tions. The diffuse peritonitis having subsided, local areas remain where the inflammation has gone on to ulceration, and caseous degeneration and masses of broken down tubercular tissues are formed usually firmly encapsulated, sometimes perforating the viscera.

Pus infection may follow any of the preceding forms or be a mixed infection from the start. In the mildest suppurative form the effusion in the peritoneal cavity may take on a sero-purulent character without adhesions or destruction of the endothelium, while in the more virulent infections the abdominal cavity may be filled with innumerable circumscribed suppurating pockets and the case be absolutely hopeless.

The symptoms of tubercular peritonitis in its different stages and varieties are so varied that the diagnosis is often extremely difficult and even at times impossible. In very acute cases the symptoms may appear so suddenly and so violently as to simulate an ordinary attack of appendicitis, while in the sub-acute cases the progress may be so insidious as to cause obstruction of the bowel by the large tumor masses, before attention is called to it. In children chronic ascites with fever is good evidence of tubercular peritonitis. If with tuberculosis of other organs there are irregular colicky pains and abdominal tenderness, tubercular peritonitis should be strongly suspected. If there are irregula: tumors in various parts of the abdomen with ter.derness, emaciation and fever with or with out ascites, tubercular peritonitis can be diagnosed. In women one of the most common errors of diagnosis is to mistake a circumscribed ascitic accumulation for an ovarian cyst.

The treatment is hygienic, medical and surgical. Taken in the very early stages, from 25 to 50 per cent. of cures result from hygienic and medical treatment alone; consisting of rest in bed, fresh air, anti-tubercular remedies, intestinal anti-septics and sterilized foods. In case the patients condition does not improve satisfactorily or has already advanced beyond the primary stage, the abdomen should be opened,-being careful not to penetrate the viscera which may be glued to the parietal wall. The fluid should be evacuated. and to avoid a recurrence of the disease the focus of invasion. as the appendix or the fallopian tubes, should be removed whenever it can be done without injuring the diseased peritoneum. No attempt at breaking up adhesions should be made as the peritoneum is friable, and rents thus made are difficult to close and fistulae are liable to follow. Drainage is unnecessary and only invites infection. The after treatment consists of the ordinary hygienic and internal antitubercular treatment.

It is surprising and almost miraculous what an immense amount of tubercular material will be absorbed from the peritoneal cavity following a simple abdominal section, and cases that appeared to be absolutely hopeless go on to complete and permanent recovery. Many experiments have been made to determine the manner in which the cure is accomplished, ad it has been demonstrated upon animals that a much greater hyperemia follows operation upon tubercular than non-tubercular abdomens, and it has also been shown that contact of air is the curative element, as a cure does not take place when section is made under normal saline solution. With the increased hyperemia occasioned, the phagocites become more active and the tubercular deposits are destroyed. Post-mortems upon patients operated on for tubercular peritonitis and dying later from some other cause, have shown the entire disappearance of the tubercular disease.

I wish to repeat two quite typical cases of this disease which came under my care at the Wesson Hospital last spring, the first a mild case of the miliary type, the second a more severe form of the fibroplastic.

Arthur R., Springfield, Mass., age 4 years. Family history negative. Had diphtheria and measles at two years of age. Otherwise well until a year ago last April, since which time he has had occasional attacks of fever, vomiting, nd abdominal pain with tenderness in the right inguinal region. April 12th, 1908, taken with another attack more severe than previous, vomiting continuing for twenty-four hours, temperature reaching 103. He was sent by his attending physician to the Wesson Hospital for an appendix operation, where he arrived on the evening of the second day. When seen a few hours later vomiting and pain had ceased, there was no muscular rigidity and but slight tenderness, temperature 99, pulse 102, operation delayed. Next forenoon temperature had not decreased and we decided to operate. Incision was made through the right rectus and the appendix was found apparently normal but miliary tubercles were scattered over the meso-appendix, the caecum and its mesentery. No fluid was present. The appendix was removed and the child made a rapid and uneventful recovery and was discharged on the 11th day. Has had no recurrence and is perfectly well at the present writing.

Lewis R., Greenfield, Mass., age 7 years. Family history good. One sister died of cerebro-spinal meningitis at 5 years. Was always well and strong until May 1st, 1908. Felt well that day and went fishing. Was awakened in the night by severe abdominal pain fol

lowed shortly by vomiting and fever. A local physician was called who treated him for worms. Patient remained in bed for ten days, afterwards getting up about the house but was weak, listless and had no appetite, was feverish and complained of abdominal pain. May 27th, four weeks from the beginning of the illness, the boy was brought to Dr. A. R. Perkins of Springfield, who sent him to the Wesson Hospital.

Examination at this time showed a patient aenemic and much emaciated, with an apparent mild tubercular involvement of the right apex. The abdomen was tender and greatly enlarged with an accumulation of fluid. Two distinct masses could be made out on palpation, one filling the whole ileo caecal region and extending well up toward the liver, the other fully as large, located in the umbilical and epigastric region. The temperature was 101, pulse 130. A diagnosis of fibrinous tubercular peritonitis was made and an immediate operation performed. A long median incision was made, free fluid allowed to escape, and abdomen explored. The peritoneur was found thickened and inelastic, the central mass was strongly adhered to the parietal wall and composed of omentum and intestinal coils, bound together by broad adhesions as thick as shoe leather, and containing a considerable quantity of serous fluid in its interspaces. The tumor on the right was also irrigated with saline solution and closed; no attempt being made to remove any organ. The patient was placed on anti-tubercular treatment, and the second day after the operation his temperature was 991/, and except for some sloughing of the stitches, necessitating a partial healing by granualtion, convalescence was uneventful and he was discharged June 16th, twenty days after his entrance to the hospital. Dr. Perkins visited him occasionally after his discharge, continuing the treatment for awhile, and now reports that he is fat and healthy with no evidence of his previous illness.

Perhaps it is too early to report these cases as cured, but all signs point to their having made permanent recovery.

Teacher: "Tommy, you should comb your hair before you come

to school."

Tommy: "Ain't got no comb."

Teacher: "Then borrow your father's.'

Tommy: "Father ain't got no comb, neither."

Teacher: "Absurd! Doesn't he comb his hair?"

Tommy: "He ain't got no hair!"

A GOITRE OF UNUSUAL PROPORTIONS.

BY NEWMAN T. B. NOBLES, M. D., CLEVELAND, 0.

This patient had an enlarged thyroid gland for thirty-five years. Recently it has grown rather rapidly and by pressure upon the trachea has threatened to suffocate the patient. Dr. Harpster of

Patient, aged 50 years. Had enlarg d gland since young girl.

Goitre made up of right lobe and isthmus and extended down between the lungs. There was as much of the tumor "out of sight" as there was visible. There was a slight enlargement of the left lobe, but this lobe was not interfered with.

Cleveland referred the case to me after nearly thirty physicians had argued against operative treatment. The growth extended well down and outwards. The picture gives a poor idea of the dimensions of the tumor. A general anesthetic was used for this case. She did well and was up in a week's time. The microscope showed a benign tumor of the colloid type. There has been no recurrence. I have operated many times for goitre but this is the largest tumor I have removed. Nor have I ever seen one as large.

It is interesting to note that goitre has a rather definite geographic distribution. For the United States it is most prevalent in the Great Lakes basin and the Columbia River Valley.

Of course many cases will respond to non-surgical treatment. Many fade away without treatment. A certain percentage do not respond to anything. These tumors grow larger and larger, cause much discomfort and have to be removed.

The so-called toxic goitre is the most dangerous type. The surgeon who aspires to operate successfully for goitre must be able to tell the difference in the various types. The operative technique varies in the different types. If the operator is careful to select his cases for operation he will be pleased with the end results. I, recently removed a toxic goitre (Graves Disease) from a boy eighteen years of age. The common carotid artery ran through the gland. He is now well. My patients leave the hospital in ten days as a rule.

There is no doubt but what more of these cases should be operated. Now that the operative technique is better understood the patient can be given a reasonable degree of assurance that all will be well. That is provided the surgeon selects his cases carefully.

SYPHILIDS.

BY GEORGE W. SPENCER, M. D., CLEVELAND, O.

The protean nature of syphilitic manifestations, both constitutional and cutaneous, make a positive diagnosis sometimes very difficult. Therefore, it is desirable to get the symptoms, both objective and subjective, as complete as possible, yet as uncomplicated as consistent with a thorough knowledge of the case under consideration. When the initial lesion is absent, and, as in many cases, the history is negative, so far as this is concerned, the only means of determining the diagnosis depends entirely upon (a) the subjective symptoms, which on account of the inability or unwillingness of the patient to impart them to the doctor, are of little value, also, because the indications of the disease are usually those of many other diseases, and not of so distinct a nature as to attract the especial attention of the most intelligent and truthful person.

(b) The objective signs then, of syphilis are the principal means by which we can make a positive diagnosis. Of these the skin eruptions are the most varied. The characteristic formerly considered