attacks, but owing to that almost universal dread of an operation, the advice was not accepted. On June 22 we were again called and found the patient in - the agonies of a most serious attack of recurrent appendicitis. Pulse was rapid, 130 to 140, temperature 103, vomiting had been characteristic and the pain was almost unendurable. We saw the case at 9 o'clock in the morning, advised that nothing but an operation had any prospect of saving life. The case was taken

to the hospital at 11 o'clock. At 2 in the afternoon the operation was performed and in the 16 or 18 hours that the case had been in progress, the appendix was almost gangrenous. The cavity of the appendix was filled with pus and there was probably a half-pint of free pus in the peritoneal cavity. The appendix was removed, the abdominal cavity drained and the case made an uneventful recovery.

At

Gas in Appendix. Case III.-J. J., 20 years of age, had had considerable digestive disturbance for a period of one year or more. times there was considerable fever, thick coated tongue, some vomiting, loss of appetite for a period of several days, usually with very little pain. At other times there were attacks of colic without fever, but accompanied by gastric disturbance and sometimes vomiting. An examination of the abdomen disclosed nothing except slight tenderness over the appendix. An operation was advised, but before submitting the case was examined by two other surgeons, who concurred in the view of the writer, consequently an operation was performed June 25, 1907. Upon inspection of the appendix in situ, absolutely nothing abnormal was discernible, with the exception that the diameter was considerably greater in the distal than in its proximal part. Upon removal and examination it was found that the appendix seemed simply constricted at the root. Its constriction hardly appeared to be the result of the inflammatory process. The

est.

mucous membrane was in symmetrical rugae similar to that lining the cervical canal. The explanation of this seemed to be that the abnormally small opening from the lumen of the appendix in the caecum had caused an accumulation of gas in the appendix, which ballooned it out and thus accounted for the excessive mucous membrane development. This was believed to be the reflex cause of the digestive disturbance and pain. The abdomen was closed without drainage and the patient went home on the ninth day, and was around town on the fourteenth day. The health of the patient apparently became perfect, and at this time there had been no recurrence of any of the old symptoms. These two cases illustrate the difference between the two treatments. In the one the operation was performed at a time when it was done safely, easily and with almost no inconvenience or pain to the patient. The other was performed at a time when all the elements of risk were the highIt was also fraught with the usual pain and suffering that is inseparable from four weeks of a suppurating abdominal wound. This might have been averted had an operation been consented to at the close of the first attack, as had been done in case number three. Cystic Ovary. Case IV-Miss M. M., 16 years age, on November 14, 1903, was operated upon for appendicitis. The operation was not during an acute attack and the results appeared to be good. For several months after the operation the patient was in a good state of health. At the end of that time, however, she began to fail and complained of pain and great tenderness located in the right ovarian region. She was kept in a state of invalidism during which time various methods of treatment were resorted to, including medicinal, electrical, vibratory, hydropathic, thermic, etc. An operation was advised within, perhaps, a year of the operation for appendicitis, but having gone through one operation the pa

of

tient was not in a frame of mind to easily submit to a second one. However, the advice was constantly kept before. the patient, and finally at the end of three and one-half years, she was driven by her sufferings to seek relief, even though it must be at the expense of another dreaded operation. An operation was performed on July 27, 1907. There was no evidence of pelvic inflammation, the uterus was in good position and there were no adhesions. The left ovary and the tube appeared to be normal, but the right ovary was in a state of cystic degeneration, being about three times. the size of a normal ovary. This was removed, together with the tube and the abdomen closed without drainage. The patient made an uneventful recovery and the soreness and pain are no longer present. The general health is becoming improved to an extent beyond anything that she had experienced since the time of the operation for appendicitis. Had this patient submitted to the operation two years before, even though it was following close on the heels of a former operation, she might have had two years start in life and thus have been saved much suffering and inconvenience.

These case histories are quoted not so much as argument as they are illustrative of the point in question.

Diseased Organs Dangerous.

We hear conservatives urge that organs should be cured, not removed. This would be the method par excellence, if the disease were a thing that could be plucked out, leaving its seat as it was before. But how well do we know that an organ once the seat of serious disease never again comes to possess its original power of resistance. Besides, the delicate nervous balance which we call health is seriously disturbed when an important organ is the seat of disease. To be sure, surgery does not always consist in removing a diseased organ; but it does aim to rapidly and rad

ically separate disease products from the human organism. Tares should be cut off or plucked out. Who would advise that the wheat should be coaxed to choke them out?

All cases may be placed in one of two classes-surgical or non-surgical. Most cases may, without difference of opinion be placed in one or the other class. But there will be certain cases near the border-line which would be claimed alike by the conservative and the radical.

Just how to decide in a given case is, sometimes, a difficult question. There are no fixed rules by which to determine, otherwise there would be no dispute When an efficient operator and adequate facilities are available the dangers of surgery are, of course, minimized. These being at hand, an operation should be advised.

1. When there is danger of sudden exacerbation which would place the case in the "high percentage fatal" class.

2. When the damage to a removable organ is irreparable and its presence threatens a profound systemic disturbance by sympathetic affection.

3. When disease products can be removed quickly, thoroughly and safely.

4. When a simple, operable case is in danger of becoming a dangerous, unoperable one.

5. When nature's cure will be with loss of important function which could be avoided with surgical means.

6. When time could be saved by the surgical method, granting that either. might cure.

To conclude, we believe that more good surgery would mean less suffering in the world. If this be true, it is sufficient justification for so-called radicalism in surgery.

DIAGNOSIS OF MENINGITIS.

LADD, in the Cleveland Medical

Journal, gives it as his opinion that lumbar puncture offers us the most satisfactory means of arriving at a correct diagnosis in the shortest space of time, and should be promptly done when there is the slightest suspicion of an existing meningitis. The presence of the meningococcus in the spinal fluid calls for the prompt use of Flexner's serum in dull doses on successive days until the spinal fluid clears and the toxemia and physical signs of meningitis have disappeared. In the event of chronic hydrocephalus developing in this type of meningitis, aspiration of the ventricles should be performed and serum injected in place of the fluid removed, as advocated by Dr. Harvey Cushing. Influenza bacilli can be isolated and grown from the spinal fluid when it is the etiological agent, and one case seen at the City Hospital, in which this organism was present and the spinal fluid extremely purulent, progressed to a complete recovery following daily administration of normal horse serum intraspinally.

Pneumococci, streptococci, staphlococci, typhoid bacilli, colon bacilli, bacillus pyocyaneus, leptothrix, and streptothrix forms all have been isolated as etiologic agents of acute cerebro-spinal meningitis. In six cases of streptococcus meningitis resulting from extension of middle ear disease, the use of antistreptococcic serum gave results which were not at all encouraging. Tubercle bacilli, if properly looked for in cases of tuberculous meningitis, can be found in the spinal fluid in 90 per cent. or more of the cases. In one case of tuberculous meningitis seen with Dr. John Phillips five hours after the first symptoms of cerebral irritation developed, lumbar puncture was performed and tu

bercle bacilli found in the spinal fluid. A plural effusion had been removed from this patient two weeks previous to the development of meningitis and had not recurred.

In examining the spinal fluid for tubercle bacilli, it is best to withdraw the fluid in two tubes. One of these can be used immediately for cytological examination. The other should be set aside for eighteen to twenty-four hours until the fibrinous strands have completely formed. Take a long and stiff platinum loop, gently detach the fibrin from the sides and bottom of the tube, and delicately scrape the bottom of the tube; now have a clean slide ready and remove most of the watery elements from the loop by gently touching the loop to the surface of the glass slide at. one end, and then with a gentle rotary motion over an area the size of a threecent piece transfer the fibrinous clot from the loop to the slide; fix, stain, and examine microscopically, using a mechanical stage for searching, and one can find tubercle bacilli in the same fluid which did not give positive results when the centrifuge was used.

URINARY COLOR INFECTIONS. Porter and Deischner, in Archives of Pediatrics, urge that great attention be paid to cleanliness of the genitals. It is said that in boys with phimosis circumcision may cause the bacilluria to disappear completely without further treatment. Removal of oxyurides from the bowel likewise often relieves the bacilluria. If the attack is acute the child should be put to bed and be given large quantities of fluid to flush the bladder, at the same time the bowels should be thoroughly moved. In addition to that, 15 grains of urotropin should be given daily. This should be diluted in a large

quantity of water. The use of the alkalies has been recommended, especially by Morse, who, unlike the writers, finds them more effective than urotropin. But, in the more intense, persistent cases autogenous vaccines give us our only hope. The method of using the vaccines will, of course, depend on the experience and judgment of the individual practitioner. Leary (Boston Medical and Surgical Journal, 1909) claims his best results to have followed small doses of the vaccine at short intervals. Thomas, of Philadelphia, in a late number of the Journal of the American Medical Association, reports a series of cases in which good results have followed enormous doses at three and four-day intervals. The latter is certainly the least distressing method to the patient. In most of the cases reported that have been given vaccines, this method has been employed, and it has seemed rational to inject the largest dose that can be given without producing a marked reaction and to repeat the injection at four-day intervals.

In the chronic cases of infection, those that show only malnutrition and incontinence with or without a slight temperature rise, the patients should be similarly treated, although they need not be confined to bed. They should be encouraged to drink freely of water and to rest content with a bland, nourishing diet. All methods that tend to improve the general condition should be employed. Anticolon serum used by Dudgeon and others has not been successful.

In concluding, special attention should. be called to the importance of culturing the urine in all cases of persistent fever of obscure origin, because this simple procedure will often clear up the diagnosis of a puzzling case.

ACUTE HEADACHES OF CHILDREN.

LeGrand Kerr, in Archives of Diagnosis, asserts that in practically every instance the acute headaches of children are associated with an elevation of temperature. The first thing that must be

done is to determine to just what extent the headache is due to that particular rise of temperature and this is decided by two factors, viz., the intensity of the fever and the character of the headache.

Given a temperature under 103 deg. F., headache is rarely present in children unless there is disease of the brain or the meninges. Under such circumstances it is likely to be more or less persistent and intense. When entirely due to a rise in the temperature, headache is usually greatly relieved by pressure over the temples, by the application of cold to the head, and by massage of the veins of the neck. On the other hand, active motion causes an increase in the pain. It is true of all febrile conditions in children that they are usually associated with some degree of headache.

It is not uncommon to find that the scalp of a child is the site of one or more circumscribed areas of inflammation and the tissue in the immediate vicinity, and occasionally for a considerable distance from the foci, is very tender, and pressure gives the child pain. Such conditions are readily mistaken for headache. Then again, more rarely, rheumatism exhibits most of its manifestations for a time in pain in the aponeurosis of the scalp and the child complains as of headache. Palpation easily discloses the true nature of both of these conditions.

The headaches due to toxemia are almost always characterized by pain which. is referred to the course of a nerve and is unilateral. If such a headache occurs in a child who is already the victim of some kidney lesion, it should at once excite our suspicion of uremia, regardless of the presence or absence of a rise in temperature. Of course, the large majority of this type of headache is due to an acute toxemia, dependent often upon constipation or overfeeding, and is relieved at once by active catharsis. The acute headache which accompanies the onset of many of the infectious dis