that there is both cystic and solid structures in the tumor. Percussion shows a flat note over all the abdomen except in the lateral lumbar regions, where we note resonance, marking the location of the intestines. We fail to get "6 wave fluctuations," because of the possibility of the contents of the cyst being colloid or myxomatous, or else the cyst wall is very thick and rigid. We make the diagnosis of cystoma or ovarian cyst, or cystic adenoma of the ovary or of some of its embryologic structures. We now open the abdomen in the median line, opening the peritoneum between forceps, enlarging the opening upon Kocher's director or the finger. Here we have exposed the wall of the cyst and on passing my hand into the abdominal cavity, by palpation, I determine that we have a multilocular cystoma,-a true tumor, a proliferating mass and not a retention cyst. Now we plunge this large ovarian trocar into each of the locuments, emptying them, and closing the opening with clamps. You notice here this locument has a colloid material, this one has mucoid, and this one has clear serum, and this one a melanotic thick substance which no doubt is due to hemorrhage. Now that all of the pockets are emptied, we can remove or deliver the tumor through this 4-inch incision. Here is the pedicle which we ligate, excise; flush out the abdominal cavity with saline, then close the cavity by two rows of sutures,-continuous catgut for the peritoneum and silkwormgut for the muscles, fascia, and skin. We now put the iodoform gauze-without dusting powdernext to the wound, cotton and bandage. This patient is now in a good condition and should have an uneventful recovery. Case 2. This colored woman is 20 years of age, giving a history of menstrual flow at 12 years of age continuing until 15, at which time it stopped and a hemorrhage has been present the past five years. Her mother died of pulmonary tuberculosis. This patient presents an enlarged abdomen about the size of a normal pregnancy at full term. She has observed the enlargement for the past three or four years, but is not able to say at what portion of the abdomen it first made its appearance, whether above or below the umbilicus. Vaginal exami nation is negative. Uterus is small and retrodeviated. No history of fever, pelvic pain or jaundice. Percussion gives

flat note except in lumbar regions. Change of position does not affect the percussion note. Wave fluctuation is marked over the whole tumor. Palpation gives resilient fluctuation, thus causing us to diagnose a cyst. The most important question now arises, viz: What kind of cyst is it and what is the primary point of origin? The physical signs that we have here can be produced by any of the following conditions: Encysted ascites, tubercular peritonitis, ovarian cyst, cyst of the pancreas, cyst of the appendix, cyst of the gall-bladder and degenerative cystic adenoma of ovary. Nothing but lifting the veil by exploratory incision will reveal the true nature of the growth. We now cautiously open the abdomen and here we find adhesions to the parietal peritoneum of a very clear sac, which is the wall of the cyst. Gently insinuating my fingers between the cyst wall and peritoneum, we come here to the intestines, which are firmly adherent to the cyst wall. Now we empty the cyst with the trocar, and find the contents at first to be very clear but now you observe it is greenish in appearance. Since emptying most of the fluid out, we now try to further separate adhesions; behold! the cyst grows from above! I now make an opening into the sac so as to insert my hand; passing the hand up into the sac, I come to the under surface of the liver, to which the sac is firmly adherent; and, on withdrawing my hand you notice an abundance of more greenish fluid escaping, hence, we conclude that we have that rare condition of cyst of the gall-bladder to deal with. It being impossible to separate the adhesions, it be comes evident that we cannot remove all the cyst wall, therefore we remove as much as possible and "marsupialize" the rest, stitching the mouth of the cyst remnant to the upper angle of the abdominal incision and putting in a Mikulicz drain; closing the lower part of the abdominal incision. This sac remnant will granulate from the bottom and ultimately will close, leaving a fibrous cord to mark its location. This is a most unusual case and no doubt if seen at its incipiency, a history of bilious colic or an evanescent jaundice could have been obtained.

Case 3. This is a case of Myoma uteri. By palpation and bimanual manipulation, we feel a nodular mass the size of

an orange attached to the upper part of the uterus. The tubes and ovaries seem normal; the uterus is freely moveable and apparently healthy. This patient complains of very great pains in the region of the tumor, hence she seeks relief from continuous pain.

The more conservative operators do not remove myomata uteri unless one or more of the following conditions are present. 1. Profuse continuous hemorrhage; 2. Interference, by pres sure, with functions of vital organs; 3. Sudden, rapid growth; 4. Severe, constant pain. Now we open the abdomen and here we find a pedunculated myoma growing from the upper portion of the fundus uteri, with many adhesions to the intestines and omentum; these we now gently separate and remove the tumor by myomectomy, making a wedge shaped section of the pedicle and placing deep, absorbable sutures into the uterus. You notice hemorrhage is quite profuse, which is, as you now see, easily controlled by the first suture; this bleeding is usually controlled in this operation by a preliminary constriction of the neck of the uterus by a rubber tube. Having finished suturing the uterus, we now close the abdominal wound by three rows of sutures, using catgut for them all.

Case 4. This man gives a history of pain in the lower right quadrant of the abdomen, of six weeks duration, attended by nausea, vomiting, constipation and fever the temperature being now 103 degrees, his pulse 120.

Inspection reveals a swelling limited to the right ilio-inguinal region. Palpation gives us tenderness and fluctuation, more marked just above the middle of Poupart's ligament; percussion gives flatness over all the swelling. From the clinical history and the physical examination, we make the diagnosis of suppurative appendicitis. We now make a three inch incision one inch above, and parallel to, Poupart's ligament, this being the most prominent point of the swelling. Here flows an abundance of yellow pus; I now insert my two fingers into the cavity which I find leads to the caput coli, thus indicating that the appendix was the primary point of infection. There being no other pockets of pus collection and the abscess wall very firm, we proceed to irrigate the cavity with normal saline without much danger of diffusing the infec

tion. If this abscess were more recent, say 10 days old, we dare not irrigate it, but would be content to swab out the pus with wet gauze sponges.

Now we put in a large tubular drain, also two or three cigarette gauze drains, and dress the wound with a copious antiseptic absorbent dressing. In forty-eight hours we irrigate and change dressing and drains; it is surprising how rapidly this abscess cavity will close, disappearing in two or three weeks. The condition of this patient shows one of the more fortunate results of appendicitis, i. e. pointing externally of the abscess. If this abscess were let alone it would have opened spontaneously below Poupart's ligament, but it is bad practice to wait for any abscess to point and spontaneously open; immediate evacuation should always be the rule when pus is located.

Case 5. This man I bring before you has great pain, shock and vomiting, his skin is cold and clammy, his pulse rapid and small and upon examination you perceive a large inguinoscrotal swelling along the line of the inguinal canal. Having a history of a previous hernia and sudden occurrence of the present large swelling, it is plain that we have to deal with a strangulated hernia. Already repeated attempts at reduction by taxis have been made in vain, and now nothing remains to be done but immediate herniotomy. So here we make a free incision over the inguinal canal into the hernial sac, whereupon you notice an abundance of serous transudate escape, which is always present in strangulated hernias of over twentyfour hours duration. Now here we relieve the constriction at the neck of the sac and draw out the loop of intestine and inspect it at two points where there is most liability to necrosis, viz: apex of the loop and the constricted neck, each of which places look somewhat suspicious, but upon applying hot water, we find normal color returning, assuring us of the integrity of the intestine. We note here that there was both fecal and vascular strangulation; now we return the loop of intestine, and as the anesthetist informs us that the patient is in good condition, we are justified in doing a radical procedure to cure the hernia. We isolate the spermatic cord from the sac, and, after ligating and excising the sac at the in

ternal abdominal ring, sew the internal oblique and transversalis to the reflection of Poupart's ligament, thus planting the cord on top of these structures. This part of the procedure gives this operation the name of Bassini. Now the aponeurosis of the external oblique is sutured over the cord, then the skin is stitched with a glover's continuous suture; gauze dressing and a spica bandage finish the case.

Had we found gangrenous intestine and the patient's condition permitted, resection and end-to-end anastomosis would have been indicated. otherwise, anchoring the intestine with sutures and making an artificial anus or a fecal fistula would be imperative.

SOME FURTHER OBSERVATIONS IN THE TREATMENT OF TYPHOID FEVER.

By O. L. Shivers, M. D., Marion, Ala.

In the summer of 1899, after seeing a number of cases of typhoid fever, some of which number died, I began to theorize about the improvement, if such a thing was possible, in the treatment of this disease, thereby abbreviating the duration of it, and thus conducing to the safety and comfort of the patient, and enabling him, or her, to leave the bed and the sick room, after a confinement therein, the time of which confinement could be estimated by a few days instead of a few weeks or months.

After hours, days and nights spent in studying the physiological effects of the different remedial agents we possess, and noting their chemical properties, I mapped out a line of treat. ment, based upon theory. But this theory, in turn, was based upon a knowledge of the influence of these medicinal agents upon the human organism.

I feel now that I have a good and just cause for believing that the theory is fully sustained and proven by its practical application.

When I began the practice of medicine, my duty to my patient, to myself and to those who had taught me, required that I should treat my patient, afflicted in any way or with