usual to find only a scratch where the spicule of bone has passed. This leaves the feeling of something being present and it is sometimes difficult to convince a patient that there is nothing to be removed. The scratch heals in a few hours, or a day or two, and the patient is satisfied by that time that the bone or other substance has been swallowed and has not lodged in the throat.

The symptoms produced by the presence of foreign bodies may be severe or slight, depending upon the position and nature of the object. Usually the symptoms are not nearly so severe as one would suppose. There may be no cough and very little choking, so that the bodies remain for several days sometimes, in children, before they are discovered and removed.

Ingals reports instances of foreign bodies in the bronchi that have been there several years before being removed-one case as long as eight years.

I have had cases of foreign bodies in the upper air tract for several weeks, without very severe symptoms. If there is not immediate choking or strangling, a local inflammation occurs that sometimes developes an abscess with more or less destruction of tissue and bone necrosis, if in the nose. Very little damage is done if the body remains only a few days, or even for two or three weeks, as a rule.

The indication, of course, is to remove the foreign body as soon as possible. In small children a general anaesthetic is necessary. The body may be located by X-ray, by a laryngcal mirror, by the finger, or by direct examination. The use of the mirror in a small child is difficult and unsatisfactory, except after it is anaesthetized. When all other means fail, I always use the finger, and I can usually find pins and needles in that way.

The examination of the nose is not difficult, and the removal of foreign bodies from the nose is reasonably easy, though general anaesthesia is often necessary in young children. In a child a one-sided purulent discharge, which is persistent, is an almost sure indication of a foreign body in the nose. I

have selected from among my cases, four to report, in connection with this paper, because they are slightly unusual, and illustrate some of the points I have mentioned.

The first one is of foreign body in the nose. Miss B. T., Aet, 20, consulted me in December, 1910, on account of pain in her head. She said she had had everything done but failed to get relief and she finally concluded the trouble might be in the nose. Among other things, she had had her eyes refracted by an eminent oculist in Boston, and had been treated for catarrh by a less eminent general practitioner not now in this county.

In the examination of the nose I found necrosis and granulation in the right side. I removed some of the necrosed middle turbinate with forceps, but had to stop because the patient became faint and could not endure the pain. Cocaine had very little anaesthetic effect. I sent her to the hospital to curette under general anaesthesia, and was very much surprised when I removed the foreign body which I have here. The patient had no knowledge whatever as to how and when this got into the nose, but she said she had had headache on the right side as long as she could remember, and it had been very severe for the last two years. My last note is January 28, 1911: "Now returns to school, no headache and nose in good condition."

Case 2.—Mrs. R., Aet about 40, was visiting relatives in New York. On June 4th, 1911, while eating dinner she had a violent choking spell, with severe pain in her throat and inability to speak.

A doctor was called at once, but failed to find anything in the throat. She was not able to swallow anything, even liquid, after twenty-four hours, for a week. During that time she was seen by five doctors, two of whom were throat specialtists. Nothing could be found in the throat, but on the 11th of June. she coughed up a chunk of meat. This gave great relief; she was able to eat some food and to travel, so that she returned home.

The throat was not comfortable and she came to see me. I

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could find nothing except what I regarded as the redness resulting from her New York experience. She improved somewhat under treatment, but was not well or entirely comfortable, until two weeks later, when, while eating grape fruit, she coughed up the bone which I show, and which had become entangled in the shreds of grape fruit. She was eating chicken pie at the time of the accident. The chunk of chicken meat remained in the throat one week and the chicken bone for three weeks.

Case 3.-E. C., Aet 71⁄2 months. The mother noticed that the child did not seem well. She thought it probably had a sore throat. She had also missed a small gold safety-pin with which the mittens were pinned to the coat when the child slept in its carriage in the open air, as it did every day. Dr. Wadhams was consulted and his X-ray plate cleared up the mystery of the ill-feeling of the baby and the disappearance of the safety-pin. The pin was vertical in the throat, open, and lodged just above the epiglottis. The removal, by forceps, under ether, was not difficult, and there were no bad after effects.

Case 4.-D. S., Aet 13 months, a patient of Dr. Barney, with somewhat similar history, that is, she did not seem well and had some sore throat. The mother thought there might be something in the throat and she was brought to me for examination. I could see nothing by means of the laryngoscope, but I could feel a hard substance on the left side with my finger in the throat. Chloroform was administered by Dr. Barney, and with forceps guided by the finger, I was able to grasp the object. By using some force, I extracted a large sewing needle about two inches long. No one knew how long it had been in the throat, but it must have been several days. The child probably picked it up from the floor while creeping about the room. There were no complications and the child made a quick recovery.

REPORT OF CASES FROM THE RIVERSIDE

HOSPITAL.

BY DR. H. B. GIBBY, WILKES-BARRE, PA.

READ MARCH 27, 1912.

The Riverside Hospital has been in operation eighteen months. There have been four hundred admissions, 75 per cent. of which were surgical. Operations have been performed upon three hundred patients, with a mortality of 3 per cent. Of these three hundred patients, over 50 per cent. were abdominal sections, while the other 50 per cent. include such major operations as thyroidectomy, prostatectomy amputation of the breast, etc.

The appendix was removed in one hundred cases; in fortytwo of which operations were performed upon some other abdominal or pelvic organ.

There were many interesting cases in this series, but lack of time prevents their consideration here.

A case of unusual interest was one of meningocele in a child aged five months. This patient, which was referred by Dr. Stiff, of Plymouth, gave a history of a congenital occipital tumor, soft and fluctuating, about one-half the size of the child's head. Examination revealed the presence of an occipital cephalocele with a broad base. There were no signs of hydrocephalus. A grave prognosis was given but the parents accepted operation, which was performed May 24, 1911. The tumor proved to be an encephalo-cystocele, or rather a meningo-encephalocystocele, for in this case the dura mater was undoubtedly present, covering the thinned out layer of brain substance which formed the inner layer of the cyst wall.

The greatest care was exercised in the surgical technic to prevent any possibility of infection. The base of the tumor and adjacent scalp was carefully shaved and the skin disinfected with Harrington's solution.

The tumor was opened and the fluid contents evacuated through a small puncture and the dura dissected from the skin. The sac was then opened widely, disclosing a longitudinal cleft in the skull, about one and one-half inches long and one quar

ter inch wide, through which protruded some of the brain substance, and in this was an opening which undoubtedly connected with one of the ventricles, probably the third or fourth, as the opening was presumably below the tentorium.

The amount of brain tissue outside of the skull was small, so no attempt was made to reduce it but after trimming away the cyst and leaving just sufficient material in the flaps to make a good closure, the dura was very accurately closed with fine chromic gut, so that no leakage could occur, and the skin was sutured with horse hair.

The mother was allowed to take the child home and returned later to have the stitches removed. The child made an uneventful recovery.

Case 2.-Mrs. M. D., aged 60. Medium sized goitre-was quite emaciated. Vaginal hysterectomy was performed January 17, 1911, for cancer of the cervix.

The patient was in very good condition following the operation and made fair progress for the next three days.

On the evening of the third day she began to have trouble with her stomach-gas eructations, some vomiting and considerable distress.

About three o'clock on the morning of the fourth day, during a hard straining effort while trying to expel some gas, the patient said that she felt something “give away", and she had a slight hemorrhage from the vagina. As the oozing did not cease the vagina was packed with gauze, and in spite of the packing some hemorrhage continued. While the amount of blood lost was not great, yet the patient's condition grew gradually worse, until on January 22, five days after the operation, a transfusion was decided upon, her own son being the donor. Not having a Crile canula, the radial artery of the donor was attached to the Basilic vein of the patient by an end to end anastomosis. A very slight oozing at the seat of the anastomosis ceased almost immediately, and a regular rythmical pulsation in the vein showed that the lumen at the union was patulous.

The patient's pulse at the beginning of the transfusion was 120; after the transfusion had continued for a half hour the