DR. J. T. DANA, Portland, Me.-I am sure that it is not rare to find inflammation of the appendix as a latent affection. In a case which I recently saw, the first symptom was the occurrence of general peritonitis which resulted fatally in seventy-two hours.

DR. A. L. LOOMIS, New York.-Recognizing the importance of the early diagnosis, I decided, some years ago, in such cases to put the patient under the influence of an anesthetic, and examine by the rectum and externally. In the first case that I adopted this plan, the chilly sensation had preceded my visit twenty-four hours. By bimanual palpa. tion, I satisfied myself that there was an increase in the region of the appendix. I expressed the opinion that perforation had occurred, and recommended operation. This was refused. Peritonitis set in within twenty-four hours and the patient died. other cases, I have made the diagnosis by the same plan.

In two

As soon as the diagnosis of perforation is made out, the operation should be performed. The association then went into executive

session.

President, Dr. S. Weir Mitchell, Philaphia.

AFTERNOON SESSION. PERI-UTERINE INFLAMMATION.

These

Under or

BY WILLIAM M. POLK, M. D., New York. The purpose of the paper was to consider those masses found about the roof of the va gina, generally to the sides of the uterus, sometimes behind, rarely in front. have been described under the head of pelvic cellulitis and peritonitis, and have been the cause of much controversy. The speaker considered these masses to be the result of salpingitis, due to uterine disease. dinary circumstances the disease travels by way of the tubes, but in septicemia it travels by all routes. Fifteen cases were reported, in which the symptoms and signs ordinarily ascribed to pelvic cellulitis and peritonitis were present, but in which opening of the abdomen showed salpingitis, peritonitis and ovaritis, there being no thickening of the cel lular tissue. Except in those cases in which there was shortening of the ligaments, the Pelvic abscess, in the writer's opinion, was, in uterus presented about the normal mobility. the majority of cases, of tubal origin.

As regards the causation of these masses, anything that will produce endometritis may produce salpingitis and cause these masses. PROGNOSIS.-Death is the exception. This result is to be expected when septicemia is

Treasurer, Dr. W. W. Johnson, of Washington.

Council. Dr. William H. Draper, of New York; Dr. Robert T. Edes, of Boston; Dr. H. M. Lyman, of Chicago; Dr. Samuel C. Busey, of Washington; Dr. Frederick C. Shattuck, of Boston; Dr. William Osler, of Philadelphia, and Dr. W. W. Welch, of Baltimore.

The proposition with reference to the formation of the Congress of American Physicians and Surgeons was presented and approved.

The following committee was appointed to confer with other organizations: Drs. William Pepper, Phila.; Robert T. Edes, Boston; R. P. Howard, Montreal; James T. Whittaker, Cincinnati, and Francis Delafield, New

York.

Adjourned.

depraved state of the system. The occurrence of abscess is usually followed by recov ery. If the mass remains, the permanent cure of the case is doubtful.

In chronic cases, after all other measures have failed, operation may be performed. The tearing of the adhesions may be sufficient. CONCLUSIONS.-Salpingitis is neither a new nor a rare disease.

It ts with peritonitis the most common form of inflammation about the nterus, holding in point of frequency almost the same relation to the extra-uterine surface, as does endometritis to the intra uterine.

The majority of cases get well.

A small number do not get well, and these are capable of causing such danger and disremoval of tubes and ovaries is a necessity. tress to the patient that abdominal section and AN EXPERIMENTAL STUDY OF GLOMERULO. NEPHRITIS.

By DR. W. H. WELCH, Baltimore. The questions which the investigator had gin of the cells which often in nephritis ocattempted to answer were: What is the oricupy the space between the glomeruli and the capsule of Bowman? Does migration of

the white corpuscles or diapedesis of the red corpuscles take place through the glomerular capillaries? What relation as to frequency and intensity do changes in the glomeruli play in the pathology of Bright's disease? In expectation that light might be thrown upon these questions, the speaker had experimented on rabbits and white mice, by the production of acute cantharidal poison.

Microscopical examination of the kidney in the mouse shows here and there foci of infiltration with small round cells, doubtless migrated white corpuscles. The epithelium of the convoluted tubes is in places normal in appearance; in other places it is swollen, and often the inner part of the cells is broken off, appearing as a granular mass in the lumen of the tube. The most marked change is found in the Malphigian bodies. In the greater number of these there is, between the glomerulus and Bowman's capsule, a wide space, partly or wholly filled with cells. These are larger than white blood corpuscles. They are frequently arranged in a crescentic mass. These appearances are similar to those described in glomerulo nephritis in man. In the latter case these cells are attributed to swelling and desquamation of either the capsular or glomerular epithelium. Such explanation does not hold in the present case. The epithelium of the capsule is often intact, and the glomerular epithelium may retain its normal position. More frequently it is swollen and may desquamate. There are no appearances which justify the derivation of the greater number of the cells from the epithelium of the glomerulus.

These cells cannot be regarded as white blood corpuscles, changed by the action of the poison, for the cells circulating in the blood are exposed to the same poison. These cells may be derived from the epithelium of the convoluted tubes in immediate communication with the Malpighian bodies. The cells in the capsular space are identical with those in the convuluted tubes. At times there can be found groups of cells arranged in the form of a ring with a central space just like the epithelium of the uriniferous tubules.

It is difficult to decide whether the cells occluding the glomerular capiliaries in acute Bright's disease are white blood corpuscles or endothelial cells, but the speaker inclined to the view that at times they are detached endothelial cells. Swelling of the endotheSwelling of the endothe lium and accumulation of cells in the glomerular capillaries appears to be a nearly constant lesion in the acute nephritis of scarlet fever. In one case examined this was almost the only lesion in the kidney: Occasionally

pathologists meet with kidneys in which the apparent changes do not explain the symptoms. In such cases careful examination of the glomerular capiiliaries should not be made. It is difficult to think of any lesion of the kidney more destructive to its function than occlusion of the capillaries.

While disposed to attach much importance to the changes in the glomerular capillaries, we are not justified in asserting that these constitute the primary and essential cause of Bright's disease; they are co-ordinate with other lesions.

BICUSPID CONDITION OF THE SEMILUNAR
VALVES AND
ITS RELATION TO AORTIC
VALVE DISEASE.

By WILLIAM OSLER, M. D., Philadelphia. A bicuspid condition may be said to exist when two of the three sigmoid cusps have more or less perfectly fused, so that the arterial orifice is guarded by only two segments. The abnormality is a well recognized one.

In over eight hundred autopsies at the Montreal General Hospital, there were eighteen cases, seventeen in the aortic valves alone, and in one pulmonary and aortic segments were both involved.

The part played by this condition in aortic valve disease is illustrated by the history of the eighteen cases. Two died suddenly from cardiac syncope. Twelve presented the picture of chronic aortic insufficiency, and in four the lesion was accidentally found, death having resulted from other causes. In sixteen cases there was hypertrophy of the heart, chiefly of the left ventricle. With the exception of one case, a fetus at the eighth month, the patints were adults. The ages ranged from twenty to sixty years. A great majority of the instances present other serious anomalies of development and death takes place before puberty.

Unquestionably the majority of the cases are congenital and result either from faulty development or fetal endocarditis. The former view seems the more probable.

GEORCE M. STERNBERG, M. D., U. S. A., in a paper on the Bacillus Typhoid Fever, said that recent researches support the view that the baccsllus described by Eberth in 1880, bears an etiological relation to enteric fever, although the final proof that such is the case, is still wanting. This proof would consist in the production, in one of the lower animals, of the specific morbid phenomena which characterizes the disease as it occurs in man, by inocculation of a pure culture of the bacillus. Thus far we have no evidence that any one of the lower animals is subject

to the disease as it occurs in man; but Fraenkel and Simmons have shown that the bacillus of Eberth, is a bathogenic organism and that pure cultures injected into the peritoneal cavity of mice or into the circulation of rabbits, cause the death of these animals, and that colonies of the bacillus are found in the spleen, which resemble in every respect the colonies found in the spleen and other organs of typhoid cases.

The researches of Eberth, Meyer, Gaffky, Fraenkel and others, indicate that this bacillus is contantly present in the intestinal glands, and in the spleen, of typhoid cases, and Gaffky has shown that pure cultures may be obtained from the spleen even in cases in which microscopical examination fails to demonstrate the presence of the characteristic colonies.

The researches of Brieger show that a toxic ptomaine is produced as a result of the vital activity of Eberth's bacillus, when it is cultivated in albuminous culture media. This injected into guinea pigs, causes salivation, diarrheal discharges, debility, dilated pupils, rapid respiration and death at the end of twenty-four or forty-eight hours.

Demonstrated facts relating to the propogation of typhoid fever indicate that it is due to an organism which is capable of multiplication exteral to the human body in a variety of organic media at comparatively low temperatures. Eberth's bacillus complies with these conditions. In consideration, therefore, of its constant presence and the absence of any other organism as shown by microscopical examination and culture experiments, the inference seems justifiable in the recent state of science, that this bacillus bears an etiological relation to the disease in question.

A CLINICAL REPORT OF NINE CASES OF HEMI

ANOPSIA.

BY DR. E. C. SEGUIN, NEW YORK. He presented an abstract of nine cases of lateral hemianopsia due to cerebral lesion. Of the nine cases, five had right lateral hemianopsia, and four left lateral hemianopsia. A very peculiar symptom in two cases of the second category, and one which the author thinks is new, was the occurrence of hallucinatory images for a short time in the darkened half-field. This is a symptom of irritation, analogous to tne convulsive movements sometimes seen in paralysis of a limb when its motor centre is being destroyed by disease. The speaker also exhibited specimens illustrating the seat of lesion in certain lesion in certain cases of hemianopsia.

DR. HENRY FORMAD exhibited specimens of kidneys demonstrating some peculiarities of cyanotic induration of those organs.

This condition is produced by anything which interferes with the circulation through the kidneys. The shape of the kidney where the cyanotic induration results from the use of alcohol is rounded and shortened. The kidney presents a pig-back appearance. Where the cyanotic induration results from heart disease, the shape of the organ is not altered, as the condition takes place gradually.

The following papers were read by title: Notes of a Case of Hepatico-Bronchial Fistula, by Dr. J. E. Graham, Toronto. Pancreatic Hemorrhage as a Cause of Sudden Death, by Dr. F. W. Draper, of Boston. Pernicious Anemia, by Dr. A. Jacobi, New York.

A Case of Hodgkin's Disease, by Dr. F. Forsheimer, of Cincinnati.

A vote of thanks was tendered the government officers and the profession of Washington for courtesies extended. Adjourned.

BALTIMORE GYNECOLOGICAL AND

OBSTETRICAL SOCIETY.

Regular meeting, held May 11, 1886. The President, Dr. Geo. W. Miltenberger, in the chair-Dr. Wm. E. Mosley, Secretary.

[CONTINUED.]

DR. T. A. ASHBY read a paper on THE INFLUENCE OF PREGNANCY AND PARTURITION UPON ORGANIC CARDIAC DISEASE. (Vide p. 34)

DISCUSSION.

DR. ERICH said that some six or seven years ago he was called in consultation to see a woman who was some four months pregnant, and had some form of organic heart disease, the exact character of which he did not remember. The question to be decided was whether or not abortion should be induced. He advised allowing the woman to go on to full term, and was afterwards called upon to attend her in her labor. He used morphia in quantities just sufficient to control the nervous system, and, when labor pains fairly set in, used chloroform systematically, and delivered very slowly by forceps, simply helping each contraction. The result was a perfectly natural recovery. He thought that if Dr. Ashby had been able to be with his patient from the first, the result would have been very differ

ent, as he believed that the death was due rather to the nervous disturbance than to the hemorrhage.

DR. W. T. HOWARD said that he had listened with great pleasure to the reading of Dr. Ashby's lucid and interesting paper. He thought, however, that the statistics collected by Dr. McDonald, giving a mortality of 17 out of 28 cases, or 60 per cent, from the deleterious effects of pregnancy aud parturition on chronic organic disease of the heart, much higher than is usually seen in private practice. He had attended many ladies in private practice during their accouchement who were suffering from severe cardiac lesions, and he did not remember a single death. Dr. H. felt well assured that he would be sustained in this statement by our president, whose experience in obstetrics, as we all know, is immense. He would ask if such had not been the result of Dr. Miltenberger's experienceif such cases did not usually pass safely through the pangs and perils of labor, with due care and attention.

Dr. H. said that the mortality in the cases under discussion would doubtless vary with the nature and extent of cardiac lesions. It is now well known that there is a physiological hypertrophy of the heart during pregnancy, to sustain the burden imposed by the demands of a quickened circulation, and the complicated exigencies of the constantly growing uterus. And some cardiac lesions are much more dangerous than others. Thus mitral stenosis is especially apt to occur during the period when child-bearing is most active, rarely occurring after 50 years of age, and is at least twice as frequent in females as in males. And as stenosis of the mitral orifice is generally accompanied by mitral insufficiency, this complicated condition is particularly dangerous during pregnancy and partu

rition.

toms. The left auricle first feels the strain, from presence of the two blood currents during diastole, one from the left ventricle and the other from the lungs, and begins to dilate and hypertrophy. This leads to compensation hypertrophy of the right ventricle, which overcomes pulmonary hyperemia and its inevitable train of dreadful sufferings, and,as long as hypertrophy of the right ventricle is sufficient to counterbalance the effects of regurgitation, serious symptoms do not result. Dr. H. remembered the case of an eminent liter

ary gentleman from Virginia, who consulted him in April, 1861, and who had a loud mitral regurgitant murmur. He is now living, and ably editing a newspaper, and occasionally writing excellent poetry.

Dr. H. thought it very probable that had Dr. Ashby been present when delivery occurred in his case, and rendered proper assistance with the forceps, as he certainly would have done, and promptly removed the placenta, his patient's life would have been saved. It is to the last degree important in all cases of labor occurring in women sufferfrom organic affections of the heart, that the accoucheur be present from the commencement to the close, in order to render prompt assistance in any exigency that may occur. But it is not always easy to discriminate between organic and inorganic murmurs, so as to determine whether a given case has a functional disorder or an organic lesion of the heart, a practical point of great moment, to which Dr. Ashby did not allude in his wellwritten paper.

Some years back, Dr. H. had seen a gentleman in consultation with his good friend, Dr. J. W. Houck, of this city. Six physicians, some of them excellent auscultators, saw the patient; three thought the loud systolic murmur indicated grave organic, and three were equally confident that it was inorganic, and induced by extreme anemia. The latter's opinion proved to be correct, as the murmur completely subsided under appropriate treat

ment.

This

he devotes to the subject will well repay perusal. Dr. H. attended a bright mulatto woman in the spring of 1862, during the last two months of her pregnancy, but was unable to be present at her accouchement. She was extremely anemic anasarcous, and suffered dreadfully from slight exertion. Anemic soft and blowing murmurs were well marked over the heart and in the carotids, accompanied by a veuous hum. But Dr. Meig's statement that the most extravagant deviations in the heart's action in such cases are greatly lessened, or wholly disappear, so long as the woman remains at rest in the recumbent position, was beautifully exemplified. This is a diagnostic point of great importance; for, as Dr. Meigs forcibly states, though the derangements of the heart's action are frightfully aggravated, when organic lesions exist, by exertion, they do not wholly disappear in a state of profound

rest.

DR. GEORGE W. MILTENBERGER, said that in his experience cases of confinement complicated by heart disease almost always resulted favorably.

DR. THOS. OPIE, considered that, although the bellows murmur heard during pregnancy, is generally due to hydremia, yet he saw no reason why the pressure of the enlarged uterus against the abdominal aorta should not cause a regurgitant murmur under certain circumstances at the aortic valve. He felt certain that he had seen reference to the same idea in print recently. So long as there was the physiological slowing of the pulse following labor, he felt safe, always considering an increase in the heart-beat, shortly after labor, as a warning of approaching hemorrhage, or later on of blood poisoning.

DR. HOWARD thought it very improbable that pressure of the uterus or any intra-abdominal tumor against the aorta would cause any heart murmur. He would ascribe such a murmur either to anemia or previous valvular disease.

DR. T. A. ASHBY closed the discussion by saying that he fully coincided with Dr.Erich's views in regard to the inadvisability of inducing premature labor or abortion in cases of pregnancy with advanced cardiac disease. There are two objections to the method: first, the effort in delivery in premature labor is, if anything, more injurious to these cases and more liable to bring about disturbances of the circulation, than labor at the full term. In the second place, premature labor almost of necessity involves the destruction of the child. and thereby jeopardizes two lives; whereas, in labor at full term, the life of the child is not necessarily complicated by rea

care

son of the existence of cardiac disease in the mother. In the case reported by Dr. Ash?y a vigorous, healthy child was born, which, to some extent, compensated society for the loss of its parent. Dr. Ashby recognized the importance of the points stated by Dr. Howard. In the case he had reported, the diagnosis of organic cardiac disease was fully made, and functional heart murmurs were discounted The patient had no edema, no anasarca, and her anemia was not sufficient in itself to have accounted for the initial reguritation and aortic obstructive murmur. The patient had a previous history of rheumatic endocarditis which unmistakably accounted for organic changes. He was clearly of the opinion that hemorrhage following the delivery of the child was insufficient to account for the disturbance of the heart's action, and he believed that this loss of blood could have been avoided, had he been present at the birth of the child. On the other hand the hemorrhage was not in itself sufficient to have destroyed the life of this patient. Had the equilibrium of the circulation been provided for by compensatory arrangements and the duty been performed of maintaining the circulation by the heart its action would not have ceased. In referring to the prognosis of pregnancy in cardiac disease, Dr. Ashley agreed with the views expressed by the President and by Dr. Howard. He thought Dr. Macdonald had taken a too unfavorable view of the prognosis. Macdonald had reported a mortality of sixty per cent., which was certainly very high. In a recent discussion before the Obstetrical Society of Eondon, (Br. Med. J., April 24th, 1886, page 78), the subject had been discussed, and this view of Macdonald's prognosis had been expressed by several speakers. The practical point to be considered in oonnection with cases of pregnancy, associated ciated with organic cardiac disease, has reference to the treatment of the patient during labor. Knowing that cardiac disease exercises an unfavorable influence upon the prognosis of the labor,the obstetricians should give close attention to their patients, and should see that the condition of the heart was not influenced by excitement or other causes liable to induce shock or suspend action.

DR. W. E. MOSELEY reported the following: A CASE OF INTRA-PERITONEAL, OR POST-PERITONEAL ABSCESS.

Mrs. F., aged 25, a light mulatto woman, between two and three years ago, first noticed a painful swelling occupying the right illiac fossa, and which confined her to her bed for several days. The tumor developed rap