lowed by bloody fluid was withdrawn. The needle was then driven farther internally, meeting with a leathery resistance. No further cavities were penetrated.

The case presents some further extremely interesting features that were reported by Doctors Roth and Gulde (New York Medical Journal, October 21, 1905), chief of which are the enormous abdominal veins. These at first thought would suggest portal obstruction due to a cirrhosis of the liver, but the patient tells us that they are congenital. They course from the pubis up to the lower part of the thorax. The abdomen presents a number of other points worthy of note. It is enlarged and gives signs of free fluid. The spleen is large and hard extending down to the level of the umbilicus. The notch is easily felt on the inner side. The liver, too, extends five fingers below the margins of the ribs, the edge is round and feels as hard as wood. The consistency of these organs, the cachectic state of the patient, and the history suggests amyloid disease. If the kidneys have undergone like change and the examination of urine can be considered of value in diagnosis, then surely the low specific gravity, the absence of albumin and the small quantity of urine argue against amyloid disease. There is another possibility of the condition being one of cirrhosis of either the diffuse or the capsular variety. This is extremely possible as pointed out by Doctor Dock in that we are sure of the increase of fibrous tissue that has taken place in the thorax and thus might expect like changes in the abdomen.

DISCUSSION.

DOCTOR GEORGE DOCK: I wish to call attention particularly to the highly developed clubbed fingers. This symptom is an extremely old one, having been described by Hippocrates, but up to a comparatively recent time it was supposed to result from pulmonary tuberculosis. The condition, however, is rarely as marked in pulmonary tuberculosis and the process a different one. The present case is a typical illustration of the form described by Marie as pneumonic hypertrophic osteoarthropathy. It is especially common in bronchiectasis and empyema. The patient's statement that it is congenital is quite unlikely and, in fact, discredited by his mother's statement. In regard to the enlargement of the spleen and liver, I think this might be due to amyloid disease, which, from the history of the case, is very likely to exist. More prolonged examination of the urine might show some such alteration as is found in amyloid disease of the kidney, especially the increased quantity without lowering of the specific gravity. On the other hand, I think the enlargement of the liver and spleen might be due to some other cause, such as obstruction of the circulation of the lungs, or there might be, in addition, a pericardial adhesion and even widespread inflammation of the serous membranes. The relations of the varicose veins have been well described by Doctor Roth, and I only wish to add that the enlargement here is greater than any I have ever seen, including some of the reported cases of posttyphoid anastomosis.

CHRONIC SUPPURATIVE middle ear disease. DOCTOR R. BISHOP CANFIELD: This patient, a boy, aged fifteen years, was afflicted with double chronic suppurative middle ear disease with cholesteatoma of middle ear and mastoid for thirteen years. He was operated upon several months ago and recently returned to the hospital for control observation. At the time of operation on the left ear a true cholesteatoma was discovered with well-defined membrane occupying the entire mastoid cavity. The growth had uncovered the facial nerve for a distance of one-eighth inch. The tumor had uncovered the brain upwards and backwards along the course of the superior petrosal sinus for a considerable distance.

The right ear showed a similar pathologic process. The vestibule had been penetrated through the posterior semicircular canal so that the cholesteatoma had reached the internal ear.

The radical mastoid operation with Koerner flap was performed in both ears. The mastoid cavities were then skin-grafted, and initial incisions were sutured for primary union.

The patient is presented in order to demonstrate the absence of deformity, and the fact that the radical mastoid operation can be performed without injury to the hearing. Previous to the operation the patient had hearing for the conversational voice at a distance of six inches. At the present time he hears the same voice at a distance of ten feet.

ANTERIOR SUSPENSION OF THE UTERUS, WITH COMPLICATIONS AND SECONDARY OPERATION.

DOCTOR WALES M. SIGNOR: I wish to report the case of a woman, age thirty-seven and married, who was admitted to the Gynecologic Clinic August 28, 1906. Her family and personal history are negative. Her menstrual history discloses menorrhagia, dysmenorrhea, and endometritis. Her marital history contemplates seventeen years, during which time seven children ranging from three and one-half to fifteen years of age have been born. Labors averaged from thirty-six to forty-eight hours, and instruments were used in all but the first confinement. Puerperal history negative.

Present affliction began some six or eight weeks prior to admission to the hospital with sharp pain in the left side, and marked swelling in the left lower quadrant, which was tender on pressure. Pain increased by standing or walking, also slightly increased at time of menstruation. Some headache and fever.

Examination showed the abdomen irregularly distended, more to the left than to the right, extending well above the umbilicus, to the left to the anterior superior spine, to the right a little more than half way to the anterior superior spine. The fundus of the uterus and appendages could not be palpated because of the tenderness of region. Under anesthesia the distension entirely disappeared. No tumor mass could be felt on deep palpation. The uterus was retroverted. tubes and ovaries were enlarged and prolapsed.

Both

Operation was performed August 31, 1906. Trachelorrhaphy, perineorrhaphy, laparotomy. On opening the abdomen the uterus was found large and retroverted, the left ovary was normal size, there was a left parovarian cyst the size of an English walnut, and the right ovary was enlarged and cystic. Both ovaries and tubes were removed, and the uterus was held forward by an anterior suspension.

On the third day the patient began to complain of severe pain in the lower abdomen, mostly in the median line. At this time the abdomen above the umbilicus began to be distended, a condition more marked a few days later. Up to the time of the second operation the symptoms consisted of the pain, which was excessive and constant, the tenderness of the lower abdomen, and the distension of the upper abdominal region. There was no appreciable elevation of temperature nor disturbance of the pulse rate. The chief complaint was the pain, which the patient described at different times as "cutting," "tearing," "lancinating," and which could be alleviated somewhat by hot applications, but controlled only by morphia.

At the time the second operation was determined upon the condition had changed very little from that at the earliest appearance of these symptoms, and that only as might be expected from the continued. pain.

The second operation was performed October 2, 1906. The abdomen was opened by incision about half an inch to the right of the scar of former operation. The uterus was found to be held firmly against the abdominal wall by an adhesion about three centimeters wide. This was slightly more toward the right cornu than the left. The omentum was also adherent to the parietal peritoneum at the site of the suspension. The uterus was removed in toto, as well as two gall-stones, the presence of which had been noted at previous operation.

Since operation the patient has been doing nicely and says that the "old pain" has disappeared.

EDITORIAL COMMENT.

THE TULASE DISCOVERY FOR TUBERCULOSIS. PROFESSOR VON BEHRING, who aroused both humorous and serious comment by declaring before the last International Congress of Tuberculosis that he had discovered a remedy for consumption, has placed the therapeutic innovation-tulase-at the disposal of clinicians whose laboratory facilities are sufficient to insure scientific test.

Tulase is a complex product of tubercle bacilli which have been subjected to treatment with chloral. It is of the consistency of honey, and is clear and colorless. Immunity may be conferred in several ways, the most important being by stomachic ingestion and subcutaneous injection. For preventive treatment in infants, the administration of

tulase in milk by stomach is recommended. In adults who have contracted tuberculosis the product is injected subcutaneously. For enteric administration the dose is 0.01 centigram, and this is doubled each day for four days, after which a period of rest for two to four weeks is prescribed. Very minute quantity is dispensed for hypodermic injection, the amount being doubled every ten days. Then follows a period of rest for ten days. The maximal dose-one centigram-is employed after a gradual diminution of the period of treatment and lengthening of the period of rest.

While the product will be distributed free to thoroughly equipped laboratories and the clinicians thereof, it will be given only under the following, conditions:

(1) Registration of observations according to the Marburg scheme of temperature curve, et cetera.

(2) Application of the remedy according to instructions agreed upon in writing, either by the stomach or subcutaneously, or periodically or continuously.

(3) Dosage, especially in the choice of the first dose and the gradual increase to the final dose.

(4) The choice of patients in relation to age, health, hereditary and other conditions which would have an influence on the prognosis, as to life and physical conditions and the possibility of future observations.

(5) Regular reports to the Marburg Institute each month whether the treatment has ceased or is in active operation.

ANNOTATIONS.

ABSINTHISM IN COMPARISON WITH ALCOHOLISM. WALKER has made some interesting observations on the effects of absinthe drinking. Absinthe is consumed quite freely by the French, and the ever increasing list of insanities in the Continental republic is probably attributable in measure to this cause. In contradistinction to alcoholism, absinthism produces no muscular tremors, while atrophy of the intellect, stupor, hallucinations, terrible dreams, nausea, depreciation of appetite, delirium and mania are common symptoms. Deterioration of the power of concentration, loss of will power and utter indifference to the welfare of dependents are also factors in the physical and moral decay. Delirium tremens is superseded by epileptic fits, which, however, cease to occur upon discontinuance of the absinthe habit. The insidiousness of the drink is apparent from the fact that the above symptoms are experienced without any decline of the muscular system, the decadence of mentality in most cases rendering the victim incapable of reform and subjecting him to mental derangement and paralysis, with ultimate death.

CANINE DISEASE CONSEQUENTIAL TO COITUS. BEEBE and EWING report the existence of a venereal disease peculiar to dogs. The principal means of transmission is through coitus, and the disorder asserts itself in nodular tumors on the genitals, multiple secondary growths of the skin, metastases of inguinal and abdominal lymph nodes, together with cachexia. The disease is often accompanied with fatal outcome. It has been classed as an infectious, malignant lymphosarcoma. Microscopally the tumors simulate round-celled sarcomata. No organism has yet been observed, and hence grounds for assuming that the disease is of parasitic origin are untenable. The investigators have succeeded in transplanting the disease in normaí animals by means of rubbing scarified mucosa with the tumor cells and also by implantations.

GONORRHEA OF THE FEMALE GENITALIA.

BOUKOYEMSKI recommends the employment of methylene blue in the treatment of gonorrhea in the female. In a series of experiments the investigator proved the efficacy of the analine product as a gonocide, it being doubly effective because of its penetrating powers. The treatment consists of washings of the external genitals and vagina with a stream of one to two thousandth formaldehyde solution, after which a saturated solution of methylene blue, four and forty-five hundredths per cent, is applied to the urethra, vagina and cervix. Administration of these agents is resorted to once daily or, in less virulent cases, thrice weekly.

TUBERCLE BACILLI IN PHTHISIC BLOOD.

LUEDKE has succeeded in demonstrating the presence of tubercle bacilli in the blood of persons affected with pulmonary phthisis. While the organisms have frequently been found in the blood of individuals suffering from miliary tuberculosis, this is the first demonstration of the bacillus in the blood of phthisic patients. Several cubic centimeters of venous fluid were extracted by means of a syringe and injected into the peritoneal cavity of guinea pigs, with the result that four of the animals developed tuberculosis.

THE BENIGNITY OF DESSICATED TUBERCLE BACILLI. CADÉAC asserts that the dust of dried tuberculous sputum is absolutely harmless both to the respiratory and digestive passages. In a series of experiments on animals he was unable to produce infection in a single case, either by inhalation or ingestion of the dessicated product. The reason that the mass of the people is not subject to some form of tuberculosis, considering the prevalence of infected dust, is explainable in the fact that the virulence of the organism is attenuated by dessication.