emorrhages, while arguillulosis may produce very severe eep lesions of the intestinal wall, the glands and the mphatics. It was impossible to discover how the anFuillulosi entered the intestine; the diet, mode of life, etc., f the patient did not differ from that of those persons ving near her. The author believes that cases of arguilulosis infection are much more common in Italy than is enerally recognized, and that the larvæ are communicaed to those who work on the land by drinking water from he streams, or by eating green vegetables.--Rivista Critica di Clinica Medicina, February 20, 1904.

The True Value of the Objections Advanced against the ntramuscular_Injection of Calomel in the Treatment of yphilis.-A. Scarenzio has found calomel used hypoermically most successful in the very obstinate cases hat resist all other forms of mercurial treatment. He ecommends using calomel prepared from the vapor, beause it does not clog the syringe, using oil of vaselin s a medium, and making the menstruum perfectly aseptic. The Pravaz syringe should be used, made of ebonite and with a long needle that is not too small. The preferred ocation for the injection is the upper part of the gluteal muscles, a little above the great trochanter, at the begining of the sacrococcygeal fold. It is to be recommended in phagedenic syphiloma of the tongue, malignant philides with early ulceration, tertiary sclerotic glossitis, severe laryngitis, rebellious secondary lesions of the congue, and old gummata of the nervous system that resist all treatment. He has not found it to have bad results in cases in which proper dosage and technique were used. No marked pain was produced at the site of puncture, nor has he observed severe stomatitis, diarha or embolic manifestations following its use.-Gata Medica Lombarda, February 22, 1904. The American Journal of the Medical Sciences, March, 1904. Hæmolymph Nodes.-Hughes Dayton concludes that oth histological and experimental evidence is strongly indicative of the existence of the hæmolymph node as an organ sui generis. In the light of our present knowledge the chief practical point, however, is to recognize the capability for phagocytic destruction of red blood cells which is possessed to a high degree by certain lymphoid structures, rather than to dwell upon the individuality of the hemolymph node. The occurrence of transition forms from the node containing blood sinuses only to that with sinuses containing lymph alone renders a strict classification impossible. For practical purposes Warthin's grouping of cell varieties under the heading of hæmolymph nodes appears eminently satisfactory.

A Study of the Caloric Needs of Premature Infants.-John Lovett Morse believes, from his study of this subject, that the caloric need of premature infants is relatively greater than that of full-term infants. This greater need is due in part to the small size and comparatively large surface Area of premature infants, which cause them to lose heat faster than do larger, full-term infants, and partly to the incomplete development of their digestive powers, on account of which they utilize a relatively smaller proportion of the caloric value of the food ingested. This conclusion emphasizes the importance of protecting premature inlants against loss of heat and of providing for them a food which will throw the least work on the partly developed digestive powers.

The

Multiple Sarcoma.-Thomas A. Clayton considers here the multiple sarcomatous growths in the skin and subcutaneous tissue, excluding that class of tumors characterized by lymphoid cells. As to the etiology of sarcoma, whether single or multiple, practically nothing is known. It may follow an injury or may take its origin from old scar-tissue, or there may be no discoverable cause. parent tumor in this variety of sarcoma is not infrequently a pigmented mole which suddenly becomes malignant. The usual cause for this change is an accidental injury or friction from the clothing. The symptoms are not distinctive. The blood shows nothing but the conditions found in any severe secondary anæmia. The diagnosis is simple in a fully developed case. In the early cases it is not so easy. The most satisfactory method of diagnosis is to remove one of the smaller nodules for microscopical examination. But operations upon sarcomata are often followed by rapid and more malignant recurrence. skin has been involved, the growth is almost sure to recur at the original site, but if subcutaneous, the danger is much less. The question of operation is one which requires careful consideration. As to drugs, arsenic is the only remedy which has proven of any value.

If the

In the

Three Cases of Pernicious Anæmia, with a Description of the Pathological Changes Found in the Spinal Cord.— Robert Reuling describes these cases, one by one. first case, in every specimen examined, there was seen a arrow strip of degeneration in both the column of Goll and that of Burdach, most marked in the former in most

sections. The degeneration was most apparent in the lower cervical and upper dorsal regions. In the Van Gieson specimens it was clearly shown that these degenerated fibers had lost their myelin sheaths, and very few axis-cylinders could be made out in the degenerated areas. The remainder of the cord was absolutely normal. The same degeneration was apparent as far down as the upper sacral cord. In the second case the spinal symptoms seemed to precede the onset of the anæmia. In all sections except those from the very lower dorsal, and the sacral regions, a well-marked degeneration, involving almost the entire posterior tract of fibers, including the columns of Goll and Burdach, was seen. The change was most pronounced in the upper dorsal and lower cervical regions. A number of nerve fibers of both right and left lateral columns had degenerated. In the third case the only change from the normal were several small circumscribed areas of degeneration limited to the anterior parts of the cord. This degeneration was due to small hemorrhages into the cord

substance.

Tuberculous Stricture of the Ascending Colon, with Sudden Total Obstruction of the Bowel; Perforation of the Intestine; Removal of the Cæcum and Half the Ascending Colon; Recovery.-Thomas S. Cullen reports this case of a patient twenty-four years old, who had practically no symptoms until about five hours before operation, and then there was moderate pain over the appendix, accompanied by rigidity of the right rectus. Examination of the blood showed a total absence of eosinophiles. The only way in which the writer can account for the lack of symptoms is that for some reason there occurred an acute contraction of the stricture, which, up to this time, had permitted the free passage of fæces. The possible existence of such a condition supplies another indication for early operation whenever trouble exists in the appendiceal region. Already peritonitis had developed, although the symptoms had existed for so short a time; and had there been a little delay, there would have been scant chance of saving the patient. After the appendix was removed and the pus wiped from the pelvis, the abdominal cavity appeared normal. The right renal pocket was exposed, however, and some dark fluid escaped.

A perforation in the ascending colon was then discovered. Where there is a free accumulation of fluid in the region of the appendix, by gravity it will travel down into the right renal fossa. The ascending colon was drawn out and total obstruction was found a short distance above the ileocæcal valve. The lower third of the ascending colon, the cæcum, and a small part of the ileum were removed. An end-to-end union was made on account of lateral tension.

Increase

An Experimental Study of the Relation of Cells with Eosinophile Granulation to Infection with an Animal Parasite (Trichina Spiralis).-Eugene L. Opie declares that the administration of trichina spiralis to the guinea-pig causes an increase of the eosinophile leucocytes in the blood, comparable to that which accompanies human infection. There is no constant alteration of the number of these cells until the end of the second week after infection, when their relative and absolute number rapidly increases, and reaches a maximum at the end of the third week. At this time embryonic trichinæ are in process of transmission from the intestinal mucosa by way of the lymphatic vessels and the blood through the lungs to the muscular system. Eosinophile cells accumulate in the mesenteric lymphatic glands and in the lungs and form foci which resemble small abscesses in which polynuclear leucocytes are replaced by eosinophile cells. These cells are provided with polymorphous nuclei and do not differ from the eosinophile leucocytes of the circulating blood. Accumulation of eosinophile cells in the mesenteric lymphatic glands and in the lungs is explained by the transmission of the embryonic parasite through these organs. of eosinophile cells in the blood and in other organs is accompanied by characteristic changes in the bone-marrow. The fat is diminished in amount, and cellular elements replace it. Cells with eosinophile granulation are present in immense number, and particularly numerous are the eosinophile myelocytes, cells peculiar to the bonemarrow, while such cells, undergoing mitotic division, are more numerous than usual. The bone-marrow is the seat of multiplication of the eosinophile leucocytes. The number of eosinophile leucocytes in the blood always diminishes before death, so that the proportion usually becomes less than 1 per cent. Infection with a very large number of trichinæ causes a rapid diminution of the number of eosinophile leucocytes, and is quickly fatal. The eosinophile cells of the bone-marrow exhibit degenerative changes, of which nuclear fragmentation is most characteristic. Similar changes may affect the eosinophile cells of the intestinal mucosa and of the mesenteric lymph glands. Mild infection stimulates the eosinophile cells to active multiplication, but severe infection causes their destruction.

Society Reports.

NEW YORK ACADEMY OF MEDICINE.

SECTION ON ORTHOPEDIC SURGERY.

In the

Meeting Held February 19, 1904. HOMER GIBNEY, M.D., CHAIRMAN. Arthropathies of Locomotor Ataxia.-Dr. GEORGE R. ELLIOTT presented patients with this condition. first patient the left knee was the only joint affected, showing genu inversum and not to be confounded with primary genu valgum. There was a certain enlargement of the head of the tibia, oedema about the knee-joint, and enlargement of the leg and thigh. The left leg and thigh measured one inch more than the right. The chief subjective symptom was metatarsal pain. Four operations have failed to relieve this troublesome symptom.

The second patient was a man about fifty-seven years old, confined to a wheel chair and bed. The joints involved were the small joints of the fingers, chiefly the first phalangeal joints. These deformities were globular in shape, painless and devoid of swelling, and had been so from the beginning. The patient in his wheel chair with overcoat on, placed the heel of both feet behind his head, demonstrating the muscular hypotonia common in locomotor ataxia.

He further presented a cast of the hand of a third patient who was unable to be moved. The cast showed very marked globular swellings of the phalangeal joints. He also had a very marked arthropathy of the left shoulder, so badly involved that he could dislocate the joint at will. The head of the bone was markedly enlarged, the acetabu

thought it rather common to find such laxity of the hip ligaments from non-use.

Dr. DANA said he could only confirm Dr. Elliott's statement that there is this relaxation, very marked, in most cases of arthropathies, usually associated with atrophy of the head of the bone. He was interested in hearing the remarks about splints for the joints. He thought it a mistake always to put splints on tabetic joints. He cited a case in illustration.

Dr. SAYRE said that in marked relaxation of ligaments it was sometimes quite possible to slip the femur on the tibia. When the patient was upright and moved in any direction, there was danger of complete luxation of the joint, and possible rupture of the skin as well by constant violent slips. He had seen those who were incapacitated for going about except with two crutches, who, when properly fitted with apparatus, could walk without a cane. There was sufficient muscular power and sufficient coordination of the muscles to move the legs in an anteroposterior direction, if something was put on to limit the lateral deviation.

Scurvy Simulating Pott's Disease.-Dr. Homer Gibney presented a child of twenty months from the Dispensary of New York Hospital referred as case of lumbar Pott's disease. No disease of the spine was, however, found, but a very marked scorbutic condition in addition to a pronounced general rachitis. The scorbutus responded quickly to treatment, and the long posterior rachitic spinal curvature is yielding to a perfectly fitted frame on which the child is placed and mother instructed as to its management.

Acute Infectious Osteomyelitis of the Spine and Acute

and ligaments-all painless from the beginning.

Dr. V. P. GIBNEY said he thought the laxity of muscles in case No. 2 very interesting, and wanted to know whether that was a common feature of the disease. He thought it extraordinary to see a patient as old as this man, with ligaments so relaxed as to enable him to put his legs over the back of his neck. In those cases he had seen, the laxity of ligaments was in the ankles and knees. The other case was interesting on account of the neuralgia in the internal plantar, and failure to get relief after section of the nerve, but he presumed that the tabes from which the man suffered, rather ruled it out as a case of metatarsalgia.

Dr. R. SAYRE said in many cases the relaxation affects the joints of knees and ankles as well He had had many cases in which the patients could walk around comfortably with lateral support on knees, when they were incapable of standing without this support, the ligaments being so relaxed. In these cases the joints were prone to luxate.

Dr. BREWER said he was interested in the case reported. He had treated a similar case: A neurotic boy who complained of pain in the metatarsal joint of the great toe. He could not step or walk. There was an extremely tender point over the joint, which was a little thickened and reddened. He had worn a badly fitting shoe, which perhaps caused slight deviation of the toe. The joint was opened and found to be healthy. A little piece of bone was taken away, and the pain was relieved. A return of acute pain occurred, which was relieved by the application of the cautery. This relief continued for a number of weeks, but the pain returned, so intense the boy could do nothing. He was in an hysterical, nervous state. He was seen by Dr. Blake, who took out about one inch of the internal plantar nerve, affording relief. Three months later he again operated and took out the whole of the nerve, which presented a small neurofibroma near its origin. The pain came back after a while and the boy underwent a fourth operation, this time Dr. Bull operating. In about three months there was a fifth operation, the result of which was unknown. Dr. Brewer would like more light on the subject of these cases.

He

this paper. (See p. 641)

Dr. DANA said he had only seen one case such as Dr Hunt reported, and could add nothing to the subject. He only rose to express his gratification at the clear and convincing way the matter had been presented. He thought Dr. Hunt's view that perimeningitis is always secondary, correct.

Dr. BREWER said he had seen only two such cases, both unrecognized at the time he first saw them. He had been looking for a comprehensive paper giving fuller statistics than could be found in abstracts from foreign literature, and such a paper had been read by Dr. Hunt. He thought. it most valuable from a surgical point of view. In each of Dr. Brewer's cases there was a perirenal abscess. The pus was found to issue from diseased vertebral bodies. In both cases there was extreme sepsis. He supposed at first that the trouble came from the kidney. After exploring the kidney and finding it normal, he made a small opening in the psoas, then into the vertebral column and removed the sequestrum. The first patient died in a week or ten days. After death an autopsy revealed a very extensive process. In the second case, a man had chills and fever, and complained of pain in the back, which had been relieved for a number of days before Dr. Brewer saw him; and with the relief of pain, there was the formation of a large lumbar indurated mass. This was opened. At the first operation a quart of pus was evacuated. The septic symptoms abated, but there was no closure of the sinus. A second operation was done to remove a supposed diseased and suppurating kidney. By making a large incision, the region of the kidney was exposed, and found to be normal. The psoas was filled with pus; also a focus in the body of the vertebra. Dr. Brewer said he had another case but was not sure it was primary septic osteomyelitis. It occurred in the arch. It was an old case operated on before Dr. Brewer saw it. He simply provided better drainage. He thought these cases should be diagnosed early, and that we should be on the lookout for them. The rate of mortality was high. The vertebral bodies were inaccessible, and required prompt

treatment.

Dr. V. GIBNEY said those who had been handling

ertebræ for a great many years would feel especially in ympathy with a differential diagnosis. In regard to rognosis and analogy of osteomyelitis of the vertebræ nd of the hip, when Mr. Smith of London began to reort cases, and Mr. McNamara followed, there was frightal mortality. As they were recognized earlier, the nortality was much lessened, because their acute infectious ature was understood and prompt measures were taken ▷ secure relief. In place of dangled hips with a few alf-opened abscesses, we now have much better hips, oing at once to the focus of disease removing sometimes head lying loose in the cavity, fixing the limb in good osition, draining well and getting prompt relief and pretty table hips. During the last year or two, when so much ad been said and observed about congenital hips, he had ound cases said to be such hips, with one or two tell-tale inuses on the outer side of the thigh with history of cute abscess which had opened, when the child began to Falk lame. A patient was brought to him recently from long distance, said to be suffering from congenital disocation. The opeaker saw a cicatrix on the inner side of he thigh. He was told that at nine months the child had ad an acute attack of hip trouble, the abscess opening nd soon healing. When the child began to walk, no attention was paid to the hip. There was an inch and a alf shortening, and the case was labeled as one of conenital dislocation of the hip. In regard to pachymenintis, etc., he was reminded of a neurological experienceOr. Putzell read a paper when we were finding a number of those cases, and the speaker had put on record two or hree cases of peripachymeningitis hypertrophica cervicalis -not acute. Those cases would now simply be eliminated, or we had to recognize the disease as osteomyelitis. We had stopped talking about acute suppurative periostitis and acute peripheral osteitis. Eight or ten years ago Mr. McNamara showed the speaker specimens in Westminster Hospital, declaring it was general osteomyelitis, and could not fairly be called periostitis.

Dr. SAYRE said he could only add his voice to those who ad preceded him. He thought, with Dr. Gibney, that The cases were recognized and operated on promptly now, nd compared with the mortality of the past, there was a gratifying number of recoveries. He had had two cases howing acute suppuration, and had opened, drained, and leaned-under such treatment the majority of cases ecovered as had those he mentioned. The difficulty, however, was in recognizing the cases in which the foci were deep-seated, and operating upon them promptly nough to give relief.

NEW YORK ACADEMY OF MEDICINE.

SECTION ON OBSTETRICS AND GYNECOLOGY.

Stated Meeting, March 24, 1904.

DR. A. PALMER DUDLEY IN THE CHAIR. Recurrent Tubal Pregnancy.-Dr. PHILANDER A. HARRIS presented this specimen and reported the case of a negress, twenty-six years old, upon whom he first operated May 20. The abdomen was found to be filled with blood and clots, and from it was removed a fœtus about ten inches in length. Before operation 425 c.c. of normal salt solution was thrown into the veins and, after the operation, 650 c.c. more. The patient made a good recovery and menstruated every four weeks after. It was comparatively painess since recovery from her previous tubal pregnancy, until February 18, when the appearance of blood was attended with severe pains in the hypogastric region, more especially upon the left side. Pains recurred almost daily. On March 22 she was seized with a severe pain in the left umbar region, and then was sent to the hospital. Physical Examination showed the cervix to be rather soft and velvety and the uterus fixed in its position with a tumor above and to its left. On March 23 abdominal section was performed. A pint or more of blood was found in the abdominal cavity, and some clots partly organized and

very adherent to the omentum and intestines. The left tube was about 8 inches long, 1 inches in diameter, closed at the ostium abdominale, and was believed to contain the product of an interrupted if not progressive pregnancy. The tube was exsected, closing the chasm in the uterus with sutures. The isthmian portion of the tube on the right side was larger, harder, nodulated, and altered in character and appearance since the operation ten months previous. This, too, was exsected. At the last meeting of the Section he stated that he had met with five women. in whom tubal pregnancy had recurred. To that he now added another, making altogether six cases of this class.

Hæmatoma of Both Ovaries.-Dr. PHILANDER A. HARRIS presented this specimen, removed from a woman thirty-nine years old. He said that apoplexy or hæmatoma of the ovary of such magnitude as the specimen presented was certainly a very frequent occurrence. It had been asserted that one effect of chronic apoplexy of the ovary was to destroy the stroma of the ovary. The case which he presented had the condition of hæmatoma in both ovaries, and it had probably existed in both ovaries for many years without inducing the menopause. For the past ten years or so the duration of every menstruation had been three or four days, while in her earlier life it lasted a full week. The shell, which was all that remained of her right ovary, had not only been sufficient to insure the continuance of menstruation, but the duration of the flow had been somewhat lengthened and its quantity increased. He had since incised and cauterized its cavity. The left ovary, which had been the seat of a hæmatoma, was removed.

Dermoid Cyst.-Dr. PHILANDER A. HARRIS presented this specimen. The cystic ovarian tumor was on the left side and was found to contain the usual greasy material of dermoid cysts, also a ball of long hair, half as large as one's fist, and one tooth growing from its wall. The ball of hair was threaded through its center by a string of tissue about 2 mms. in diameter, either end of which was attached to opposite sides of the cyst wall.

Extensive Primary Peritoneal Tuberculosis; Tuberculous Omentum, Fallopian Tubes, and Ovaries.-Dr. HERMANN J. BOLDT presented these specimens, which he had removed from a patient forty-two years old. Her present illness began eight months ago with pain in the abdomen. and increase in its side. She had very obstinate constipation. She lost much flesh and strength. The abdomen was greatly distended with ascitis. On opening the abdomen a large quantity of dark gray-greenish fluid was evacuated, as well as numerous masses of gelatinous material. A smooth tumor wall presented itself, which was proven to be of pyogenic membrane, enclosing the entire viscera. Upon opening this sac intestines came into view, and they were found to be thickly studded with small tuberculous nodules, and the bowels throughout intimately adherent to each other. These adhesions were broken up and much bleeding occurred. The brittleness of the structures was so that no ligatures could be applied and tight tamponading became necessary. The entire omentum was rolled up in a tumor-like mass above the transverse colon and was amputated with the Paquelin cautery. The patient was making a smooth recovery. No tubercle bacilli were found in the sputum. He said the peritoneum was undoubtedly primarily affected.

Inflammation about a Meckel's Diverticulum Resembling an Appendicitis.-Dr. BOLDT presented this specimen. At operation, when looking for the appendix, there was brought up into the wound what was thought to be an inflamed appendix, but which proved to be a large diverticulum, so closely resembling it that it could not have been distinguished from one had it not been for the small intestine. The appendix itself was found to be normal.

Unusually Large Suppurating Tuberculous Tuboovarian Tumor Removed with the Uterus; Tuberculous Peritonitis; Recovery. Dr. BOLDT presented these specimens. The

left lower abdomen was more prominent than the opposite side, and was filled with a tumor which reached above the level of the umbilicus. It was very adherent and some what sensitive to pressure. Whether the tumor was the primary tuberculous condition, or whether its tuberculous change was secondary to the tuberculous peritonitis was a question not determined. The sac wall measured from 1 to 1 cms.

Vaginal Hysterectomy for Uncontrollable Uterine Hemorrhage. Dr. BOLDT reported this case. Extirpation of the organs was resorted to because, with such frequent recurrences of adenomatous proliferation of the endometrium, practical experience had shown that malignant disease was the usual outcome.

Extensive Rupture of a Tubal Pregnancy. Dr. BOLDT reported the case of a woman, twenty-six years old, who was supposed to be pregnant ten weeks. Rupture took place about five hours after consultation, and she was operated on immediately while pulseless and in collapse. The surgical work required scarcely five minutes and the bleeding tube was secured in a fraction of a minute, but, despite all efforts, she died.

Retroperitoneal Abscess Simulating a PyonephrosisDr. A. STURMDORF presented a kidney removed from a woman twenty-six years old. She had had two severe attacks of suppurative appendicitis, which were treated simply by cutaneous incision by the attending physician. When first seen by him last May there was pain and tenderness in the right inguinal region, and examination showed suppurative disease in the right side of the pelvis. The operation revealed a long sclerosed appendix, whose tip was adherent to the abdominal wall, and there was an abscess involving the right tube and ovary. Some months later she returned in a septic condition, and operation then revealed what was supposed to be a very large suppurating kidney, and then pus appeared in the urine for the first time. The ureter was evidently occluded and could not be made patulous. The functional activity of the other kidney having been determined, the injured kidney was extirpated. What had closely simulated a pyonephrosis proved to be nothing more than a retroperitoneal abscess, surrounding and involving the perirenal connective tissue.

the

The Treatment of Post-operative Peritonitis.-Dr. EGBERT H. GRANDIN presented this paper. He said that the initial treatment of post-operative peritonitis was summed up in the one word prophylaxis. This prophylactic treatment consisted of attention to the following points: Absolute asepsis in the operating room; avoidance of germicides, such as bichloride, during the operation; the handling of intestines, and the exposure of omentum as little as possible; the covering of raw surfaces with peritoneal flaps as far as possible, and where this was impossible the protection of such surfaces by sterile gauze.

If

In any case in which the presence of pus was suspected before operating or in which it seemed probable that pus might form, ten grains of calomel combined with twenty grains of bicarbonate of soda should be administered three hours before operation to provide for catharsis afterward, thus avoiding futile attempts at such administration in the presence of an irritable stomach. after such precautions peritonitis developed he distinguished three types: The paretic or pseudo-peritonitic; the inflammatory; the septic. Not infrequently after abdominal section, the belly became gradually tympanitic, the stomach rejected food, the pulse and temperature were slightly elevated, and the operator, in despair, proceeded to dose the patient with a multiplicity of drugs, with the result that the patient died. This type of peritonitis, viewed from the standpoint of the clinician, he termed spastic or paretic. In these cases he employed only one drug, either atropine or hydrobromate of hyɔscin, in full doses, hypodermically to the physiological

extent, with the result that the spasm of the bowel relaxed and the patient recovered.

In the inflammatory type of peritonitis the temperature and pulse began to rise three or four days after an aseptic abdominal section, and this to the vital point. The bowels might or might not respond, the stomach was intolerant of food and medication. Here the operator, who had administered calomel before operating, was fortunate. In such cases we had to differentiate between general and pelvic peritonitis, and if it became apparent that we were dealing with an inflammatory condition of the peritoneum it was evident that what this organ needed was rest, not the spur. To the rest we might add with advantage the ice-bag to the abdomen, washing out the stomach, and rectal feeding. Fordyce Barker taught the free exhibition of codeine under such circumstances, as this drug neither paralyzed peristalsis nor upset the stomach. The case should be carefully watched, and if pus formed locally or in the pelvis it should be attacked under wellrecognized surgical rules. In septic peritonitis also that operator was fortunate who had the calomel in the stomach of his patient before the operation. He employed the term septic generically, as the bacteriologist afforded no definite help as to the exact germ or toxin that we were dealing with. This form of peritonitis was characterized by rapid pulse and respiration and low temperature. The belly might or might not be tympanitic, the stomach was apt to be intolerant, the bowels were apt to be loose and the kidneys to be torpid. In these cases we were dealing with a deep toxæmia, and the best we could do was to institute a sustaining treatment, in the hope that Nature might throw off the toxins or the products of the toxins. He suggested toning up the heart's action by means of alcohol and of strychnine. When the kidneys were inefficient he used digitalis. He threw plenty of salt into the circulation by means of the veins or the rectum or through the medium of the skin, taking the hypothetical view that we were thus diluting the toxins. If pus could form in the pelvis or abdomen, open. The injection of formalin into the veins, the insinuation through posterior section of iodine into the system, etc., had yielded no better results than the sustaining methods. In regard to local septic peritonitis he could show as good results from opening the cul-de-sac and impacting plain sterile gauze as those recently heralded from the use of a specially prepared iodoform gauze.

The Treatment of Post-puerperal Peritonitis.—Dr. ROBERT MURRAY said that this, like all forms of peritonitis, was due to sepsis, or the introduction of virulent bacteria at the time of confinement, and should be differentiated from the other attacks of peritonitis. There was not usually one organ involved, but the uterus, the adnexa, the vagina and external parts, all might be involved in the septic process. It was important to note that, in such cases, the condition was not autogenetic, but the poison was introduced by the hands of the surgeon, nurse, or some attendant. The virulence of the course of peritonitis was to be determined by the particular bacteria causing the infection and also, in a measure, by the methods of their entrance into the system.

He said that puerperal peritonitis was only one of the septic puerperal diseases, and yet it was the one which, in greater or less measure, was a complication of all of them. Confining himself to peritonitis, clinically peritonitis in the puerperium, he said it might be local or pelvic peritonitis, or it might be diffuse, and then so severe that the rapidly fatal result left neither time to produce an exudate on the surface of the peritoneum, nor any chance for good to result from treatment, and all depending upon the virulence of the infection. The local variety, or pelvic peritonitis, was often present, the result of leakage from the Fallopian tubes, extension from an inflamed and septic endometrium, from an ovarian abscess, or of ex

tension through the uterine wall by the lymphatics. An exudate may be formed at the sides of the uterus, circumscribed, and may terminate in suppuration, with the formation of a pelvic abscess involving the tubes and ovaries, or again, after some time, it may become absorbed. Diffuse peritonitis resulted from an extension of a pelvic peritonitis, from tears in the vagina or uterus, from a sloughing uterus or pelvic tumor, or from gonorrhoea.

The treatment was really the prophylactic one; this meant cleanliness. The treatment was considered under the following three heads: (1) To limit or do away with the source of infection; (2) to combat the systemic intoxication by supportive measures; (3) to treat such symptoms as might depreciate the patient's powers of resistance to infection, or themselves cause a fatal result. At the first signs of a peritonitis occurring, the external parts should be most carefully examined; then the uterine cervix should be carefully inspected. Then wash out the uterine cavity, thoroughly clean it, and examine with finger. He had been asked if all cases should be cleaned out, and answered "Yes, if saprophytic." He said that we might determine whether we were dealing with streptococci, staphylococci, pneumococci, or the colon bacilli, yet such information did not give us practical points for working. But if the bacteria found were shown to be streptococci, the uterus should be washed out but not curetted. Clinically and practically all that then could be done was to clean out the uterus thoroughly. Application of the ice-bag was advocated and, if this was not well borne by the patient, the application of heat. If the vagina become boggy open, break up exudate with finger, and pack the part with gauze; the limiting of the exudate will prevent the carrying of infected material into the peritoneum.

Medicinally, supporting measures, the use of large saline enemata after thoroughly emptying the bowels by a dose of calomel followed by saline laxatives, particularly Epsom sa ts, to prevent the exudat on in the peritoneum forming a culture ground for bacteria, should be employed. The bowels are prevented from becoming paralyzed and food is more readily absorbed when such a procedure was followed. Alcohol, strychnine, and the heart tonics should be used, with easily digested nourishing food given frequently. If tympanites was marked with vomiting, lavage of the stomach was of the greatest service. Hypodermoclysis with decinormal salt solution and intravenous injections were often of great service in sustaining the patient and, perhaps, diluted the poison and caused excretion of toxins by the free action of the kidneys. The fever should be controlled by tepid sponging or the icebags, and not by the coal-tar products which weaken the heart if used freely. As phagocytic agents, nuclein and albuminose had been used and had certainly seemed to aid, though other agents were employed at the same time. When the uterus was septic, hysterectomy and drainage of the peritoneum had been done. When done early, the uterus might be sacrificed unnecessarily; when done late with diffuse septic peritonitis, the results were fatal; the proper time, if any, to interfere surgically was so hard to determine that, unless the peritonitis was limited when the operation was not called for, the operation was useless. The Treatment of Gonorrhoeal Peritonitis.-Dr. A. ERNEST GALLANT read this paper. He described the gonococcus and the manner in which it reached the peritoneal cavity. One should endeavor to check its ravages by timely education, timely eradication, and timely enucleation. He urged at length the duty of the profession in instructing the laity in regard to the dangers of infection and their serious consequences. As to eradication, he first considered children. He described the symptoms of gonorrhoea in little girls, and said that while it might involve the tubes, ovaries, and peritoneum, it never involved the uterus. The disease was occasionally, though rarely, seen in the new-born. The prognosis for little girls was

good, and the disease usually terminated within three months. In the treatment of these children the vagina was irrigated with warm boric acid solution, and with the same "p" syringe one-half ounce of one-per-cent. silver nitrate solution was injected. This process was repeated every third day. A 10-per-cent. boric-acid ointment was applied twice daily to the vulva, and an alkaline diluent with copious draughts of water were administered internally. He questioned whether the disease was eradicated in these cases and whether the girl at puberty would not show the effects of her early infection. In females, after puberty, the most important indication was to arrest and limit the disease to the vagina and urethra, before the gonococcus found its way into the cervix and uterus, Fallopian tubes and peritoneal cavity. The drugs which had rendered most efficient service were silver nitrate and ichthyol. The introduction of a sound or instrument carrying a drug into the cervix was no longer practised on account of the danger of conveying the gonococci higher up and thereby infecting the uterus. He believed with Neisser that once the gonococci invaded the uterus there was little chance of medical treatment availing; one must never lose sight of the danger of stirring up the enemy and thus facilitating his entrance into the tubes and peritoneum. When the gonococci invaded the peritoneal cavity, pelvic and abdominal pain was incited. There was increased temperature and pulse. As the gonococci did not grow at a temperature lower than 79° F., or above 100.4° F., we might take advantage of this fact and make use of an apparatus suggested by Stroynowski (Centralblatt für Gynäkologie, December 13, 1902) for the local application of cold to the female pelvis by a continuous current of hot or cold water within the vagina. In regard to timely enucleation, in a majority of active gonorrhoeal infections, uterine, tubal, or peritoneal, one hesitated to bring into play either the curette, or the vaginal or abdominal incision, until after the acute symptoms had subsided, and then only if the general health suffered or local symptoms persisted to such a degree as to disturb menstrual, marital, or maternal functions. He related a case upon which an operation was performed for appendicitis, and upon opening the abdominal cavity gonorrhoeal peritonitis was found as well, as an illustration of some of the difficulties that prevented one from making hard and fast rules. He related another case which illustrated the too common course of gonorrhoea, viz.: Early infection, exacerbations, metrorrhagia, pyosalpynx, tuboovarian abscess, ovarian cyst, appendicitis, operation, postoperative neurasthenia.

Dr. S. MARX said that Dr. Grandin's paper was interesting to him and particularly his division of post-operative peritonitis into the paretic or pseudo-peritonitis, the inflammatory and the septic, and also his means of differentiating them. He did not believe the line of demarkation could be so finely drawn as depicted by the author. Some years ago he had used codeine in the treatment of peritonitis, but found that it was not as efficacious as had been claimed for it, and lately he had been using opium in enormous amounts, following out the teachings of his late teacher, Dr. Alonzo Clark. In the inflammatory conditions he attempted to paralyze the patients with opium. Regarding the septic form of peritonitis he advocated radical surgical means, opening the abdomen, washing it out, etc., and then using the antistreptococcic serum. In the puerperal cases laparotomy plus the serum did not yield good results with him. He said that something more radical should be attempted in these cases. He said that Dr. Murray's paper was a very important one from the standpoint of drawing the attention of the members to the treatment of puerperal peritonitis, i.e. its septic nature, and to the vast importance of an inspection of the genitals. During the past six weeks he had seen from thirty to thirty-two cases, and in not a single instance did he find it necessary to enter and wash out the uterus. There was found in each instance a local exudate in the