Patient's general health had always been good. She had never had any disease of the gall-ducts or appendix or any acute painful abdominal condition. Present Illness: Two weeks before admission patient states that she had had intense headache, backache, malaise, lassitude, extreme weakness and fever. She had been confined to bed for one week prior to admission. Physical Examination: On admission, temperature 101, pulse 106, respiration 20. The heart and lungs were negative, spleen was enlarged and palpable, there were rose spots on the abdomen. Widal was positive, leucocyte count was 6000, blood culture was negative, urine showed slight trace of albumen. The temperature, pulse and respiration were as follows between September 2nd, and October 15th. September 2-29, temperature 102 to 103 3-5, pulse 90 to 114, respiration 20 to 22. September 29 to October 8th, temperature 102 to 99, pulse 90 to 130, respiration 20 to 22. impulses at the apex were 140 to the minute. The abdomen was not distended. On palpation there was marked rigidity over the entire right side of the abdomen. The chief point of tenderness being over McBurney's point. The gall-bladder was palpable. It seemed only slightly enlarged. Percussion was then done over longitudinal and transverse lines passing through the gall-bladder, McBurney's and other anatomical points. The greatest point of tenderness on percussion was constantly over the gall-bladder. The liver dullness was increased at the site of the gall-bladder and we consider that this was due to the enlargement of the gall-bladder. After thorough consideration of the history and the physical findings, a diagnosis was made of acute suppurative cholecystitis, complicating typhoid fever. Immediate operation was advised as soon as the patient and the operating room could be prepared. Operation by Dr. John W. Price, Jr. An upper right rectus incision was made and the gall-bladder exposed and found to be October 8-14, temperature 100 3-5 to 99, about the size of a turkey egg. The internal pulse 112 to 98, respiration 20 to 22. On October 14th, 1914, the patient had an acute sudden, agonizing pain on the right side. of the abdomen. It seemed greatest in the region of McBurney's point to which she pointed with her finger when asked to locate her pain. The pain was followed by nausea and vomiting. On this day the maximum temperature was 100 3-5, pulse 90, respiration 20. The vomiting was persistent the night of October 14th, and continuous during October 15th. At 3:00 P. M., October 15th, temperature was 102, pulse 140, (counted by Dr. Phipps) respirations 28. Examination showed marked rigidity of the abdominal muscles, and tenderness especially over McBurney's point. At 6:00 P. M., temperature was 101 4-5, pulse 140. She was vomiting continuously a dark, green vomitus, containing stomach and duodenal secretions, bile and a few food particles. The patient's condition during the next two hours was extreme. The prostration was very pronounced. The pulse was counted by the attending physicians as high as 160. The leucocyte count at 8:00 P. M. was 12,000. The attending physicians thought the patient was suffering with an acute involvement of the appendix or gall-bladder and believed that she was in need of immediate surgical attention. The writer was called and found the patient's condition as follows: tension was extreme. The color was that of pearl, except at the attachment to the liver, it was red. There were no adhesions. Great care was used in placing packs around the gall-bladder before draining it, so as to protect the rest of the abdominal cavity from contamination with the virulent gall-bladder contents. The gall-bladder was then drained by inserting a trocar and canula. The contents were a creamy, brownish fluid, containing mueus and pus. The last portion expelled contained some blood. The odor was foul. The wall of the gall-bladder was thickened, infiltrated, edematous and leathery. The blood supply seemed to be almost completely shut off at the fundus. Several seconds elapsed before the cut edges bled freely. The opening in the gall-bladder was enlarged and gauze strips were inserted to completely absorb any fluid remaining in the gallbladder. A search was made for calculi and none found. The cystic duct was palpated and found to be enlarged and rigid. A rubber drainage tube was inserted into the gallbladder and secured by turning in the cut. edges with the purse-string suture. A Mickuliez drain was inserted to the neck of the gall-bladder and another one at the fundus around the rubber drainage tube. The drains were brought out through the upper angle of the incision and the remainder of the incision was closed. She was vomiting continuously during the examination. The forehead was covered with great heads of perspiration. The eyes were anxious, restless and pleading. The facial expression was that of one in great agony. Examination of the chest showed the lungs to be clear and the heart was regular. The showed a pure growth of typhoid bacilli. The culture made from the gall-bladder contents removed in the operating room, October 16th Post-Operative History: drainage from the gall-bladder was bile, temperature 98 4-5 and pulse 112. October 17th, temperature 101 3-5, pulse 120, respiration 24. October 18 to 21, temperature 98 3-5 to 100, pulse 100 to 110, respiration 23 to 24. October 22 to 27, temperature maximum 99 3-5, pulse 100 to 108, respiration 20 to 22. Blood Examinations: October 15, white blood cells, 12,000. October 17, white blood cells, 14,200; lymphocytes, large 6, small 27; Polymorphonuclear leucocyte, 67. October 20, white blood cells 10,800; lymphocytes, large 8, small 22; polymorpho nuclear leucocytes, 70. October 26, white blood cells, 11,000; lymphocyte, large 7, small 25; polymorphonuclear leucocyte, 66. On October 20th the red blood cells were 3,500,000. October 29th, culture was made. from gall-bladder drainage. Gram positive cocci in clusters and large gram positive bacilli (S. P. Albus, B. Subtilis) were found. Cigarette drains. were removed October 24th, nine days after operation, rubber tube was removed from the gall-bladder on October 26th, eleven days after operation. The silkworm gut sutures were removed on October 27, the wound had healed by first intention up to site of the fistula. On November 12th as there was only a slight bile stain discharge, the fistula being almost completely healed, the patient's general condition being excellent, she was discharged from the hospital. Alexicef-For Resume see Keen, p. 268. Camac Johns Hopkins Hospital Reports, 1900, VIII. Davis-See Ashhurst, Amer. Jour. Med. Sciences, 1908. (Records Episcopal Hospital, Philadelphia, Pa.) Deaver and Ashhurst-Surgery of the Upper Abdomen, Vol. II, Blakiston. 1914. Erdman-Annals of Surgery, 1903, Vol. I. Keen-Surgical Complications and Sequels of Typhoid Fever, (Saunders, 1898.) Gilbert and Girode-See Keen, p. 249. McMillan, John-British Medical Journal, Vol. I, 1912. Osler-Practice of Medicine, 1901. Osler--Trans. Asso. Amer. Physicians, 1897. Vol. XII, p. 288. (For Resume see Keen, p. 270.) Prince, E. M.-Amer. Med. Asso. Jour., Vol. I, 1909. Richardson, M. M.-Boston Medical Journal., Vol. II, 1897. Thomas, B. A.-New York Med. Jour., Vol. II, 1907. Williamss & Shield-For Resume see Keen, p. 265. Lancet, 1895, Vol. I, p. 534. Wescott-See Keen. p. 248. Worms, G. & Hamant-Arch. Gen. de Chir., VI, No. 2, Feb. 1912. (Abst, A. M. A. Retention of Nitrogen in Chronic Nephritis.— Rochat and Hijmans have been investigating the urea content of the blood in 110 persons with. healthy kidneys, as they describe in detail. The range was from 0.117 to 0.667. Computed by Ambard's formula, the range in 112 persons was below 0.09. Accepting 1.00 as the standard in health, not one of the healthy subjects surpassed this, while the patients with chronic kidney disease always gave a much higher figure, and the increasing urea content was always paralleled by aggravation of the clinical symptoms. The discovery of a high urea content often cleared up a puzzling diagnosis, before any definite symptoms of uremia became apparent. A number of experiences are related, all confirming the simplicity and reliability of the Ambard formula for sifting out the cases of kidney disease with retention of salt. This gives the clue to treatment and saves inflicting useless restrictions on the patients. With retention of nitrogen, of course, nitrogenous food should be restricted and the calories supplied in other ways. He lists for comparison some of the more common foods showing that 100 gm. each of sugar and butter represent 400 and 786 calories with no albumin; 100 gm. rice and berad, 253 and 235 calories with 7 gm. albumin; while 299 gm. potatoes represent 276 calories with 6 gm. albumin; 200 gm. green vegetables, 6 calories with 5 gm. albumin; 50 gm. meat, on the other hand, has 10 gm. albumin to 66 calories. Ambard's formula and the bases for it have been described in The Journal of the A. M. A.; one communication on the subject was published March 7, 1914, p. 813. Toxins of Helminths.-Paulian injected guineapigs with alcoholic extracts of various intestinal parasites, including ascarides, oxyuris and tenia. Other tests were made with macerations of their bodies. He found evidences of severe toxic action, from congestion and hyperemia to actual degeneration of tissues, loss of resisting powers of the red corpuscles, intense anemia and eosinophilia. The nervous disturbances and even the eosinophilia may be regarded, he thinks, as phenomena of anaphylaxis. His findings confirm those reported by others except that he never detected the lesions described by Rachmanov in the nervous elements. The organs predominantly affected were the spleen, kidneys and liver, the latter showing fatty degeneration in one auimal. The suprarenals were always hyperemic and with intertrabecular hemorrhages. COUNTY SOCIETY REPORTS Barren The Barren County Medical Society met in Glasgow, November 17, 1915. Members present, Turner, Miller, Botts, Biggers, Smock, Acton, White, Taylor, Siddens, Depp, Palmore, and Howard. The society was called to order by Vice President Miller. The minutes of last meeting were read and approved. Interesting clinical cases were reported by Drs. White, Smock, Botts and others, and the lively discussion which followed proved the deep interest awakened by the reports. A. T. Botts, reported the following unique case: A woman past middle age, experienced difficulty in passing her urine, which the doctor thought may have been caused by paresis of the muscles involved in urination, or possibly a growth in the urethra. The trouble grew worse, and worse, and yet she was too modest to submit to a rigid examination. Necessity in her case was indeed the mother of invention. Reasoning from analogy, and remembering how she had seen milk drawn from the breast with a hot glass or bottle, she made the inside of a long glass very warm with hot water, and fitted it tightly over the meatus urinarius. Instantly the urine started, and the bladder was quickly emptied. She has repeated this procedure many times, and always with perfect satisfaction. Dr. Botts does not expect this plan to come into general use, but reports it merely to prove that "Truth is stranger than fiction." C. C. Howard's paper on "Local Anesthesia" was well received and a motion carried that a copy be sent to the Journal for publication. After arranging an interesting program for our next meeting, the society adjourned to meet December, 15, 1915. J. MORGAN TAYLOR, Secretary. Christian The Christian County Medical Society met in regular session Tuesday, November 16th, in the City Court Room, Hopkinsville, with President Gates in the chair, and the following members present. Drs. Gates, Williams, Croft, Lovin, Durham, Keith, Southall, Rice, Paine, Stites, Barker, Harned, Bell, Caudle, Rozzell, Wright, Reynolds, Gaither, Sargent, Stone, Grace, Jackson, Thomas, Lacy, Gower, Stephens, and Sandbach, and W. R. Davidson, of Evansville, Ind. and E. M. Sanders, of Nashville, Tenn., and W. L. Moore, of Hopkins county as visitors. After the reading and adoption of the minutes of the last meeting the President called for volunteer contributions to pay an indebtedness of $31.05 and the amount at once contributed. Owing to our large program the report of cases and clinical cases were passed and the program called. W. R. Davidson, of Evansville, read an excel lent paper on "Early Diagnosis of Tubercle.' As this paper will appear in the Journal the secretary will not quote. This paper was favorably and freely discussed by Drs. Barker, Rice, Bell, Caudle, Rozzell, Stites, and Durham. W. L. Davidson, in closing, said: To meet with such a kind reception is worth two or three trips down here. I certainly have enjoyed the discussion. The tubercle in children is in the lymphatic system. If we wait for lung symptoms we are far advanced. What was once called early is now called late diagnosis. E. M. Sanders, of Nashville, read an excellent paper on "A Plea for Efficiency in Small Town Hospitals." As this paper will appear in the Journal the secretary will not quote. Drs. Davidson, Bell, Stites, Moore, and Gaither discussed the paper at length. F. M. Stites offered the following resolution which was passed unanimously. We commend the City of Hopkinsville for its enforcement of teh sanitary regulations and note with approval the improvement in the sanitation of the city. We would respectfully urge on the new city government, taking office January 1st, 1916, that it continue and enlarge such sanitary ordinances as already exist, and, We assure the city government the co-operation of this society in every effort to protect the health of the public. This being the last program of the year and one of the best meetings we adjourned. W. S. SANDBACH, Secretary. Woodford The Woodford County Medical Society held its November meeting in Midway on the evening of the 12th instant with Dr. Stedman occupying the chair. The following members were present: Drs. Anderson, Arnold, Blackburn, McCauley, Risque and Collette. The meeting was devoted to consideration of means whereby Communicative Diseases may be better cared for, the public better protected and the State Board of Health kept in closer touch with the occurrence of such cases than heretofore. It is the sense of the Society that the public welfare demands that much closer attention be given this matter. A motion was adopted authorizing a committee of three to advise with the Fiscal Court in the effort to have a secretary to the County Health Officer appointed. It shall be the duty of this secretary to receive reports from all the physicians of the county relative to the existence of communicative diseases; to send notice of such diagnosis and the regulations necessary and obligatory in such instances, to the patient or family in which the disease exists; report to the State Board of Health, etc. The Court will be asked to grant this secretary a nominal salary and incidental expenses covering blank forms, postage, etc. It is patent that too much negligence has existed in the past and this has probably been due to some extent at least to the attitude of the patients and families of patients of this class. They often object strenuously to quarantine and to proper after attention to fumigation, etc., and antagonize and severely criticise any physician who attempts to enforce proper regulations. This antagonism perhaps would be largely eliminated were notices sent from à secretary who is a member of the laity and the regulations made mandatory under the authority of the County Court. It will relieve any physician of responsibility for any blame and unkind feeling that is frequently engendered under present conditions. It will also have the much to be desired effect of directing the attention of those concerned in a more legal manner and create a greater consideration and respect for, the proper restrictions that should be thrown about these cases, and to which so little importance is usually attached by the majority of the very ones to whom this should especially apply. The society adjourned to meet in Versailles the second Friday in December. WM. T. COLLETTE, Secretary. Clark-Clark County Medical Society met November 9, 1915, and the Winchester Hospital question was again taken up. It was decided to push the campaign to raise the necessary funds for a hospital. About $17,000 has already been pledged and the Fiscal Court has promised to donate $5,000 when $25,000 has been raised. A committee was appointed to confer with the Fiscal Court in an effort to have the $5,000 paid when $20,000 has been raised by public subscription. This committee is composed of Dr. J. W. Ishmael, Dr. How ard Lyon and Dr. I. A. Shirley. If the Fiscal Court agrees to this it will be an easy matter to raise the balance and it is hoped that work of the new hospital can be started by the first of the year. The need of a roomy, public hospital for Winchester, is more forcibly emphasized every day. We no whave two prvate hospitals, and both of them are doing much good, but they have been crowded ever since they were established and still many persons have been compelled to leave the city for attention. It is hoped that this last campaign will be pushed through to a successful end and not be permitted to grow lukewarm as the other one was. NEWS ITEMS AND COMMENTS FIRST SUCCESSFUL FIGHT AGAINST HAY-FEVER.-WOMEN'S CIVIC LEAGUE ASSISTS. After having started a campaign of public education in the United States, showing that hay-fever is due to the pollen of weeds and that fall hay-fever, the most common form, is due in almost all cases to the two varieties of rag weed, the Common Rag-weed (Ambrosia Artemisiifolia) found in the Middle and Northern States and the Giant Rag-weed (Ambrosia Trifida) more common in the moist lands of the Coast, the American Hay-Fever Prevention Association has concentrated its first efforts in New Orleans with the first inning to its credit. The public was first educated regarding the rag-weeds, so that they could be easily recognized. Illustrations of the weed were published in the Bulletin of the State Medical Board of Health and the public press, and the live weeds, in full development, were exhibited in the show-windows of the principal street. The City of New Orleans, through the Commissioner of Public Works, placed at the disposal of the Association twenty convicts, who cleared the streets and sidewalks of the outer sections of the City of the weeds, in accordance with a map prepared by the Topographical Committee of the Association showing the areas infected with rag-weed. The State Board of Health published the illustrations of the rag-weeds and abstract of the instructions for hay-fever sufferers, and the City Board of Health assisted by enforcing the cutting of weeds on vacant lots. The Commissioners of the various Parks had the rag-weeds destroyed in the Public Parks under the direction of the Association. Valuable assistance was given by the Women's Civic League, which appointed a special Committee on Vacant Lots. This Committee made arrangements with labor bureaus so that they not only reported lots infected with weeds but offered to send workmen to cut them at low rates. The storm of September 29th, completed the fall work of the American Hay-Fever-Prevention Association in New Orleans by almost entirely destroying the leaves and flowers of the Giant Rag-Weed in exposed places. As a result of this, and the efforts of the American Hay-Fever-Prevention Association, Hay-Fever in New Orleans practically disappeared several weeks earlier than the usual time. As there are about 5,000 hay-fever sufferers in that city, the health and economic value of this can easily be estimated. Dr. W. Scheppegrell, President of the American Hay-Fever Prevention Association states that what has been effected in New Orleans can be done in all other towns and cities, and efforts in this direction will be started in the Spring. Hay-Fever is a distinctive preventible disease, and Dr. Scheppegrell believes that in a few years cases will become rare. The length of time will depend upon the degree to which localities are infected with the hay-fever-producing weeds and the energy of the people in destroying them. In some of the smaller towns, especially those catering to summer visitors, this will probably be accomplished before next Sum mer. The statement that a town is free of hay-fever will prove an advertisement, that will easily repay the cost of destroying the hay-fever-producing weeds. The Lincoln County Medical Society met in Crab Orchard, Tuesday October 19th, 1915, at 10 a. m., at the office of Dr. Harmon. In the absence of the president and secretary, Dr. O'Bannon was elected chairman pro tem and Dr. Harmon secretary. Dr. L. F. Jones was the first essayist, suband Treatment of ject. "The Prevention Puerperal Eclampsia." An interesting elucidation was presented, giving the up-to-date views of many distinguished authors as well as his own valuable experience. He dwelt and specifically upon albumen-uria urea, especially the latter, in the form of uremia as being a great factor in the pathology of eclampsia. The paper was highly instructive, full of scientific facts. Discussions were made by Drs. Harmon, Edmiston, O'Bannon, Southard, Jones and Carpenter. Dr. Harmon was the second essayist, subject, "Tonsilitis." He gave the many causes of the disease, differential diagnosis between tonsillitis, croup, diphtheria and phlegmonous inflammation of the palate and tonsil, morbid anatomy and local and constitutional treatment. These essayists proved themselves worthy of the honor bestowed upon them by appointment. Drs. O'Bannon, Edmiston, Jones. Southard, Carpenter and Harmon made instructive discussions. Dr. Carpenter made a talk on Instrumental Delivery with presentation of a complete obstetric "outfit" of surgical instrubents, describing their use in certain indications. The day was a most enjoyable one. An elegant dinner was served at the Hiatt Hotell by the Crab Orchard confreres. This society was a post-graduate course for one day and what those present gained in knowledge and wisdom, the absent ones lost. When doctors fail to attend their county and |