Within the last few years much that is encouraging has been written concerning massage of the heart. The reports of successful cases, however, render it desirable to record an occasional failure, in order to make one appreciate that the method, like all others, is not infallible.

The heart may be approached in two ways-through a "trap-door" in the chest wall, or through an abdominal incision. The first method permits of direct massage, while the latter enables the operator to indirectly manipulate the heart from within the peritoneal cavity by kneading it, through the relaxed diaphragm, against the anterior thoracic wall.

So far as can be judged at present, indirect massage is as reliable as direct, and is certainly a quicker, easier and less formidable procedure; hence it should be the method of choice, especially where an abdominal incision already exists.

Some time ago, at the Denver City and County Hospital, I had occasion to remove a number of gall-stones from the common bile-duct of a woman 38 years of age, who had been profoundly jaundiced for four months, the operation being one of necessity rather than choice. Her condition was poor and her resisting power low. One hundred grams of ether were given by the "drop method," together with three drahms of chloroform. As soon as the abdomen was opened the patient stopped breathing and was resuscitated with difficulty by means of prolonged artificial respiration. Somewhat later the pulse became so feeble as to be scarcely perceptible at the wrist, but under the administration of strychnine, and especially after the more formidable operative manipulation had been completed, it increased in volume, although still weak.

At this point somewhat less than two pints of normal salt solution were injected rather quickly into the median cephalic vein, resulting in immediate improvement of the circulation.

After the completion of the operation, and while the wound was being sutured, the patient's breathing again ceased. Artificial respiration, continued for ten minutes, resulted this time in failure. Meanwhile the cardiac impulse had stopped, hence it was determined to resort to massage of the heart. Inserting a hand through the adbominal incision and passing it in front of the stomach, I could easily feel the flaccid and motionless heart through the relaxed diaphragm, but in spte of rythmical kneading of the organ against the ribs for fifteen minutes, no response was obtained, although at one time I thought I perceived a slight quiver. Artificial respiration was combined with the massage, but resulted in nothing but the expelling of such a quantity of frothy serous fluid from the lungs as to suggest an acute edema.

It occurred to me that an acute edema of the lungs might have been caused by the ether, aided by the rapid administration of the saline solution, an excess of fluid in the blood having a tendency, as emphasized by Crile, to inundate the lungs. Against this assumption, however, was the fact that respiration had also stopped in the beginning of the operation before the salt solution had been given, and also by the fact that the breathing stopped suddenly and without obvious signs of increasing fluid in the lungs. In addition, the amount of fluid injected was not excessive.

It should be clearly understood that the failure of heartmassage to revive the patient in this particular instance should not discourag' such attempts in the future, although it should teach us not to expect too much.

A CASE OF APPENDICITIS WITH UNUSUAL

SYMPTOMS.

By H. G. HARVEY, M.D.,

Denver, Colo.

This case was of especial interest on account both of the condition found at the time of operation and of the symptom that developed subsequently.

Miss -, age 16, was first seen Sept. 29, 1906, at which time there was a history of pain in the region of the appendix, of a paroxysmal but not very severe character, for the previous twenty-four hours. Examination elicited tenderness over the region of the appendix with slight muscular rigidity. Temperature and pulse were normal, urine normal, no vomiting or constipation. No history of a previous attack. Food was withheld and on the third day, all symptoms having disappeared, milk and meat juice were given. Twenty-four hours later a more severe attack of pain and tenderness developed with slightly increased pulse rate and a temperature of 99.5° F. She was taken to the hospital and there seen with me by Dr. I. B. Perkins, who agreed as to the advisability of operating.

On opening the abdomen by the side of the rectus muscle, the stomach was found overlapping the region of the appendix, and that part of it was highly congested. The local condition of the stomach did not seem to be such as to warrant operative procedure. It did not seem best to enlarge the incision to such an extent as to make out whether there was a dilatation or displacement of the stomach. The appendix was removed ·

and the mucous and submucous coats were found inflamed, with a small amount of purulent material in the canal of the appendix.

The after symptoms were uneventful till the third day, when the patient became wildly delirious and apparently totally unconscious of her surroundings. Temperature and pulse remained normal. The bowels and kidneys up to this time had acted normally. Just at this time, however, the urine showed the presence of albumin, some casts and red blood cells but no acetone; sugar was present toward the later stages of the delirium. Upon the development of these symptoms I again asked Dr. Perkins and Dr. Pershing to see her. It did not seem possible to make a diagnosis other than a toxic condition, due probably to the condition of the kidneys. An associated condition of hysteria was suggested and thought not improbable.

This condition continued for about forty-eight hours and terminated with a sudden restoration of the mental faculties to normal, the urine clearing up at the same time. Recovery was then uninterrupted and no abnormal symptoms have since developed. She still wears the abdominal belt, my idea being to support the stomach and thereby aid its recovery. Sugar is still largely excluded from the diet.

Practically the only medication used was codeine, for its sedative effect during the time of delirium. The use of normal salt solution, both under the skin and by the rectum, was attempted, but on account of the extreme activity of the patient its administration was unsatisfactory.

AMPUTATION OF THE PENIS.

By PERRY JAFFA, M.D.,

Trinidad, Colo.

In response to a call that a man was bleeding to death, I found a man hardly able to sit in his chair, with a large pool of coagulated blood at his feet and fresh blood trickling down. from his pant's leg. Naturally my first impression was that he had been cut or shot, but upon inquiry as to where the blood was coming from, he answered that he did not know, but he thought that it was coming from the penis, which proved to be the case, a large hematoma on the dorsum having broken.

History. H. C., a man 38 years of age, contracted a severe case of gonorrhoea about six weeks before my seeing him,

and had been treating himself with Peruna and other "sure cures." Three nights before I saw him he awoke with the penis in a state of erection and attempted to turn over in bed, while in this condition. In doing so, he rolled onto the penis, causing it to break in the middle (as he stated). The pain did not last long and he soon fell asleep. The following morning the gonorrheal discharge was tinged with blood and there was a hematoma, the size of a hen's egg, on the dorsum. Being employed on the railroad grade about fifteen miles from town, he was unable to obtain medical assistance until three days after the accident, and while on his way to my office the tumor broke. The hemorrhage was so profuse that it filled his shoe, and every step he made left an imprint of blood on the sidewalk. After dressing the injury temporarily, he was sent to the hospital, where a more thorough examination was made, and the following condition was found:

About one inch behind the corona was the lacerated opening of the tumor, directly under which was a deep sulcus, which showed there had been a rupture of the corpora cavernosa. The discharge from the urethra being bloody, also showed that the mucous membrane of the urethra had been torn. He was warned of the danger of gonorrheal infection, and the unfavorable prognosis.

Treatment. He was given a urethral irrigation of permanganate of potash of one-half per cent. strength, and the entire penis was enveloped in a moist bichloride dressing. The irrigations were given three times a day, and the urine drawn with catheter when necessary, in order to prevent it from passing up through the wound. Forty eight hours later a sore developed in the meatus, and in spite of all treatment continued to slough, to such an extent that within sixty hours the entire glans was perforated, so that when urinating there would be five or six streams. The sloughing continued with such rapidity that amputation behind the gonorrheal focus was advised in order to save at least part of the penis. This was done in the usual manner, leaving him about three-quarters of an inch. His recovery after this was uneventful, the gonorrhoea disappearing entirely, and he left the hospital in three weeks perfectly well. He has since married.

UTERUS BIFIDA UNICERVICALIS WITH PYOSALPINX CYSTIC OVARITIS AND ADHERENT

APPENDIX.

By N. A. JOHANSON, M.D.,

Denver, Colo.

The rather meager and incomplete description in textbooks and literature as to the symptomatic history in these cases, especially during gestation, has led me to report this infrequent condition.

This case, Mrs. C., came to me the 14th day of April, 1906, with the following history: Brunette; age, 35; height, 5 feet 6 inches; weight, 134 pounds; robust and strong looking; born in Sweden. There is nothing in the family history of interest.

Menstruated at the age of fourteen; the first menstruation was very painful and the subsequent ones up to the birth of the first child, but were regular. The pain, situated principally in the pelvic region, started the day before menstruation, continuing twenty-four hours after the flow had started, the flow lasting for five days, rather profuse at times and always of a dark color. She also had pain in both eyes and inside of thighs during the menstrual period, and had backache.

She married at the age of twenty-four, and became pregnant that same year. During the period of pregnancy she would have a slight bloody discharge at the usual menstrual period, but no pain, and felt quite well during the time she carried the first child. At the seventh month she delivered a well-formed 1 1-2-pound babe, which lived twelve months. After the first child, the pain, during the menstrual period, disappeared, but the pain in her eyes and thighs remained. The following year she again became pregnant, but felt very poorly. She could not step without causing severe pain in the pelvis, and feeling as though she would abort, consequently she had to remain in bed most of the time. In the fourth month, about the time of the usual menstrual period, while walking across the floor she had a sudden burst of watery discharge, amounting to a half pint. She thought this was the bag of waters that had broken. This was followed by a more or less bloody discharge at intervals. She felt very badly until the seventh month, when she grew much better, and the eighth month gave birth to a 3 1-2-pound babe, which lived for sixteen months. The child was delivered in three hours from the time the pain began and the bag of waters was ruptured.