der Universität zu Leipzig. Mit 126 Abbildungen in Dreifarbendruck auf 65 Tafeln und 25 Abbildungen im Text. Zweiter Band. Zwickau, Sa.: Förster und Borries, 1899. As the title indicates, this is primarily intended as a guide for practical work and to assist the inexperienced or occasional performer of autopsies in making a correct diagnosis. The tone of the book is therefore much less philosophical than is usually the case with German productions, and it is well adapted to compensate for lack of practical training in this difficult subject. The chief interest naturally attaches to the plates, which are exquisite examples of what can be done by the three-color process, and show a clearness of detail and fidelity to natural coloring rarely attained. The value of the pictures is greatly enhanced by the fact that the originals are the actual handiwork of the authors themselves, and therefore have been painted with a discrimination impossible to the lay artist. All but three of them were done directly from the fresh specimens, special care being taken to catch the proper color shades before these should have become altered by the rapidly oxidizing effect of exposure to the air. The important features of each case are concisely presented in appended paragraphs of description. In the volume of text the entire field of gross pathology is clearly discussed from the purely practical standpoint, and many helpful tables of conditions occurring in each organ are given. The work is surpassed by few in beauty or in usefulness. A TEXTBOOK OF LEGAL MEDICINE AND TOXICOLOGY. Edited by FREDERICK PETERSON, M.D., Chief of Clinic, Nervous Department of the College of Physicians and Surgeons, New York; and WALTER S. HAINES, M.D., Professor of Chemistry, Pharmacy, and Toxicology, Rush Medical College, in affiliation with the University of Chicago. Vol. II. Philadelphia, New York, London: W. B. Saunders & Company, 1903. WITH the second and last volume of this work is included a eaflet with evident suggestions for the reviewer, which -end as follows: "In fact, the entire work is overflowing with matters of the utmost importance, and expresses clearly, concisely, and accurately the very latest opinions on all branches of forensic medicine and toxicology." In spite of this optimistic statement we regret that we cannot alter our views expressed after reading the first volume when it appeared, for we find little here that has not been said before in a better way; and a great deal has been omitted. It was hoped that a textbook with these pretensions would naturally contain much fresh matter, and be clearly a new departure, but to our disappointment we find that the bulk of the book is modelled upon trite and oft-repeated lines, and we fail to find among the names of the contributors more than two or three who have taken even a prominent place in their profession. We are sorry to find that the medicolegal consideration of insanity has received such scant notice, for beyond the purely clerical reproduction of the laws of the various States, which are as likely as not to be modified at the next meeting of the various legislatures, there are but four or five pages devoted to the consideration of the powers and duties of the committees of incompetent persons, and nothing is said about civil or criminal responsibility. The articles of most value are those which have done duty before in Witthaus's or Hamilton's treatises, and beyond slight modifications or additions, such as the blood-serum tests in Dr. Wood's contribution, are practically the same as when they appeared in their virgin state, and even a superficial comparison will show this. In this connection it is inconceivable how men with a reputation and position of those who have erred in this way, could offer practically the same literary material to two publishers. Certainly the editors themselves have shown a lamentabie carelessness in not securing original articles. The make-up of the work is good and eight of Hoffman's vividly colored plates that were not used in the first volume are utilized in that before us. THE TENEMENT-HOUSE PROBLEM, Including the Report of the New York State Tenement House Commission of 1900. By various writers. Edited by ROBERT W.DE FOREST and LAWRENCE VEILLER. Vol. I and II. New York and London: The Macmillan Co. THIS work very satisfactorily fulfils its mission in discussing the various and intricate problems of tenement-house reform. No pains have been spared to obtain accurate information regarding existing conditions from expert sources, and the result is a mass of statistical data that cannot fail to appeal to the social economist and the sanitarian. In no other city can overcrowding be studied to better advantage than in some of the lower and east-side districts, where the tenement population is more dense than in any similar locality in the world. The numbers that are thus massed are truly appalling. Nor can the causes for this be easily obviated. Manhattan Island, long and narrow as it is, has very few facilities for expansion. The poor to be near their work must be necessarily massed in accessible quarters. With high taxation space becomes necessarily limited, and property holders, to realize upon their investments, are forced to multiply living rooms in every conceivable way. The room that cannot be gained on the ground is obtained by piling up structures to increase their height. Backyards are sacrificed, light and air excluded, and the diseases of poverty multiply in proportion. All these conditions are graphically described in this admirable report of the commission. The truth of the adage that one-half of the world is ignorant as to how the other half lives is strikingly shown by the flash-light pictures of the dark, unventilated, and foul rooms of many of the populous tenements. Even the air-shafts are receptacles of filth, the fire-escapes encumbered with litter, and the inner waterclosets uncleanly beyond description. These are the object lessons that must force conviction on the most apathetic observer. How to remedy this deplorable state of affairs is the burden of the argument of the different writers. Whether we view it from the moral, social, or sanitary standpoint, the necessity for radical reform is apparent. Every human quality is tainted in such an atmosphere. Hence it is not surprising to learn that moral instincts become suppressed, that vice thrives, intemperance increases, and, last of all, death from preventable disease balances the unequal struggle for existence. The commission has done very commendable work in mitigating many of the present evils, but it is merely a commencement in reform rather than a consummation of even reasonable expectations. The problem is tackled from the right quarter by educating the poor as to their rights and privileges, at the same time by force of law compelling the owners of tenements to respect ordinary sanitary regulations. Each contributor has done his part in such direction, especially those who have treated of the dangers of tuberculosis and other diseases from overcrowding. As a contribution to the cause of municipal reform, this book is a notable and enduring monument to the conscientious and painstaking efforts of its contribu tors. Society Reports. NEW YORK ACADEMY OF MEDICINE. Stated Meeting, Held January 8, 1904. Dr. ROBERT F. WEIR said that Cushing had been the first in this country to undertake this operation, the spinal accessory nerve being used in his cases. While there was improvement, it was associated with conjoined synchronous motions of the trapexius. This was quite a serious objection, and hence, the hypoglossal nerve was substituted. Personally, he did not expect the same success from grafting into the hypoglossal as when the spinal accessory was used, because the one did not secure an end-to-end anastomosis and could not expect so much nerve regeneration. He had tried the method in his ward upon a woman who had developed facial paralysis after a mastoid operation. Because of the long duration of the palsy it was not to be expected that the operation would be followed by as much success as in the more recent palsies. He had found the technique very satisfactory, and the operation had been followed by primary union. It was too soon, of course, to speak of the result. Dr. H. LILIENTHAL thought one should be pretty sure that spontaneous recovery might not take place before resorting to this operation of nerve anastomosis. He knew of at least one case in which, after rheumatic paralysis, recovery took place after an interval of a number of months. If he remembered correctly, Cushing's case was of considerable duration. He was of the opinion that even associated shoulder movements were to be preferred to a possible permanent derangement of the tongue. Dr. THOMAS H. MANLEY entirely agreed with the last speaker as to the possibility of spontaneous regeneration of the nerve. He recalled one case in which this occurred even after ten months. It was well known that there was no other tissue in the body which possessed the regenerative activity of nerves. In one of the reported cases a certain degree of wry neck followed the operation. Dr. C. A. ELSBERG referred to two cases coming under his observation. The first occurred in a man who had had a rheumatic paralysis of eight months' standing. The paralysis had not been benefited at all by persistent treatment in the out-patient department. He was kept under observation, however, for a considerable time, and when heard from a few months later, no operation was necessary. The second case occurred in the Montefiore Hospital, and when seen there was a palsy of about eight months' standing. In that case, after one or two months, improvement began, and it was now proceeding quite rapidly. If these cases had been operated on quite soon they would have probably yielded very good results, but it could not be said that the recovery was due to the operation. He had searched the literature, and had found that some of these cases recovered spontaneously after from eight to twelve months. The operation described by Dr. Taylor was certainly a beautiful and attractive one, and the improvement had taken place rather more quickly than in most of those reported. Dr. FRED KAMMERER thought a distinction should be made between rheumatic cases and those in which the paralysis was caused by a loss of nerve substance. Dr. A. S. Taylor said that of course the question of spontaneous recovery must always be considered. In socalled Bell's palsy such recovery was the rule, but sometimes in chronic cases there were contractures of the muscles which were even more disfiguring than the paralysis. In his second case, that of the woman, treatment had been carried on for three months by the neurologist, and there had been not only no improvement, but a tendency toward contracture had developed-at least this was the opinion of the neurologist who worked with him. The question of derangement of the tongue should be borne in mind, but with proper technique there would be no unnecessary disturbance, and the derangement of the muscles of the tongue would probably be slight and temporary. This was rather a matter of faulty technique than a defect inherent in the operation itself. As Dr. Kammerer had well said, the traumatic cases, in which there was a loss of substance of the nerve, afforded almost no chance for regeneration of the nerve. The greater the length of time from an infectious paralysis to the time of surgical intervention, the less the chance of obtaining a good functional result from nerve anastomosis. A New Procedure in Rhinoplasty.-Dr. CARL BECK presented this case that it might be judged of before the final result. Some years ago a rhinoplasty had been done on the patient by a well-known surgeon, but the result of that operation had been destroyed subsequently by an extension of the process for which the operation had been done, i.e. epithelioma. When the case came under Dr. Beck's care he could find no tissue on the face for an operation, and, hence, adopted the plan of taking it from the arm. The result of this operation was good, but a recurrence of the disease caused a destruction of nearly half of the nose. He had then resorted to what he believed to be a novel procedure. A large triangular flap was taken from the lower lip. This was partially separated a week after the operation to shorten the patient's sufferings, and the remaining portion of the pedicle was separated only five days ago. One advantage of using the lower lip for this flap was that mucous membrane was thus obtained. Another advantage was the thickness of the flap. He would have employed the x-ray treatment were it not for the shrinkage of the tissues which would have resulted, and which would have interfered with the operative procedures. X-ray treatment would be employed as soon as practicable after the operation. Fecal Fistula Following Appendicitis.-Dr. A. ERNEST GALLANT presented this patient, a little colored girl. He said that fistula of the small intestine in conjunction with appendicitis he had not met with before. He had first closed the opening of the fistula, and then dissected out the scar. In doing this, the fistula was cut through a second time, and such a large gap was made that it became necessary to resect the bowel. The result was entirely satisfactory, there being primary union and a total absence of pain. The bowels moved without any medicine on the sixth day, and the child was out of bed on the tent day. Dr. MANLEY asked whether the perforation of the small intestine was due to trauma at the first operation, or to some disease, such as tuberculosis. He would also like to know whether the union was made by means of button or suture. Dr. GALLANT replied that from the history he understood that the original operation wound had been drained, but further than this he knew nothing about it. His closure of the opening had been by means of an end-toend anastomosis with the Lembert suture. There was Gunshot Wound of the Abdomen.-Dr. J. J. HIGGINS presented this case, and reported another. The case reported was that of an Italian who had a bullet wound midway between the umbilicus and the pubes. The operation was done five hours after the shooting. one opening into the jejunum, and there were seven holes some distance lower down in a space of about six inches. This portion of bowel was excised, and an end-to-end anastomosis done. Recovery took place without further incident. A week later the second patient came into Fordham Hospital with the same injury, but he absolutely refused operation. For five days there were vomiting and hiccough, the pulse and respirations were rapid, and the temperature varied between 101.2° and 103°F. During this time he was very ill, but on the fifth day his stomach was washed out and from that time on recovery was rapid The bullet was not located, and no blood was passed per rectum or vomited. Retroduodenal Choledochotomy for Impacted Calculi in the Retroduodenal Portion of the Choledochus.-Dr. A. A. BERG reported this case and presented the patient. The woman had been admitted to the surgical service of Dr. Gerster in the Mount Sinai Hospital last July. She had been jaundiced for eight months, and gave a straightforward history of repeated attacks of biliary colic for some time. She was emaciated, and had had chills and rises of temperature on several occasions. A diagnosis of cholelithiasis was made, and an operation undertaken. Upon exposing the biliary apparatus, the gall-bladder was found free from calculi, but reaching from both branches of the hepatic duct through the main hepatic duct down through the common bile duct to the papilla in the duodenum was a continuous chain of calculi, varying in size from a marble to a split pea. The cystic duct was empty. It seemed to be a primary formation of calculi in the hepatic ducts, and on subsequent exploration of the hepatic ducts in the liver he was able to deliver about half a dozen stones from the ramifications of the main hepatic duct in the liver itself. The common bile duct was first opened and the stones accessible through the incision were easily removed. One stone was very firmly impacted just above the papilla, and could not be dislodged by a sharp spoon passed through the incision or by manipulation through the duodenum. Last May, in a paper on cholelithiasis, the speaker said, he had proposed a procedure recommended by Kocher for gastroduodenostomy, i.e. the reflection of the descending portion of the duodenum and rotation of this portion upon the longitudinal axis, turning the duodenum to the left, and exposing the common bile duct on the posterior surface of the duodenum. In this way the common bile duct became accessible in that portion which had always been a bugbear to the surgeon. In this case the common bile duct did not pass through the head of the pancreas, but even when it did so it could be easily shelled out. The advantage of this procedure was that the duodenum was not opened. The mere opening of the healthy duodenum with a healthy peritoneum was not very serious, but it was entirely different with a diseased duodenum. Dr. Lilienthal had antedated the speaker in the actual performance of this operation. It had been recently stated that this procedure was an old one, but on looking up the literature it was found that in no previous case had it been the intention primarily of the operator to do the operation which he recommended. Where there were numerous adhesions around the second portion of the duodenum this procedure was easily done. The woman upon whom he had done this operation was now pregnant, but there was no hernia present. Dr. LILIENTHAL said that he did not do the operation as described by Dr. Berg, but opened the peritoneum, introduced the finger, and rotated the descending portion of the duodenum so that the stone presented through the peritoneum to the inner side; he had not thrown the gut over and taken the stone out from behind. He thought, however, that Dr. Berg's method was a good one. Dr. JOSEPH A. BLAKE said that it was quite difficult to remove stones from this portion of the gut, and this seemed to him to be a good method if it could be carried out without infecting the retroperitoneal tissues. Dr. KAMMERER said that theoretically this method of reaching the common bile duct ought to be good; he had reached the duct in this way twice this winter. Dr. W. S. BICKHAM said that he had seen a pathological specimen in which the calculus had passed down the common bile duct to the duodenum. It had then ulcerated its way safely through the duodenum, had passed down several inches, and after the lapse of a considerable time had caused the death of the person. This was a rather remarkable circumstance when it was considered that the stone had passed safely through the narrow duct, and had finally, by reason of its unusual size, caused obstruction of the larger duodenum. Dr. BERG said that no doubt this procedure had been resorted to many times, but it had not been previously described as a typical procedure. An interesting feature of his case was that there was a primary formation of stones in the hepatic ducts. Some Surgical Features of Typhoid Perforation, with a Report of Four Cases.-Dr. CHARLES A. ELSBERG read this paper. The patients had been operated on by him on the surgical service of Dr. Lilienthal at the Mount Sinai Hospital. He had also observed eleven other patients operated on by others at the same hospital. He said that the operative treatment was indicated in every sense of typhoid perforation of the bowel as soon as the diagnosis had been made. Operative interference for suspicious symptoms was a course which had been declared justifiable by a number of writers on this subject. However, delay was advisable in some cases. There was still no unanimity of opinion as to what constituted the symptoms of perforation. The only symptoms of perforation per se to be conceived of were sudden abdominal pain and the presence of free gas in the abdominal cavity. Sudden abdominal pain was evidently not a distinctive symptom, and although the presence of free gas was almost pathog. nomonic, if demonstrable, this was not always possible. Moreover, all cases of perforation were not associated with the presence of free gas in the abdominal cavity. Diagnosis. In the cases upon which this paper was based there was usually a history of sudden abdominal pain or of increase in existing pain and tenderness. At the time when the diagnosis could be made there was more or less increase of pulse and respirations. Some of the patients had been in collapse; the abdomen had been distended and more or less rigid; at times there had been free fluid and gas in the abdominal cavity. Collapse did not occur as often as might be expected, having been present in only four out of the fifteen cases. In six of the cases the distention of the abdomen was very marked; in one case there was no distention. Diminution of the areas of liver dulness was of great assistance in making the diagnosis. This diminution was usually due to the abdominal distention. Abdominal pain and tenderness were usually most marked on the right side of the abdomen, although the entire abdomen was often tender in these cases. Free gas could only be demonstrated in five out of fourteen patients giving evidence of diminution of the area of liver dulness. In endeavoring to demonstrate the presence of free gas he had found it useful to have first the head and then the foot of the bed raised considerably while percussion was made. The temperature changes presented nothing characteristic. gard to leucocytosis he had come to the conclusion that it had little value; its absence did not at all exclude the possibility of perforation. With re Indications for Operation.-In most of the cases considered, the diagnosis of perforation of the bowel could be made almost certainly in from four to twelve hours after the occurrence of the perforation. These patients bore the operation remarkably well if the manipulations were carried out quickly. When the diagnosis was only probable, if the patient's condition were steadily growing worse it was desirable to make a small exploratory incision. If nothing were found, the operation could be completed in ten minutes, and the patient could be returned to his bed with a good expectation that his general condition would be made little, if any, worse by the operation. When the symptoms of perforation had existed for at least twelve hours and were fairly clear, the operation was justifiable. If, however, the symptoms had existed for more than twenty-four hours, and the patient's general condition was still good, and the diagnosis was yet in doubt, the surgeon was justified in advising a few hours' delay if the case could be carefully watched. In ten of the fifteen cases the abdomen contained seropurulent fluid in considerable quantity, and there were no adhesions between the coils of intestine. In all of these cases the operation had been done in less than twenty-four hours from the occurrence of the symptoms of perforation. In six of the fifteen cases the abdominal cavity contained free gas. Deeply ulcerated Peyer's patches could be plainly seen through the peritoneal coat of the bowel in some instances. In one case he had sewed over four such ulcers, and had desisted from sewing others because of the danger of unduly narrowing the lumen of the bowel. The patient did very well for a time, - but subsequently died from the perforation of one of the ulcers that had not been sewed. Of his own four cases, three were in distinctly better condition at the close of the operation than before it. In the fatal cases death occurred in most instances from the infection of the peritoneal cavity as a result of the perforation. Typhoid perforation commonly occurred while the fever was still high. In a number of the operative cases a sudden fall of the temperature took place in the first twenty-four hours after the operation, and he had come to look upon this as of good prognostic import. The abdominal wound should be drained, otherwise it was likely to become infected. Rapidity of operating was a sine quâ non in cases of typhoid perforation. The average duration of the operation in his own cases was a trifle over fifteen minutes. In most instances the prominent loop of bowel was found to be the one containing the perforation. When the perforation was too extensive to suture, the omentum could be sewed over the area or the affected portion of bowel anchored in the abdominal wound. When the perforation was walled off from the general cavity by adhesions it was advisable to do nothing but drain. He preferred to use general chloroform anæsthesia, preceded by a dose of morphine. Dr. J. A. BLAKE said that the possibility of securing good results from operation had been well emphasized by the paper just presented, and he hoped the medical profession at large would not overlook this important fact. He could agree with all that had been stated in the paper. In only one case had he been able to demonstrate free gas in the peritoneal cavity. He had found three perforations in every case but one, and there was always some suspicious part requiring to be turned in. The perforations were usually closed by means of a purse-string suture, the peritoneal cavity was washed out very freely and the wound was drained so as to avoid infection. The first three cases, done in the past year, got well except the one dying on the twenty-eighth day from a relapse of typhoid fever. All of these patients had a relapse of the typhoid fever. He had also noticed a fall of temperature to the normal in the twenty-four or thirty-six hours after operation, and this had been present, he believed, in all but the fatal cases. He laid considerable stress upon rigidity of the abdominal walls as a diagnostic sign. The cases were operated upon in the hospital always less than eight hours after the perforation. Dr. LILIENTHAL said that Dr. Blake had been very fortunate in being able to operate upon his cases so soon after perforation. Personally, he had operated upon a number of cases, and all but one had died. In a hospital a good house staff would make the diagnosis quickly, the operating surgeon could be summoned and the operation could be undertaken quite early if the necessary consent could be obtained. It was different in private practice; the diagnosis was made after much hesitation and there was still further delay before the case was seen by the surgeon. It was not surprising that under such conditions operations for typhoid perforation done in private often proved disastrous, and, as a result, the operation itself unjustly fell into disrepute. Medical men should have an understanding with the surgeons so that when a typhoid perforation was suspected there need be no unnecessary delay in securing the services of the surgeon. The Operative Treatment Hardly Applicable to Private Practice.-Dr. A. A. BERG did not think that the exploratory operation in private practice would ever come to be a recognized procedure in typhoid-fever cases. The oblitera tion of liver dulness he considered a very important diagnostic sign of typhoid perforation. If there were free gas in the peritoneal cavity, there would be found on percussion a diminution along the upper margin as well as the lower margin of both the liver and spleen. The diminution of the dulness at the lower margin was not of great importance. The number of recoveries from operative interference in these cases at the Mount Sinai Hospital had not been very brilliant. One must take into consideration the type of the epidemic among other things. The older practitioners spoke of many cases of so-called peritonitis complicating typhoid fever which recovered without operation, and so long as the surgeons could only show a recovery of 30 per cent. under favorable conditions, and with operations done within a few hours after the occurrence of the perforation, the operative treatment could not be very forcibly urged upon the medical profession. Dr. Crile had shown that one of the best ways of producing shock in animals was by washing out the peritoneal cavity; hence, it was very questionable whether the washing out of the peritoneal cavity after perforation was advisable. Free Gas Due to Another Cause.-Dr. ROBERT T. MORRIS said that he had recently operated upon a case for supposed perforation, there being much free gas in the peritoneal cavity, but had been surprised to find that the free gas was not due to perforation but to the action of the bacillus aerogenes capsulatus. Mention was made of a case that he had seen in which a patient had recovered from a typhoid perforation and had died subsequently from strangulation. If the surface were lightly scarified and two or three inches of Cargile membrane were applied to the ulcers which were on the point of perforation, he thought sufficient temporary protection would be afforded in many instances. Dr. J. A. BLAKE said that the trouble in operating upon these cases in private was attributable not so much to the surgeon as to the physician. We should not hesitate any more to operate upon a case in private practice than upon a hospital case, and if the patient were too near to us, by reason of kinship or friendship, we should have nothing whatever to do with the treatment. One reason that he had been able to operate so early in the hospital in many cases was that he had an understanding with the medical house staff, and had been promptly called by them when perforation occurred. He knew what Dr. Crile had written on the subject of washing out the peritoneal cavity, but he still felt that this procedure was valuable and persisted in employing it. His cases had done much better since he had abandoned drainage of the peritoneal cavity as much as possible. Dr. ELSBERG closed the discussion. He said that Dr. Morris's suggestion concerning the use of Cargile membrane impressed him as both novel and useful. According to all authorities, less than 5 per cent. of all patients with typhoid perforation recovered without perforation, and the general recovery rate from operative treatment was about 20 per cent. Even with this rate there was a considerable saving of life from resort to operation. Claudius' Catgut.-Dr. A. V. MOSCHCOWITZ read a brief paper on this subject. He said that catgut prepared by this method had been used almost exclusively at the Mount Sinai Hospital for the past seventeen months, and had stood the test exceedingly well. The bacteriological tests made by Claudius and others were sufficiently conclusive as to the sterility of this iodine catgut. It was not only aseptic, but, owing to the imbibition of iodine, was also antiseptic. It was now used at the hospital unhesitatingly in any and all operations. They had noticed a slight loss in the tensile strength, particularly with the heavier grades, but this loss was so slight as not to mar its utility. The preparation of the catgut was simplicity itself. The catgut, as it came from the dealer, was wound in a single layer upon the glass spools and was immersed |