deemed necessary.

In the preparation of this last edition, both Morris and Gray have been consulted, so that it can be used with either of these standard works.

Selections.

FOREIGN BODY IN THE BRONCHUS.-H. H. Germain, Boston (Journal A. M. A., July 8), reports a case of inferior bronchoscopy in a child aged twenty-one months, illustrating the value of the operation, and especially of the instrument first devised by Dr. E. F. Ingals, in which a small electric lamp is carried at the lower end of the tube. The foreign body, a peanut kernel, was easily extracted without anesthesia. He also speaks highly of the forceps designed by Coolidge of Boston, which he says is much better for this operation than that of Killian. While superior bronchoscopy requires skill and practice, the inferior method is easy and can be carried out, he says, by any one who has ever used a cystoscope or endoscope.

SURGICAL ASPECTS OF GALL-STONE DISEASE.-J. Wiener, Jr., says that the ideal method of handling doubtful cases of gallbladder disease is to treat them medically during a few attacks. If one or more small stones are passed, followed by relief of the pain, then an operation is not indicated, because nature may effect a cure; but if one or more severe attacks of colic are not accompanied by the passage of any stones per anum, then an operation is indicated, and indicated long before there has ever been any jaundice. In discussing the symptomatology of the disease and the methods of making an early diagnosis, especial emphasis is laid on the fact that jaundice is a very inconstant symptom, as it is absent in 80 per cent. of gall-stone attacks, and is but rarely due to an obstructing stone in the duct.

To carry out a rational plan of treatment it is necessary to determine the location of the stones and the degree of inflammation present, and careful individualization is necessary. The analogy to appendicitis is very striking, and just as the mortality of that

disease has been greatly reduced by an appreciation of the necessity for early operation, the same reasoning must be applied to gall-stone disease. Early operation saves the patient much pain and the dangers of suppuration, cancer, and peritonitis. A cholecystectomy done early is not much more dangerous than an interval appendectomy, whereas stone in the common duct is dangerous not only on account of the difficulty of removing it, but also of the resulting cholangitis with its sequelæ.

The whole trend of modern progressive surgery is toward the removal not only of the gall-stones, but also of the diseased organ in which they develop, the gall-bladder. Primary cholecystectomy is to-day the operation of choice in the large majority of cases of gall-stones. The reasons for this are manifold: (1) The mortality is very small, lower even than after cholecystotomy; (2) The wound heals much more rapidly; (3) There is no danger of recurrence, either of the cholecystitis, or of the formation of new stones; (4) No secondary operations are necessary.— Medical Record, July 8, 1905.

RUPTURE OF THE LIVER.- Dr. Tilton reported to the New York Surgical Society the case of a man who had been on a prolonged spree. When he was admitted to the hospital, he was apparently very ill. There was no history of an injury, and no external signs of it. The liver was apparently enlarged, and this was thought to be due to the presence of an abscess. Upon opening the abdomen, a complete longitudinal rupture of the liver was found, the edges being necrotic and softened. This had apparently existed for several weeks.— Annals of Surgery.

DIAGNOSIS OF GONORRHEA.— Alexander, of Breslau, spoke of a new agent for the diagnosis and treatment of gonorrhea. He injects a 1-per-cent. solution of peroxide of hydrogen into the urethra after the gonococci can no longer be demonstrated. The resulting secretion often shows the organism again. The author assumes that the foam formed opens the choked-up glands, and renders them susceptible to treatment with bactericidal injections. -Courier of Medicine.

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THE MORE SERIOUS COMPLICATIONS OF LA GRIPPE, OR INFLUENZA.*

BY E. A. COBLEIGH, M. D., CHATTANOOGA.

It is my purpose merely to present some of the clinical observations happening to myself in connection with this ailment, as I have observed it since its reappearance in this hemisphere in 1889. As, too, it has since seemed to have become fixed in our land, through its recurrence every winter for the intervening decade and a half, I take it that every clinician with wide opportunity for observation, whether in public or private practice, has noticed these same events.

Primarily it appears that the public, and quite a body of medical practitioners as well, regard grip as a joke rather than Read at 72nd Annual Meeting of the Tennessee State Medical Association.

otherwise. But this is the very thing which experience has disproven to me, and which I believe ought to be fully impressed upon the laity by professional sentiment, broadly expressed. Indeed, so often do I hear the phrase, "I had the grip, and have never fully recovered from it," that to me it is ominous of distress and mischief altogether.

One of the primal results of grip which was impressed upon me early was not simply the usual debility which accompanies most of our cases, and seems out of all reasonable proportion to the appreciable conditions presenting, but its indefinite persistence and extreme degree in quite a good many cases. These patients, wholly without regard to age or previous vigor, are as limp as rags- too feeble for any movement or exercise beyond the minimum of vitality required to stay alive. This one element of debility passive existence alone is profound, and the sole cause for uneasiness. Instead of recovering within ten days or a fortnight, most of these sufferers linger for weeks, sometimes even for months; and not a few dwindle on for a year or two to die of sheer exhaustion at last.

I particularly recall the medical director of a prominent life insurance company, in this connection, who experienced just such effects of grip every year for four successive seasons. The last one he visited my city en route to Florida for rest and recuperation, and was my patient for a brief period, going and coming. He was a little past the half century in age, and had been quite a vigorous man all his life; yet his age did not at all account for the exquisite lifelessness of the patient. He was simply too weak for anything. He said to me, "I must never, never have grip again, and shall run away from it next time." While perfectly clear in his mentation, he was indisposed even to think; and his mind was about as debilitated as his body. There was no cough nothing left of his seizure except the desperate depression of vitality. He lingered four or five months longer, and died, utterly worn out-beyond the possibility of recuperation.

This is but one of numerous similar instances which have come under my observation, some of them in childhood and youth. The pulse in these cases may be either subnormally slow, or may

show tachycardiac features, but is characterized by its smallness and its thread-like feebleness; the respiration is shallow and weak, sometimes sighing, but without pulmonary changes; the temperature is perhaps normal, seldom feverish, and generally below par; and these are about the only objective features.

The next condition, often occurring by itself, is marked by extreme nervousness. This sometimes goes hand in hand with the condition just described-giving us, then, a double manifestation of neural dejection. Frequently, however, the nervous feature is dissociated from the weakness of vitality happening in the preceding state; but is quite as extreme in its way. These victims are fidgety, uneasy, tremulous, apprehensive, forgetful, despondent sometimes, altogether changed in characteristics from their normal selves by the grip attack. They suffer often from insomnia, occasionally from stupidity, the former being the general state. And there is no safe limit for prognosis as to when the sufferer shall regain normality of nerve equipoise. The centers of neural vitality and co-ordination seem overwhelmed into extreme instability by the poison or shock of the grip seizure. There is no special change of temperature, but breathing as well as circulation sympathize with the neurotic status, and are generally rapid or irregular, or both.

A third condition, not very frequent, but seen often enough to impress the clinician, is marked mental involvement, occasionally amounting to prolonged delirium, to stupor little short of coma, to hallucination during or even after convalescence from the real attack; and, rarely, to mania, or continuing insanity. In none of these forms, however, has it been my lot to note a permanency of the condition, all cases which fail of dissolution through the very intensity of the original grip attack ultimately recovering normal mental stability, or nearly so. Some may have severe recurrent headaches or other neural explosions afterward. But I have been fortunate enough not to have encountered permanent unbalancing of reason after grip. Yet I am sure such an event might occur, at least to the already pre-disposed. But my personal experience warrants me in assuring these afflicted people and their relatives of the ultimate recovery of mind, no matter