pain, and his condition was not serious and an operation was not allowed. The young man, twenty years of age, did well, but after several days, against the advice of his physician, he got up and went to stool. He was immediately seized with a severe pain and died soon afterwards in a state of collapse.

Rich

Dr. W. W. Johnston said: The subject of appendicitis was one of such interest that he could hardly avoid saying something. The question was a growing one; opinions regarding operation were now divided into two opposite factions; one believed that all cases should be operated upon at the earliest moment, the other that we should wait until urgent symptoms arose. Since last year his own experience in appendicitis had been in support of the plan of delay: three striking cases the details of which he remembered, recovered without operation. The operations had been deferred from time to time, as the urgency of the symptoms did not demand immediate interference. That we should operate on all cases as soon as they were discovered was the opinion of McBurney and others, but Dr. Johnston did not think that we should subscribe to that opinion; we should wait until the case was manifestly going steadily from bad to worse. ardson of Boston, gives two periods in which the operation can be safely performed. The first period was within two days after the onset of the disease; the second safe period was after five or six days had elapsed, when firm adhesions had formed around the abscess. During the intermediate period an operation would be dangerous; yet this was the very time when physicians usually first saw their cases, and was most frequently selected for operation. In his (Richardson's) opinion if an operation were absolutely necessary an early operation was best, and after that the third period should be selected. In the present stage of our knowledge of the disease it seemed to be better not to operate in the first period. If the symptoms were not progressively worse, septic fever did not develop, or if the tumor were diminishing in size, we were justifled in waiting. The temperature was not always a safe guide in such cases; a case may grow

worse rapidly with a lowering tempera

ture.

Dr. W. P. Carr said: Dr. Johnston was certainly correct in his position. He believed that fully fifty to seventy per cent of cases would get well without an operation. He had seen three such cases recently and had refused to operate, and they all got well without an operation. If the attacks were recurrent the patient should be operated upon between the attacks. But if the attack begins with violent symptoms an operation should be done at once.

Dr. Storh, in closing the discussion, said: That an early laparotomy in appendicitis proved successfully in his third case, while complications at a later period of the disease such as perforation, peritonitis, abscess, septicæmia and exhaustion would have lessened the chances of recovery.

The non-surgical interference was thoroughly tested in his second case where under the treatment already stated the patient steadily improved and all dangerous symptoms had apparently subsided. Nevertheless, the patient upon getting up and going to stool where he mode a strong effort to move his bowels was suddenly seized with severe pains in his abdomen and shortly afterward died in a state of collapse. No doubt death being due to rupture of a large pus-sac. This case undoubtedly would have been saved by an early laparotomy.

MEETING OF NOVEMBER 11, 1896. Dr. S. C. Busey, President, in the Chair.

LITHOLAPAXY.

Dr. Wm. Forwood, Lieut. Col. U. S. A., presented a specimen and exhibited the patient with the following history:

W. H., aged thirty-seven years, a cavalry soldier, in May, 1887, was hurt in the back being jammed forcibly against the feed trough by a fractious horse at stables. He passed bloody urine immediately after this accident and went under treatment in the hospi

tal for two or three weeks. Returned to duty and experienced no further effects of the injury until about two years later in 1889 when he was suddenly seized with pain in the region of the left kidney accompanied by very urgent and frequent desire of micturition, which was followed by the discharge of small clots of blood from the bladder. The bladder was sounded at that time for stone, but none was found. This attack lasted two months, then the soldier returned to duty until the early part of 1890, when he suffered another similar attack with the same symptoms including hematuria. Other attacks occurred in 1893 and '94; and in February, 1896, after active physical exertion he was seized with pain in the left side of the back and frequent urination without blood, but with marked increase in quantity of urine. With this attack he went to the hospital and remained until May, 1896, when he was. discharged from the army for cystitis and stricture of the urethra. Patients general health now failed rapidly with great weakness, loss of weight and a large flow of urine. There was constant irritation of the bladder and all the usual symptoms of vesical calculus. He was at length admitted to the Soldiers' Home and taken in the hospital, where on examination the following items were noted.

Patient much emaciated, pale, anemic, weak, trembling and out of breath; urine pale, and of low specific gravity; quantity from 90 to 160 ounces in the twenty-four hours; no albumen or sugar. Many leucocytes and other evidence of cystitis; soft ulcerated stricture, 54 inches from meatus; small, very hard movable calculus in the bladder. After rest in bed and a course of preparatory treatment, to improve his general health, October 11, ether was administered, the urethra rapidly dilated and the stone was crushed and washed out at one sit

ting. The patient got up on the third day and has gained in weight and in general health since that time. The calculus was of the black calcium oxalate variety which is said to have its origin in the kidney and in this case, no doubt, formed around a small blood clot following the renal contusion in 1887.

In presenting this case I take the opportunity to call attention to the very favorable results obtained within the last few years from litholapaxy by several operators of experience who claim that it is a safer and better operation than either perineal or suprapubic lithotomy. The following statistics are from very recent reports:

Comparative mortality after different methods of operation.

children and gives a shorter convalescence and a higher percentage of recoveries than either the high or the low operation, at any age. The operation that gives the highest rate of mortality at all ages is suprapubic lithotomy and this is precisely the operation which for a while back has been most in vogue, but it should not now be practiced without first considering the claims of litholapaxy wherever the latter is applicable.

DISCUSSION.

Dr. J. Ford Thompson said: No surgeon would hesitate to employ litholapaxy for small stones, but in bad cases of stricture or chronic disease of the prostate litholapaxy was the most dangerous operation, and required a most skillful operator. He had performed suprapubic cystotomy on an old man for the purpose of operating on the prostate, but when he opened the prostate he could find no stone. Several days after

ward, in passing an instrument through the incision it came in contact with a hard substance, which he then ascertained to be an encysted stone. In this case it would have been utterly impossible to perform litholapaxy, for the stone could not have been found. The difficulty in performing litholapaxy was in getting away every last piece of stone,

and in order to accomplish this it was often necessary to keep the patient on the table an hour and a half or two hours. Taking all cases together, both bad and good, it was a question whether there would be this difference in the mortality of the different operations which Dr. Forwood claimed.

Dr. Wm. Forwood, in closing the discussion, said: That there certainly were contraindications to the use of litholapaxy. For instance, when the nucleus was a substance which could not be comminuted, such as a bullet or an iron arrow head, as he had once seen, then a crushing operation was not applicable. Likewise with dense fibrous stricture in the deep urethra or severe cystitis with vesical spasm and tenesmus. But these were exceptional conditions, and it was a great mistake to suppose that litholapaxy was confined to mild cases and small stones. Cases had been reported where stones weighing 800 grains and more had been crushed and washed out at one sitting. A a rule large stones had the advantage of being soft and hard stones had the advantage of being small. On the whole, operation by means of litholapaxy had a far wider application than any other. It was being employed within the last two or three years by the best operators, and they were not hesitating to use it in the difficult as well as in the mild cases.

Some time last year 1 had the pleasure of demostrating to you a new instrument designed for the purpose of taking hold of the handle of the malleus in order to mobilize the ossicula auris, a proceeding toward which all treatment for deafness and tinnitus tends principally.

This instrument I have found to do very good service, but in some cases, where the drum or portions of it are attached to the inner wall of the tympanic avity, it was found not applicable with

out taking more risks than I wished to incur. For the purpose of meeting this difficulty, I devised the following methods:

The use of collodium applied to the drum in such a way as to produce its contraction had been recommended a number of years ago, but seems to have been given up again, probably because it was, as proved also in my hands, ineffective. In order to be able to give some more tractional power to it, I de

vised this little disk of paper, attached to a handle of some stiffness, like for example a toothpick, fastened with the help of collodium to the drum in such a way, that any pulling at it will be directly transmitted to the drum and the ossicula, thereby enabling us, when it is desirable to exert a stronger pull on these ossicles than can be produced either by aspiration with the Delslancher rarefactor or forcible inflation with the catheter. When we use a stiff handle we can also

produce alterative traction and pushing force such as is produced by Leucæ's elastic probes.

DISCUSSION.

Dr. S. M. Burnett said: The instruments devised by Dr. Bermann were certainly very ingenious, there could be no question about that, but there was a question about their intrinsic value. There were a great many cases of anchylosis of the middle ear which were due to adhesions of the stapes to the round window, and these cases an apparatus could not affect. There were a few cases, without doubt, in which the malleus alone was involved, but these were due to adhesions which could be divided with a knife. Those cases of anchylosis which were the result of a change of the soft mucous tissue into dry cicatricial tissue nothing could remedy. The plan which he followed for the mobilization of the ossicles was the suction apparatus of Siegle, by which he could use much force as was safe. Dr. Bermann's plan was certainly ingenious, but he would like to see the results of its use before endorsing it.

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Dr. C. R. Dufour said: The instrument exhibited by Dr. Bermann might accomplish what he claimed for it, but there were better and more exact methods of treating a retracted membrana tympani. This condition might be caused by a closure of the Eustachian tube which caused a rarification of the air in the middle ear. When such was the case there was no better method than the Politzer air bag or the Eustachian catheter for equalizing the atmospheric pressure in the ear and thus cor

recting the retraction of the drum membrane. When the retraction was due to contraction of the tensor tympani, and adhesions in and around the oval and round windows, and of the membrana tympani to the walls of the middle ear, then the otoscope of Siegle, which was a pneumatic masseur, would correct this condition by imparting decided movements to the drum membrane and the ossicles. This massage, by increasing the nutrition of the parts, tended to promote absorption of the exudates and of the adhesions, unless the latter had become too dense, in which case a teno

tomy of the tensor tympani, the disartic

ulating of the includo-stapedial joint, the freeing of the stapes from the adhesions in and around the oval window, would, in a large majority of cases, correct the retraction and improve the hearing. One or all of the above named operations might be necessary, and statistics warranted him in saying that the results in most of the cases where they had been performed had been beneficial. He thought another objection to the instrument of Dr. Bermann was the method of its application; of fastenining it to the drum membrane by some adhesive material, and which, after the time employed in its application, yielded no better results than Siegle's otoscope and inflation as above described, if indeed they were as good.

Dr. Bermann said: He must have expressed himself very badly, for both Dr. Burnett and Dr. Dufour had been discussing dry catarrh, and he was not aware that he had spoken of dry catarrh at all, but of mobilization of the ossicles. The methods described by Dr. Dufour were well known to him, but the method which he had devised was intended to apply to those cases to which the other methods were not applicable. He considered that any operation at all for dry catarrh amounted to malpractice. Operations could not improve such cases and only made them worse.

Dr. S. M. Burnett said: Dr. Bermann was mistaken if he thought that outward traction on the malleus would move the other bones of the ear, for Helmholtz had shown that the peculiarity of the malleo-incudal joint allowed an inward

movement of the malleus to affect the other bones, but its outward movement was independent. This was a wise provision to prevent a violent outward movement of the malleus from tearing the stapes from its insertion in the oval

window. Procedures such as this one recommended for these conditions were of doubtful value, and he did not believe in changing a method which he had always found to be without danger at all for more dubious operations.

Diphtheritic conjunctivitis in my experience is sufficiently rare to warrant the presentation of a case recently under my care. Out of more than 4,000 eye cases of which records have been kept I have had the opportunity of seeing only two of this disease.

The one presented this evening and one seen with Dr. Shute were in the Foundling Asylum, where I believe a number of cases of diphtheria developed. Why it should be a rare disease when diphtheria of the throat is so frequent is a question. Possibly the reason may be due to some antitoxic action of the tears or mucous gland secretion which renders the conjunctiva less susceptible to infections or to the ease with which any irritating agent is diluted or washed out by an increased flow of these secretions. That this is not entirely the cause is shown by the fact that the tears may carry the infection through the nasal duct into the nose and throat and start the lesion there, and also by the case of a physician into whose eye some secretion flowed from the mouth of a child suffering from diphtheria, and notwithstanding the fact that it was immediately washed out, the eye was lost by diphtheritic conjunctivitis.

The case which I would present this evening came to my clinic October 26, 1896; a white female, aged thirteen months, with the following history:

Child had had what the mother called weak eyes for a long time, but became worse about October 8th or roth. October 12th a child, aged six years, in the same family developed sore throat of a mild type, which rapidly recovered, but sufficiently severe to call the family physician who made only two visits and at the same time prescribed for the baby's eyes. In the meanwhile a child from a relative's family came to the house and died from croup on October 23rd, eleven days after. The attending physician did not pronounce the sore throat diphtheria but thought it, "approached that disease". When first seen both eyes were involved; both upper and lower lids showing thickened infiltrated condition with grayish white membrane adherent; much more marked in right than in left.

The cornæs were clear as far as able to examine, but later a marked infiltration of the right (the worse eye) was discovered. Physical condition of the child was good, except being anæmic. It nursed well. Diagnosis confirmed by bacteriological examination, The clinical picture is much the same as when the disease is seen in the throat or nose. The early stage is characterized by swelling of the lids, with the development of a board-like hardness, and with the formation of a grayish white exudate which as the disease advances becomes more abundant and more purulent and