With such a history, one must consider as most probable, one of three conditions: gastric cancer, gastric ulcer, and chronic gastritis. In favor of the first, there is the age (fifty years); the great loss of weight and strength during the past six months; the dark stools; and the sudden onset, about six months ago, after a period of comparative health; frequent vomiting and dimished appetite. In favor of ulcer, there is the severe, localized pain in the epigastrium; dark stools; vomiting of blood (this occurred ten years ago); and tenderness in the epigastrium. In favor of chronic gastritis, chronicity, there having been vomiting and nausea at times, with much mucus present, and eructations for about ten years; vomiting independent of kind of food. cr time of eating.

On examination, the patient lies, a cachectic, emaciated, miserable looking individual, on the left side with the legs drawn up. Skeleton slender, arms can be encircled by the thumb and forefinger, the legs and thighs by the hand. Panniculus absent. Skin very sallow, mucous membranes pale. Conjunctival fat slightly increased, face somewhat sallow; joints of hip and knee somewhat fixed; cannot be moved without pain; no enlarged glands. Abdomen scaphoid, iliac bones prominent; pelvis tilted so that umbilicus is to left of median line. The abdomen is somewhat fuller to the left than right, due to position, and appearing as if viscera had fallen to that side. Skin harsh and scaly. Active peristalsis from left to right and up and down below umbilicus. On palpation, in region of umbilicus, there can be felt a band one and onehalf inches broad, lying transversely, slipping under the fingers, not affected by respiration, and seeming like intestine. Inflation shows greater curvature of stomach two fingers below, lesser two fingers above the umbilicus. Nothing in the examination of the thorax to throw iight on the case. On May 14, a hard, rounded, irregular mass in the median line, extending to the right and left toward the margin of the ribs, was felt, descending on deep breathing only a little. This was also felt on May 16. At this time patient had no complaint except sleeplessness and pain in the limbs; no vomiting, appetite good. On May 19 a mass was felt the size of a lima bean, one inch below the ensiform.

The stomach examinations, granose test meal, showed one hundred seventy-five to three hundred cubic centimeters, no long bacilli, few yeasts; hydrochloric acid ten to eighteen, total acid thirty-two to forty. During the time that the patient was in the hospital, she grew gradually weaker. She began to cought on May 19; she was too weak to raise sputum. On May 24 the urine, previously negative, showed well-marked diazo reaction. The patient died on May 26, 1903.

At the autopsy, which was conducted by Doctor Warthin, the heart showed brown atrophy. Lungs: the left was less voluminous than the right, and weighed nine hundred and seventy-six grammes (right weighing four hundred and sixteen grammes); left firm, almost airless. Fresh fibrinous pleurisy. On section, both lobes were found infiltrated, pus escaping from cut surface and small bronchioles; surface mottled, gray

ish to reddish, slightly granular; many small lighter spots over surface, yielding purulent exudate. Stains of pus, modified Gram's, show encapsulated diplococcus similar to pneumococcus, in almost pure culture. Right lung, vesicles distended, purulent exudate from bronchioles. Few old tubercles in pleura.

Stomach small, extends only two fingers below ribs in nipple line. In the lesser curvature, about three fingers above pylorus is a deep excoriated ulcer with overhanging edges. Floor covered with yellowish exudate. in the floor is valve-like flap of mucous membrane resembling stomach mucosa, in the middle of which is a communication with the duodenum. This flap is entirely separate from and below the level of the stomach mucosa. In the duodenum, just below the pylorus is a small round polypoid mass, the size of a cherry. No distinct pedicle, rather broad base, covered with mucosa. On section this is homogenous, no alveolar structure, yields no cells on scraping. Lowest edge of ulcer four centimeters from pylorus; opposite edge six centimeters from esophageal opening; in duodenum opening thirty-two centimeters distant from pylorus. Microscopic section showed no carcinomatous change.

A CASE OF OBSTRUCTION OF THE BOWEL.

DOCTOR LOREE: A number of you saw this girl operated upon last Tuesday morning. The case is of special interest to those of us who saw her here last summer, as so many of the operative cases are not heard of after they leave the hospital; but the return of this patient affords an opportunity to examine an old field of operation.. Patient came to the hospital a year ago. She had been sick about ten days with vomiting and pain. After one day's illness she was able to be around for two days, when she was subjected to another seizure. The vomiting recurred and the pain became localized in the right side. Patient grew worse until she was brought to the hospital about ten days after the first attack, where she was operated upon for appendicitis. She was not a favorable patient for operation. Her temperature was about 101, pulse 130 to 140, and she had all the signs and symptoms of a person who was pretty badly poisoned. There never was a mass in the right side, and this is probably due to the fact that the appendix was found lying. well in the pelvis. This class of cases very seldom show a mass on the right side and the only diagnostic signs were pain and tenderness on pressure. Pus was present. The patient was in the hospital about forty days at that time.

She was allowed to go home before the wound was entirely healed, but I saw her several times afterward. When she had been home for three weeks, the small sinus which had persisted closed over for two days, and I then noticed a small black speck, which proved to be a piece of the black silk ligature that was passed around the appendix. We heard nothing more of this patient until she came to the hospital last Tuesday.

A week ago yesterday she was taken sick early in the morning with

very severe pains in the stomach region, colicky in nature. Later she grew better but that night she began to vomit and the pain became more localized in the right inguinal region. She was brought to the hospital last Tuesday, about a week after the attack, and was operated upon for intestinal obstruction. The obstruction was a general inflammatory thickening of the bowel. The small intestine did not leave the large at a right angle, but followed the course of the large bowel more or less and was becoming adherent thereto. The obstruction was near the junction and a perforation was found close to the obstruction. The patient at the time of operation was in a very poor condition and consequently time was a necessary element. It was probably the ideal place for anastomosis with the Murphy button and one was employed. There was no time for a McGraw ligature. At the time of operation, and when she came into the hospital, her pulse was 140 to 150 and her temperature registered 101°. Since the time of operation her pulse has gradually decreased until today it is 114; yesterday it was 128. The next day after the operation she began to have movements of the bowels. She has been getting a little nourishment, milk and beef-tea, and yesterday we administered calomel followed by salts. The wound was dressed at the time of operation with gauze carried down to where the Murphy button was placed and this gauze was removed twentyfour hours after the operation. There was some discharge but no fecal matter. Since the original piece of gauze drainage was taken out we have kept the wound open by means of rubber tubing.

The patient was transfused after the operation, and one of the alarming features about the case was that she did not respond to the transfusion at all, and from my experience here, when the heart does not respond the case is very unfavorable.

The case is interesting because of the fact that it has presented the complications of not only delayed operation for appendicitis but also delayed operation following obstruction.

DISCUSSION.

DOCTOR DARLING: This case is one of great interest because of the length of time the obstruction had existed before operation. Most of the cases of intestinal obstruction are fatal unless operation is performed early, and especially so if there is fecal vomiting. In this case there was fecal vomiting and plenty of it two days before operation. I saw the patient in consultation with the attending physician and informed him that I thought she would die if she was not operated upon and would probably if the operation were performed. While I was present she vomited material which not only had fecal odor, but which contained formed feces. There was a question in this case about the passage of gas: whether air had been admitted into the lower bowel when giving enemas, or whether some of the gas had passed that point. Another matter of importance was the perforation. The small intestine was perforated, and there was also a beginning perforation in the colon, showing that if this patient could have been kept alive that there would

have been a cure for the present; and also showing the possibility of a cure taking place by one damaged intestine opening into another with which it comes in contact. In this case we employed large quantities of salt solution for irrigation, and it was surprising to see the effect on the intestine. The bowel was greatly congested and fairly purple during the operation, but the hot salt solution had excellent effect, and one could see the color change, although I did not think that this was wholly attributable to the action on the heart. I thought it had some local effect on the intestine. Where it was perforated, fecal matter ran out into the abdominal cavity, and there were also signs of general peritonitis. In this case the washing with very hot salt solution had a favorable effect. Within the last two weeks I have had two cases of peritonitis with perforation, wherein there was pus in the abdominal cavity, and in both cases I employed gallons of hot salt solution, 120° to 130°, and by this thorough flushing I have been able to remove all the symptoms of infection. It is surprising to see how little pus was formed, even at the site where the abscess was opened. In one case which I opened, wherein the pelvis was full of pus, the patient has had no signs of general peritonitis worth mentioning after using this large quantity of hot salt solution. It is quite interesting to see how hot the intestine will bear this. and how well the peritoneum seems to withstand the heat. I am satisfied that these cases, and this one in particular, were saved by the free use of hot salt solution because I have seen cases exactly like these die in a few hours after opening the abdomen. The anastomosis by the button was the only one to be considered at this time. The patient is not well yet, and may die of perforation or hemorrhage, but she looks as though she was destined to live.

ORIGINAL ABSTRACTS

MEDICINE.

BY JAMES RAE ARNEILL, A. B., M. D., ANN ABBOR, MICHIGAN.

INSTRUCTOR IN CLINICAL MEDICINE IN THE UNIVERSITY OF MICHIGAN.

AND

DAVID MURRAY COWIE, M. D., ANN ARBOR, MICHIGAN.

FIRST ASSISTANT IN MEDICINE IN THE UNIVERSITY OF MICHIGAN.

FETAL, CONGENITAL AND INFANTILE TYPHOID.

JOHN LOVETT MORSE (Medical News, Volume LXXXIII, Number V) collects from the literature and critically reviews the cases of fetal, congenital and infantile typhoid.

A few undoubted cases of fetal typhoid prove beyond doubt that the typhoid bacillus can pass through the placenta, but perhaps this does not occur through the normal placenta. The Widal reaction does

not prove the existence of fetal typhoid, as agglutinin may pass from the maternal to the fetal circulation. The child does not necessarily contract the disease when the mother is affected. When affected the fetus most often dies in utero, or, if born alive, dies soon of an acute cachexia without special characteristics. If it lives longer, it may develop some classical symptoms, and even recover.

The pathologic lesions in intrauterine and extrauterine typhoid vary, because of the fact that extrauterine typhoid is a secondary septicemia, slowly developing on a primary intestinal affection, while intrauterine, typhoid is a septicemia from the start. There is no proof that the fetus can pass through the infection in utero and be born alive and well.

As to infantile typhoid, only thirty-two cases are reported in infants under two years of age in which the diagnosis was confirmed by the Widal reaction or cultures, or both. This number being so small, it is evident that the disease is uncommon or else unrecognizable because of nonresemblance to the type seen in older children and adults. In the first year of life the exposure to typhoid infection is, of course, less because of the manner of feeding, but in the second year this reason cannot hold good. Inasmuch as the symptoms in the cases collected were similar to those seen at other ages, it is probable that the future will show that the infrequency of typhoid in infancy is real and not apparent.

SURGERY.

BY HENRY O. WALKER, M. D., DETROIT, MICHIGAN.

PROFESSOr of surgery and CLINICAL SURGERY IN THE Detroit college oF MEDICINE.

AND

CYRENUS GAVITT DARLING, M. D., ANN ARBOR, MICHIGAN.

LECTURER ON SURGERY AND DEMONSTRATOR OF SURGERY IN THE UNIVERSITY OF MICHIGAN.

THE RADICAL CURE OF UMBILICAL HERNIA. DOCTOR WILLIAM J. MAYO, of Rochester, Minnesota, read a paper before the Section on Surgery and Anatomy at the fifty-fourth annual meeting of the American Association, on his continued experience in the vertical overlapping operation for the radical cure of umbilical hernia (Journal of the American Medical Association). He calls attention to the fact that the conditions favorable to the production of this form of hernia, as weakness of the abdominal muscles, rigidity of the ring and obesity of the patient, are not favorable to repair. The natural defect in all cases is the separation of the recti muscles above the level of the umbilicus. The muscle separation is greater in corpulent persons. The causation of hernia is due to the downward traction of the abdominal wall, the contents of the abdomen having a fixed point at the umbilicus. Continuous pressure at this point causes elongation of the abdomen and