first in the recognition, by the profession at large, that it is an exceedingly active factor in the production of intestinal indigestion and chronic invalidism. That its acute manifestations are often but exacerbations of a more or less chronic condition of distortion or other pathologic change. That its treatment is in no way, or at any time, medical. That its surgical treatment, in order to produce the best results, must be instituted at a time when the disease is confined to the appendix, and hence when all diseased structure can be removed. That this time often precedes the recognition of well localized right iliac inflammation as evidenced by pain, tenderness and rigidity; but that the presence of these three symptoms render a further delay much more dangerous than is proper surgical interference.

It may be said that all these things are and have been recognized and emphasized; but every surgeon still meets cases which have not received proper recognition at the proper time.

Dr. J. W. Kennedy, in a recent article which appeared in the New York Medical Journal, of November 23, 1907, referring to the clinic of Dr. Joseph Price, of Philadelphia, says: "Over 80 per cent of our appendical work for the past two months has been pus, gangrene and peritonitis."

No ideal surgery can be done under such conditions. Finally such improvement as may be made in surgical treatment will not, in my opinion, be in the line of elaboration; but will tend toward simplicity. Drainage will be reserved for those cases in which it is impossible to remove the major portion of the product of destructive inflammation.

We shall learn to avoid all unnecessary traumatism, either of the abdominal wall, the parietal peritoneum, or the structures of the caecum. The trained finger will locate the appendix, and will deliver little else, through an incision that will grow shorter as that finger increases its tactus eruditus. Greater freedom of motion and the earlier getting out of bed will lessen the danger of the formation of thrombi and pulmonary complications. The employment of a competent anesthetist will relieve us of much anxiety; and surely if slowly will lessen our mortality.

1434 Glenarm Place.

PERFORATION OF THE INTESTINES BY SWAL

LOWED PIN.

By FRANK M. McCARTNEY, M.D.,
Denver, Colo.

Surgeon to St. Anthony's Hospital.

Perforation of the wall of the gastrointestinal tract by swallowing foreign bodies is not of rare occurrence.

Within the past few months I have had a very interesting case, which is as follows:

Ralph E., age 4 years. Admitted to St. Anthony's hospital September 19, 1907; discharged October 5, 1907. This patient was referred to me by Dr. E. W. Elliott of Fort Morgan, Colo., with a history of having swallowed a steel pin

three inches in length with a black head about the size of a pea. The accident occurred the morning of the above date. The patient complained of pain in the region of the stomach for some hours after. He was kept in the hospital, where he could be watched, and was given mashed potatoes, bread and milk and such articles of food that might encase the pin and carry it through the intestinal canal.

The case was referred to Dr. Stover for X-ray examination, the pictures of which are shown below. Picture No. 1, taken September 20, 1907, shows the pin to be to the right and perpendicular with the spine, with head down. A sec

ond picture, which is not shown here, taken September 21, 1907, showed the pin to be nearer the median line, head down. At the time these two pictures were taken the pin evidently had not left the stomach. Early on the morning of September 25, 1907, the patient cried with a sudden pain in the abdomen, which lasted but a few minutes, but caused the patient to refuse nourishment. A third picture (fig. 2) was immediately taken, which located the pin to the left and perpendicular with the spine, with the point downward.

When I examined the patient three hours after he complained of the pain, he was feeling well and playing around the room. On palpating the abdomen, I could find no tenderness or rigidity, but with the history of swallowing the pin, having the sudden pain, refusing nourishment and with the X-ray picture of that morning, showing the pin to be point downward, I thought it advisable to operate at once and remove the pin. This was accordingly done under chloroform anesthesia, twelve medical men being present at the operation.

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The abdomen was opened by an incision through the left rectus muscle in the epigastric region. The stomach was delivered and examined, but nothing found in it. I then located the duodenum and followed it up to the junction of the jejunum and found the pin sticking through the intestinal wall at this point. It had also perforated a neighboring coil of intestine, thus making three perforations. A purse-string suture

of silk was placed in the wall of the intestine, around the pin at each puncture of the neighboring coil of intestine, before the gut was pulled from the pin. These sutures were then tied. I then placed a purse-string suture of silk in the wall of the intestine around the head of the pin, then opened the gut over the head of the pin, thus removing it. The purse-string suture was then tied, and several Lembert sutures were introduced to enfold the wound in the intestine. The abdominal cavity was sponged out, and the wound closed in the usual manner, without drainage. The patient made an uninterrupted recovery, leaving the hospital in ten days.

THE HEALTH OF THE CITY.

By W. H. SHARPLEY, M,D,.
Health Commissloner
Denver, Colo

About the 1st of December, 1907, Denver was comparatively free from scarlet fever, and at that time there were only a few placarded houses in the city, and those, I think, were on the West Side. On or about December 3, about 30 cases were reported in the Capitol Hill district in one day, the infected territory extending from Seventh to Twenty-sixth avenues and from Corona to Columbine streets, and on the next day about as many more were reported in the same district. The department immediately investigated the schools in the district, in order to find out the source of contagion, but without results. About that time Dr. Whitney telephoned me that he had several cases on hand and that all of his patients were taking milk from the same dairy. Upon receiving this information I immediately paid a visit to the dairy and found the statement of the doctor absolutely true, and upon investigation found the following state of affairs:

About three or four days previous to the outbreak a man brought in a load of hay from the vicinity of Montclair. He arrived at the dairy about dusk, and as he was feeling sick and it was dark when he finished unloading, he asked permission to sleep in the bunk room, which was readily granted by the proprietor. This was a large corrugated iron structure, well ventilated and about 40x15 feet and contained eight or ten beds. In the morning the man was quite ill and a physician was called, who pronounced the case scarlet fever, and the patient was immediately removed. He arrived at the dairy about 5 o'clock and was removed about 11 o'clock the next morning, making a total of about 18 hours he spent in the dairy.

Now, in regard to the dairy and its surroundings: The bunk house was about 150 feet from the milking sheds and about 50 feet from the cooling room and sterilizer. The milking shed was a large, open building, thoroughly drained, with cement floors and draining gutters. The cooling room was a large, well-ventilated room and contained a modern steam sterilizing apparatus. All bottles and vessels were thoroughly sterilized with steam, and the milk was conveyed from the cooling vat to the bottles by machinery, and was in no way handled by any of the employes. I draw your attention to all of the details, simply to demonstrate from a sanitary standpoint that the entire dairy was absolutely perfect. Over 100 cows are milked morning and night, and about eighteen men do the milking. Now, whether the infection was conveyed through the milk, or whether the hands employed contaminated the vessels, I am unable to understand. I simply came to the conclusion that the entire herd of cattle were infected and acted accordingly.

The dairy was completely closed, the bedding, beds and clothes of the men in the bunk house were destroyed by fire, the udders of the cows were washed with a solution of bichloride, the floors of the entire buildings were also washed with the same solution, the wagons were also washed, and no milk was allowed to be sold for two weeks. The contagion stopped at once and there has been no trouble from the dairy since that time. In the meantime I wish to mention that 105 or 110 cases were reported from that dairy in about four or five days, which resulted in two deaths, the most of the cases fortunately proving mild. Since this experience the health department has inquired very carefully as to the milk supply in all cases of scarlet fever.

I also wish to call the attention of the members of the society to the importance of reporting contagious diseases promptly, especially chicken-pox, measles, erysipelas and whooping-cough. If you have read the statistics of deaths during the year, you will observe that the mortality of measles, erysipelas and whooping-cough is exceedingly high. This is due to the lack of reporting cases. The ordinances of the city and the laws of the state board of health make it compulsory to report any and all contagious diseases at once. I recognize the fact that physicians are busy men, and I am also sorry to state that I recognize the fact that many are also careless. Since I have been commissioner of health I have endeavored to treat the fraternity with the same consideration I would expect were I placed in their position. The arrests by the department during the past few years, as you