start afresh an infection which was already present, or did they produce another and quite independent form of fatal infection? The abdominal cavity was never distended as is the general rule in cases of pelvic peritonitis. The total suppression of urine on the seventeenth day following the operation accompanied by vomiting is an unusual complication of an abdominal operation unless the ureters have been tied. The urinary examination before the operation was negative, but immediately following it and again on the seventeenth day hyaline casts were found. Death took place on the eighteenth day after the operation although up to the thirteenth day the convalescence progressed normally. 702 Rose Bldg.

Intussusception of the Jejunum, Report of a Case and Presentation of Specimen

By WILLIAM E. LOWER, M. D.

The reasons for presenting this case of intussusception are: (1) the infrequency of the location, (2) the duration of the condition, (3) the result.

The location of the intussusception, which was in the upper part of the small bowel and as nearly as I could determine in the jejunum, is according to most observers of rather infrequent occurrence. Although my experience with intussusception has not been large, I have probably seen as many as come under the observation of the average general surgeon, and with this exception I have never seen an intussuception at this location.

Three varieties are generally spoken of: (1) the enteric, (2) the ileocecal, (3) the colic. A few cases of intussusception of the duodenum have been reported.

The enteric variety, to which this case belongs, occurs in from 20 to 30% of all cases of intussusception, according to Smith, but many authors think this figure too high. It certainly is greater than has been observed by most of the surgeons of this city. Intussusception of the small intestine is supposed to occur most frequently in adults and is most often observed in the lower end of the ileum. This case was in a child and located in the upper end of the small intestine. Codman's report of 27 hospital cases showed only four of the small intestine.

The ileocecal variety is the most common form and of this no doubt you have all seen a number of cases. Ileocecal invagination occurs most frequently in childhood. At least 70% of cases occurring in children are of that variety.

Age: Dr A. Jacoby says that 25% of all intussusceptions occur in the first half year of life, two-thirds of these between the fourth and sixth month, and 53% of all cases occur before the end of the first year.

The most complete report on intussusception that has appeared recently is that of Clubbe, of Australia, who reports 144 cases, and of these only 14 were over one year of age, and only eight were over two years.

Diagnosis: Codman says that this disease should be almost invariably recognized instead of rarely diagnosed within the first 24 hours. In young children the symptoms are singularly uniform while in adults they are often most varied and a diagnosis has seldom been made until the abdomen is opened. For instance, the classical symptom of blood in the stool was almost always present in children and absent in adults. Differentiation from volvulus presents special difficulty. The absence of bloody, mucoid stools and tenesmus makes diagnosis uncertain. A tumor may occasionally be felt in both conditions, but the mass is generally larger in cases of invagination. Volvulus is generally very rare in quite young children. Differentiation from appendicitis is more readily made. In very young children this is not so common as intussusception and the onset not so violent. Pain becomes progressively worse and does not come at intervals. Vomiting comes on early in appendicitis and fever usually occurs. earlier and is much higher than in intussusception. Bloody stools are absent in appendicitis. Tumor in appendicitis is much more sensitive. In Clubbe's series the presence of a tumor was so constant that in only two cases did he open the abdomen without first observing the mass. He says the classical sausage-shaped tumor is not characteristic. In the early cases the mass is more rounded than oblong, and it is seldom that the mass when sausage-shaped is straight.

Treatment: Clubbe does not advocate irrigation as a curative measure, but as a preliminary step in aid to operation. In a series of 144 cases 10% were cured by this alone, the duration being 18 hours. Stone says in spite of the fact that Clubbe's results are the best yet reported, it is still a matter for the individual surgeon to say whether or not he shall use injection as the first stage of the operation, and, if used at all, injection should be as an aid to operation and never as a preliminary measure unless all preparations for immediate laparotomy are completed.

Results: Clubbe's results, from a substantial total of 144 cases, have been the best reported up to this time. Of the 114, 14, or a little under 10%, were reduced by injection alone. Two were moribund when seen and died without operation. Two died during administration of chloroform before operation. This leaves 124 laparotomies. Of these, 84 were cured and 40 died, a mortality below 1/3. Dividing his cases into three groups he had his mortality rate reduced each time. In the first 50 cases 50% died; in the second 50 cases, 24%; in the last 44 cases 12.5%. In the cases which recovered, the average length of time between the onset of the symptoms and the operation was, in the first 50 cases, 28 hours, in the second 50 cases, 23 hours, and in the last 44 cases, 17 hours. Although most of Clubbe's cases were operated upon in the first 24 hours, he has been able to save many cases after 24 hours, and a considerable number after 48 hours.

My report is as follows: The patient was a boy of 12, a Bohemian. His parents, one brother and one sister were well. He had always been a healthy boy, and had never had any digestive disorders or constipation. He never had had typhoid fever.

The family physician, Dr Pav, was not called until the fourth or fifth day of the illness. At the time he saw him (February 11, 1908) the boy was suffering from constant pain in the abdomen and had been vomiting for three days. The attack came on suddenly while he was playing at school but he was able to walk home. Excruciating pain and vomiting followed. On February 10 his bowels moved for the last time without enema. On February 11, when Dr Pav was called, he found the temperature elevated and the abdomen distended, the greatest distension being in the right hypochondriac region. The greatest pain was also referred to this region. An enema of oil was given and 10 drops of tincture of opium. The temperature was 99° in the evening. The patient vomited again during the night. February 12 an enema of oil was given. The temperature was almost normal. The pain was less severe and bloody mucus passed from the bowel. February 13 he vomited fecal matter. Another enema was given and the movement showed bloody mucus. Dr M. A. Albl was called in consultation. Operation was advised. The patient was sent to the hospital and I operated upon the case the same evening. The temperature was 100.5, pulse 120, and respirations 40.

Operation was performed on February 13, the eighth day

of the attack. An incision was made along the right border of the rectus about four cm. in length. The appendix was bound down by adhesions. An intussusception of small intestine within small intestine was observed. About eight inches of small intestine was resected. The invaginated portion was gangrenous. The incision was closed in the usual manner. The patient was discharged March 10, perfectly well.

Hip-Disease-A General Survey

By HENRY O. FEISS, Cleveland, O.

Definition: Although every disease of the hip may be characterized as hip-disease, the term usually refers to tuberculosis of the hip, and it is with the so-called tuberculous hip that I wish to deal tonight. It must be stated, however, that even the term "tuberculosis of the hip" is a very loose one. Modern advance in bacteriology and in the use of the Roentgen pictures will undoubtedly further separate this type into a more distinct. classification, so that certain kinds of hip-disease, which have been known as tuberculous in the past, will probably go into some other classification in the future. It is too early, however, to make this separation and at present we must be content with the old-fashioned symptom-complex which answers to tuberculous hip-disease.

Morbid Anatomy: In tuberculosis of the hip the characteristic lesion is in the epiphysis of the head of the bone. Occasionally, the acetabulum is first attacked. In either case the acetabulum may enlarge upward, and we have a so-called "migration" of the acetabulum. This is due either to a contraction of the muscles which forces the head against the upper rim of the old socket, so that it gives under the pressure, or it is due to an actual advance of the disease. Instead of the "migration" of the acetabulum there may be a direct dislocation of the head. In such a case a new acetabulum may be formed. This dislocation is probably due to the contraction of spasmodic muscles when the femur is adducted and flexed. In the head of the femur we also have alterations in shape, due both to pressure and to actual disease, and this is easily supposed if we assume diminished resistance in this part of the bone as occasioned by a destructive ostitis. There may be destruction of the entire head or part of the head, or there may be mushrooming. Finally, in some cases we may find ankylosis which may be either fibrous or bony. Presented at the Lake County Medical Society, Painesville, May 4, 1908

These things are manifest in the skeleton in the later stages, but, of course, certain pathologic changes take place earlier, and let me now briefly run over the course of the disease.

Course: A typical case of hip-disease begins as one or more minute foci near the epiphyseal line. These foci join one another and form a mass of granulation tissue which breaks down at the center. This mass of tissue may either spread or become walled off, but in either case we are almost certain to get a characteristic synovitis in the joint itself, taking place at the same time as the inflammation in the epiphysis: for even before the actual disease in the epiphysis attacks the joint there is an irritation in the capsule and it is this irritation of the capsule membrane which brings on the symptoms-a very important point to remember. The actual disease in the epiphysis may take one of three courses-first, it may become walled off, secondly, it may form an abscess discharging into the tissues about the joint, and thirdly, it may perforate directly into the joint. If the abscess becomes walled off, we have the most favorable termination and in some cases we may perhaps get complete absorption. Discharge into the tissues around the joint is rare because the joint membrane completely surrounds the head of the bone so that, unfortunately, the third termination must be the common one—namely, perforation into the joint itself. As soon as perforation takes place, the cartilage of the head and the acetabulum and the lining membrane of the synovial sac become attacked and we have the marked signs of joint inflammation-namely, exudation, fibrillation and ulceration of the cartilage, pannus formation, the exposure of bare bone and the formation of pus. The capsule becomes thickened by granulation and scar tissues. Of course, these changes are due to the direct inflammation and are not a result of the original synovitis which takes place. sympathetically in the joint while the disease is still confined to the epiphysis.

After the disease has perforated into the joint, the contents of the bone abscess together with the fluid formed in the joint cause distension of the capsule and finally the fluid mass finds. its exit through the joint as an abscess which may appear externally as a swelling and finally burst. Meanwhile, the bone changes due to the destructive ostitis begin and continue until the actual disfigurations, described above, take place.

The position of the leg with respect to the pelvis also tends to become characteristic. In the first part of the disease, during the stage of synovitis in the joint, we get a little lengthening and