OBSTETRICS FOR NURSES. BY JOSEPH B. DE LEE, M.D., Professor of Obstetrics, Northwestern University Medical School; Obstetrician to Mercy, Wesley, Provident, Cook County, and Chicago Lying-in Hospitals; Lecturer in the Nurses' Training Schools of same. Fully illustrated. Philadelphia, New York, London: W. B. Saunders & Company, 1904. ALTHOUGH this book is intended by the author to be primarily for nurses, it is nevertheless, full of material valuable to the medical student, who frequently finds in his early years of obstetric practice the work of a nurse devolving upon him. Two main subjects are considered-obstetrics for nurses and the actual obstetric nursing. But the author has so skilfully combined them that the relations of one to the other are natural and helpful. This whole subject is one of such vital importance that a book of this kind, embodying as it does the experience of eight years of lecturing to the nurses of four different training schools, is most welcome to all those interested in obstetrics, whether nurses or physicians. The text is divided into three parts: Anatomy and Physiology of the Reproductive System, Nursing During Labor and in the Puerperium, and The Pathology of Pregnancy, Labor, and the Puerperium. There is an appendix treating of Visiting Nursing in Obstetric Practice, Hospital vs. Home Nursing. The Obstetric Nurse and Dietary. An excellent glossary and an index are appended. The illustrations, which are plentiful, are nearly all original, and were made expressly for this book. The author has taken the photographs from actual scenes, so that the details are true to life. We can warmly recommend this work. MALADIES DES PAYS CHAUDS. Manuel de Pathologie Exo tique. Par PATRICK MANSON. Traduit de l'Anglais par Maurice Guibaud, Médecin de la Marine, Jean Brengues, Médecin de l'Armée Coloniale, et Augmenté de Notes et d'un Appendice par M. Guibaud. Avec 114 illustrations et 2 planches en couleurs. Paris: C. Naud, 1904. THE interest in tropical diseases has assumed such importance of recent years that a contribution to the subject like this comprehensive work now translated into the French language, is a most welcome addition to this branch of literature. In the introduction the author considers the etiology of tropical diseases. The book is divided into seven sections. In the first, various fevers are considered-malaria, yellow fever, bubonic plague dengue, Mediterranean fever, tropical typhoid, typho-malaria, sunstroke, unclassified fevers, etc. The second section treats of beriberi, epidemic dropsy, and the sleeping sickness. Then follow the abdominal affections-cholera, dysentery, diarrhoea, liver abscess, infantile biliary cirrhosis, etc. Leprosy, ulcerating granuloma of the genitals, and Oriental bubo are then discussed. Diseases due to animal parasites and associated maladies are accorded considerable space, and include such affections as lymphangitis, lymph scrotum, elephantiasis, bilharzia hæmatobia, endemic hæmaturia, craw-craw, trichocephalus dispar, ascaris lumbricoides, ankylostomum duodenale, strongylus, subtilis, tænia and nana, and bothriocephalus mansoni. The section on cutaneous diseases is divided into four parts, non-specific diseases, diseases due to bacteria, those due to vegetable parasites and those caused by animals. The last chapter deals with local maladies of an undetermined nature. One hundred and fourteen illustrations are scattered throughout the text. There are, besides, two colored plates.. A MANUAL OF HYGIENE AND SANITATION. BY SENECA D. EGBERT, A.M., M.D., Professor of Hygiene and Dean of the Medico-Chirurgical College of Philadelphia; Member of the Academy of Natural Sciences of Philadelphia; Third Illus Member of the American Medical Association. edition, enlarged and thoroughly revised. trated with 86 engravings. Philadelphia and New York: Lea Brothers & Co., 1904. THE third edition of this valuable book will receive a warm welcome from the many classes to whom it appeals. The treatment of the subject is so scientific and systematic that the book fills a want not well met by many other volumes on these topics. Since its appearance, five years ago, the text has increased by more than one-third of its original volume. The author has shown in the introduc tory chapters what practical hygiene and the employment of comparatively recent discoveries in this field are doing for the improvement of this country, the data being de rived from the Reports of the United States Census of recc. The writer calls attention to the fact that improvement of sanitary conditions within ten years has resulted in the lowering of the death rate for almost twenty-nine millions of people, for consumption, 24 per cent.; for typhoid fever, 27 per cent.; for diphtheria, 50 per cent.; and for malaria 54 per cent. The reduction of the general death rate for the same number of people means a saving of almost fifty-two thousand lives, as well as the prevention of an incalculable amount of sickness. The volume deals with personal as well as public health, and is an invaluable addition to the library, not only of the physician but also of the layman. THE JOHNS HOPKINS HOSPITAL REPORTS. Volume XI Baltimore: The Johns Hopkins Press, 1903. THIS Volume of the reports contains three monographs: (1) Pneumothorax: A Historical, Clinical, and Exper mental Study, by Charles P. Emerson, A.B., M.D. (2 Clinical Observations on Blood-pressure, by Henry Wireman Cook, M.D., and John Bradford Briggs, M.D.) The Value of Tuberculin in Surgical Diagnosis, by Martia B. Tinker, M.D. The writer of "Pneumothorax" presents an exhaustive study of this subject. The first chapter gives a history of numerous cases reported by many different writers, going back to the earlier times. In later chapters the history, etiology, and pathology, with the clinical histories of cases, the mechanics of pneumotherex. the symptoms, course, prognosis, diagnosis, and treatment of the disease are discussed. The authors of "Clinical Observations on Blood-pressure," give the history of the principal methods of clinical sphygmomanometry; bloodpressure observations in surgical cases, in obstetrical cases, and in medical conditions. They finally treat of the comparative value of general stimulant measures. In the last paper, the value, dose, harmful use, injection, preparation and reliability of tuberculin in surgical diagnosis are discussed. THE PRACTICAL CARE OF THE BABY. BY THERON WENDELL KILMER, M.D., Associate Professor of Diseases of Chil dren in the New York School of Clinical Medicine, Assistant Physician to the Out-patient Department of the Babies' Hospital, New York; Attending Physician to the Children's Department of the West Side German Dispensary, New York. With sixty-eight illustrations Philadelphia: F. A. Davis Company, 1903. THE author has presented his subject in a clear, concise, and interesting manner. He has gone into the explanation of details in a most painstaking fashion. The text is made very clear by numerous illustrations. The prerer development, clothing, and feeding of the infant are al discussed. Then follow chapters on the diseases incident to babyhood. Finally, there are sections treating of the Nursery, the Wetnurse, Bad Habits, and Food Recipes. The text is so plain that the book cannot help but be great value to mothers and nurses as well as to physiciors. A MANUAL OF CLINICAL DIAGNOSIS BY MEANS OF MICROSCOPICAL AND CHEMICAL METHODS. By CHAS. E. SIMON, M.D. Fifth Edition, revised and enlarged. New York and Philadelphia: Lea Brothers & Co., 1994. SINCE its first appearance in 1896 this work has come to be regarded as one of the standards in this country in its particular field. The great strides made in this subject during recent years have necessitated frequent additions to the book in its successive editions, and the present one, the fifth, has attained the dimensions of a large octav of almost 700 pages, with numerous illustrations. The purpose of the book is well stated in the author's preface, where it is said that exact methods of diagnosis necessarily underlie successful therapeusis, and should therefore be part of the equipment of every physician, Dr. Simen has at tempted to simplify the physician's work and to increase its efficiency by enabling him to eliminate doubt from his diagnosis. Besides a careful revision, this edition embodies much new matter which has appeared during the last few years. The section on the blood has been entirely rewritten and has been enlarged by sixty pages, especia pains having been taken with the chapter on technique A section dealing with the nature of anilin dyes and th principles of staining has been introduced. For con venience of reference, the subject of leucocytosis has bee arranged in such a manner that hyperleucocytosis an hypoleucocytosis are separately considered in connection with the different varieties of leucocytes. A new section deals with the cryoscopic examination of the blood. chapters on the parasitology and bacteriology of th blood have been enlarged, with separate sections o paratyphoid fever, gonococcus septicemia, bubonic plagu trypanosomiasis, and spotted fever. Many other addition and changes have also been made in other sections. ΤΗ Society Reports. NEW YORK ACADEMY OF MEDICINE. DR. VIRGIL P. GIBNEY, IN THE CHAIR. The Distinctive Character of the Temperature Curve of Measles, and of Scarlet Fever the Treatment of Hyperpyrexia in These Diseases.-Dr. H. W. BERG read this paper (see page 1). Dr. HENRY KOPLIK said that the temperature curve during the enanthemata could not be considered exact as yet, because there had not been enough cases under observation to warrant any conclusion. During the enanthemata there would be apparently a slight rise of temperature, which might fall to normal, rise again and, in two or three days, would rise further with the appearance of the eruption. As to there being anything characteristic about the prodromal stage he hesitated to state; there was in all probability the temperature curve of an infection, same as would appear in an attack of tonsillitis or other infections. Even before the enanthemata there might be a slight rise, the child not being apparently well, running a temperature of onehalf or one degree. There it was difficult to say when the temperature curve began or when it ended. With reference to the critical drop in measles he said that Dr. Berg was correct in the chart drawings, but there were uncomplicated cases which did not show this critical drop; in other words, all cases did not conform to this critical drop curve, because there were many cases recorded without any complications, so far as one could tell after the most careful and painstaking examinations, in which the temperature dropped by lysis. He could not, therefore, support Dr. Berg's assumption that uncomplicated cases of measles dropped by crisis. With regard to the statement of Dr. Berg that he had never seen a case of measles without temperature being present, he referred to a baby that was under observation for six days, and he did not know what the matter was. The baby was brought into the hospital with a slight bronchitis, and for a day it was watched carefully. The temperature was normal, being 99.4° by rectum. Soon the child broke out with an eruption, there was a conjunctivitis, the spots were well shown in the mouth, and the case proved to be one of well-developed measles. The baby was transferred to Riverside Hospital. Here was a well-marked case of measles without scarcely any pyrexia. In regard to the scarlet fever temperature curve, he agreed with Dr. Berg that it acted as depicted by him in normal cases, but he said he had seen cases with temperatures of 103, 104°, etc., which failed to drop, and when there were no complications. In these cases there was general enlargement of the lymphatic glands and a severe dermatitis. He remembered distinctly just such a case in which he was asked to point out the complication which kept up the fever; he looked for it everywhere but failed to find one. He thought it might be explained by the fact that the desquamation was so marked, and the glandular enlargement and toxæmia so marked that it kept the temperature running a week or two. He would endorse Dr. Berg so far as he had gone. There was nothing so typical as a scarlet fever normal curve, and nothing so varied as measles when the eruption was at its height to predict whether it would show a critical drop or not. There was another class of cases that had not been referred to in which there was no typical temperature curve at all, i.e. the malignant cases with temperatures remaining at 105°, 106°. To build a therapy upon the temperature curve he thought would be rather risky, for each case should be studied by itself. If left alone he believed the normal cases of measles would get well; at the same time, if the temperature remained up he did not hesitate to sponge them and adopt mild measures. He did not recommend cold sponging, but luke-warm water, as a rule. The more he saw of scarlet fever the less he felt that he knew of its treatment, and he believed that each case should be studied by itself. Lately he had seen a child, six years old, who was very ill with scarlet fever, and what helped this child more than anything else was placing him in the cold pack and then adding cold water; here no sponging was used. On the other hand, in private practice, he treated his cases of scarlet fever with sponging; some children bear cold sponging well with good reaction, and others bear warm sponging well. Again some children may go to pieces in a bath at 80°, but if the water was raised to 100° it would revive them. Dr. ALEXANDER LAMBERT said that his experience coincided in the main with Dr. Berg's. Measles was associated with a distinct crisis, but the typical absolute crisis, as depicted on the charts, was the exception rather than the rule. When complications appeared, as a sudden attack of bronchitis, a temperature of 105° may be reached within thirty-six hours. He referred to one girl who had the typical rash, general adenitis, slight throat symptoms, etc. It was a very brilliant rash, and the case went on to complete desquamation at the end of six weeks, and at no time was the temperature above 99°. In another case there was the red and congested throat, the rash, adenitis, and a marked general desquamation and no temperature. He agreed with Dr. Kop lik that in cases of scarlet fever, with very brilliant eruptions, in uncomplicated cases, the temperatures may run along for two or three weeks before coming to the normal. Dr. Wм. P. NORTHRUP Said that measles, scarlet fever, and smallpox had exact charts, and related an instance in which he predicted what the chart would be in a child who contracted the disease from her sister who was suffering from scarlet fever. The thermometer should not be studied so much but the child's condition. He advocated the use of water inside and out, and said that the old adage, "keep the feet warm and the head cool," was a good one to follow. Dr. Berg closed the discussion, and said that a great deal hinged upon the question of complications, and sometimes even the most astute clinician would overlook a complication. The question of irregular temperature curve at once raised the question as to the existence of complications. He was interested in what Dr. Koplik had stated regarding those cases which presented no temperatures in measles. He was very skeptical regarding such statements, because every case that he had noted showed a temperature rise of from one-half to one degree above the normal. With regard to scarlet-fever cases he had seen children playing and seemingly enjoying life when they had temperatures of 103.5°. He was skeptical regarding any acute eruptive disease going through its course without temperature. In reference to the malignant temperature curve of measles and scarlet fever he believed the word malignant brought at once before one's eyes the most toxic cases, and the high temperatures depended upon the septic manifestations, and these cases he did not include as being uncomplicated. By studying these curves he said he was able to look for complications which otherwise would have escaped his observation. In regard to balneotherapy it was his custom to place the patient in a luke-warm bath at 80°, and raise the temperature about 10 degrees, thereby practically giving a warm bath after a cold one; by so doing he got rid of toxins, and the temperature would be lowered even further than if a bath at 60° had been given. He had seen temperature of 105° drop to 99. 5° after one of these baths and stay there for nine or ten hours. A Few Words Concerning Radium.-Dr. H. G. PIFFARD read this paper (see page 999, Vol. 65). Dr. ROBERT ABBE said that he wished to express his opinion regarding this extraordinary agent, for he believed that there certainly was something in it; it was a very subtle agent, and was similar to the x-ray, the ultra violet, the Piffard, and Finsen rays. In its efficiency it lay between the x-ray and the Finsen light. Dr. Abbe then reported certain experiments that he had made showing the retarding effects of the radium upon the growth of seeds; the results were unquestionable. If twenty seeds were taken out that had been radiumized four days, and twenty more that had been subjected to its influence for two days, and twenty more that had not been radiumized, if these seeds were planted for ten days it would be shown that the seeds unradiumized would have grown seven inches, those that had been subjected to its influence for two days would have grown four inches, and those radiumized four days would have grown only two inches. The retarding influence upon these seeds as a result of the influence of radium was unquestionable. The same retarding effect was noted when the meal-worm was subjected to the influence of radium. Thousands of experiments had been made to show this retarding influence in both the vegetable and animal kingdom. Now if radium be laid upon the skin for a few hours it will produce a welt-like urticaria; the next day it will appear like a burn, and continue its effect, producing a dry necrosis, scaling off and leaving a scar with infiltration. A condition of necrosis and destruction of the tissue cells are produced. Under the microscope there will be found a leucocytosis, a thrombosis of the small blood-vessels, the nerves will be infiltrated, the leucocytes will infiltrate the tissues, all this excitation being produced by radium. Dr. Abbe had experimented upon himself and upon others. He found a suitable case for experimentation in the mammary gland which he was to amputate. There were two or three outlying nodes in the skin, and he allowed the radium on the skin for six hours on one place, then on another, etc., doing this for six days, when he had pathological lesions running over a period of six days. He then took a piece of radium and plunged it into the mammary growth, leaving it there for twenty-four hours, and then amputated the breast. The pathologist did the rest, and reported the following facts: For a distance of one-quarter of an inch there was a marked effect of the radium upon the tissues. The nest-cells had begun to be disorganized, and the superficial tissues of the skin necrosed. There was a vascular leucocyte infiltration which was very marked for one-quarter of an inch beneath in the mammary tissue, and at right angles to the line of section; there was a destructive necrosis of these nest-cells. The pathologist said he wanted tissue showing the influence of the radium for a longer period of time. He had another patient with cancer, and by the application of radium nineteen times in a period of three months he reduced its size one-third, and then cut out one of these cancerous nodules and gave it to the pathologist. Microscopically there was shown a fibrous infiltration and a reduction of the cancer cells, and the nest-cells were present, but much smaller in number. It was interesting to note that one could produce practically the same effect with a weak radium with longer applications, as with a strong radium with short applications. Dr. Abbe reported the case of a young man with a giant-celled sarcoma of the lower jaw. Six months ago the gums became swollen around the left lower canine tooth, which became loose. Four months ago he sought advice at St. Luke's Hospital. A soft spongy dark tumor occupied the lower jaw from the middle portion toward the left, and bulged inward under the tongue and outward under the skin. It was so soft that it seemed to fluctuate. It seemed to rise between the teeth. Three teeth were so loose that they could be lifted from the sockets. A radical operation was impossible without great deformity, and with a surety that the growth would recur; therefore he decided to try the influence of radium upon it, and this was applied over the growth within the teeth for one-half to one hour daily, a lead shield protecting the tongue. He next attacked the outer portion of the tumor by laying the tube between the lip and the tumor; this so blistered the mucous membrane that he decided to penetrate the tumor; he penetrated the tumor in its various parts, leaving the radium imbedded for two or three hours at a time. The growth was not only arrested, but there was an appreciable shrinkage in its bulk of about one-third its size. The boy to-day was in apparent perfect health. One week ago he took a trocar and removed a cylinder of tissue from the tumor, and examined it microscopically, and it still showed that it was a giantcelled sarcoma, but merely a shell. Dr. Abbe had the influence of the radium upon the seeds, and the mealworms in his mind all the time, and he believed that he had greatly retarded the growth. This was a vast problem; he believed that, although the cells develop they can be held in check by radium, and he said what a tremendous contrast was presented in this patient with what would have happened if the growth had been unradiumized. Lupus and other conditions can be cured by radium, and those using this agent were having suc cesses in various other conditions. A wart was a typical hypertrophy of one of the layers of the skin, and prac tically a tumor. He had a patient with warts upon both hands; on one hand he tried radium, and on the other monochloracetic acid; the warts disappeared from the hands at the same time. Radium had an extraordinary effect in producing a retrograde metamorphosis. AMERICAN MEDICAL ASSOCIATION. Fifty-fifth Annual Meeting, Held in Atlantic City, N. J., June 7, 8, 9, and 10, 1904. (Special Report to the MEDICAL RECORD.) SECTION ON OBSTETRICS AND DISEASES OF WOMEN. Third Day-Thursday, June 2, 1904. The Surgical Treatment of Bilocular Uterus and Bifid Vagina.—Dr. H. W. LONGYEAR of Detroit referred to the meagre literature on this subject, and called attention to the fact that as the malformation was easy of correction, it should be operated upon as soon as discovered, so as to avoid the accidents of pregnancy and parturition which are liable to attend this anomaly of development. Before operating care was necessary in making a differential diagnosis between uterus duplex and uterus bicornis. The treatment recommended consisted in dividing the septum which separated the two uteri and vagina, and creating one cavity. The septum was grasped between clamps and cut with scissors, after which the Pacquelin cautery was applied to the cut edges, and the cavity packed with gauze. In the two cases which he reported, dysmenorrhoea was a marked symptom, but was relieved after operation, although in one of the cases an oophorectomy had to be done subsequently. Dr. DUNNING of Indianapolis stated that he had seen two cases of bilocular uterus and vagina. During labor the septa were torn through. One was thin and offered little obstacle to the progress of the presenting part; the other was somewhat thicker. There was but light hemor rhage. Both cases did well, and he doubted whether an operation was necessary, as a general thing. Dr. JOHNSON of Washington had seen a case in which, if operation had been done, much annoyance could have been avoided. The woman had been curetted for an apparent miscarriage and five months later was delivered of another foetus. The condition was then found to be a double uterus with a pregnancy in each. Dr. CARSTENS of Detroit reported two cases with septum which he divided, and although previously there had been miscarriages, full term pregnancy resulted. To prevent adhesions, he recommended the application of carbolic acid to the interior of the uterus after operation. A Plea for More Thorough Examination of Doubtful Specimens of Ectopic Pregnancy-Dr. J.W.BOVEE of Washington stated that many cases of ovarian and tubal hemor rhage have a symptomatology precisely similar to disturbed tubal or tuboovarian pregnancy, particularly tubal abortion. Specimens from such cases usually do not receive precise examination and are considered as pregnancy. For the sake of more reliable statistics, he thought that more careful histological examinations should be made. He reported ten cases in which the history indicated tubal pregnancy, but this diagnosis was not confirmed by microscopical examination. In two, malignant ovarian tumors were found. Some Cases of Ectopic Gestation with Atypical Symptoms.-Dr. W. B. DORSETT of St. Louis called attention to the fact that many cases were occasionally found which did not present characteristic symptoms. Thus a rightsided tubal pregnancy might be mistaken for appendical inflammation. He had operated on forty-one cases with a mortality of six, and in some of these no diagnosis had been made, but other indications were present calling for surgical interference. He believed that the general condition of the patient should be made the guide for surgical intervention and not alone the history of the case. Dr. CARSTENS of Detroit said that he had a case of supposed appendicitis, without fever or increased pulse rate, which turned out to have been a right-sided ectopic. He claimed that it was right to operate first and decide the pathology afterward. Dr. MASSEY of Philadelphia entered a plea for more conservative measures in dealing with ectopic gestation, as in many cases nature had already begun the process of obsorbing the mass when operation was undertaken. He advocated the destruction of the fœtus by the electric current, where practicable, as an aid to this process. Dr. GOLDSOHN of Chicago thought that the only difficulty lay in diagnosing the cases before rupture. In some cases microscopical evidence of the existence of a pregnancy could only be found in the cavity in the center of the blood-clot. He considered that the idea of the digestive function of the peritoneum was far-fetched. Dr. HUMISTON of Cleveland said that after rupture he did not wait for subsidence of shock before undertaking operation, but after injecting saline solution under the breasts, he proceeded to carry it out immediately. Dr. DUDLEY of New York considered that it was not necessary to remove the entire tube for non-septic conditions. After the foetus was turned out, the ovary and tube could be dropped back, all occlusions, etc., having been corrected. The Influence of Ovarian Implantation on Menstruation in Women.—Dr. A. P. DUDLEY of New York presented the following points for discussion: (1) Is the operation justifiable as a surgical procedure? (2) Is it worth the effort from a physiological standpoint? (3) Will the transplanted eventually resemble the fibroid in its action? (4) Is it possible that pregnancy may ultimately take place? (5) and provided it does, what is the prospect for normal delivery? Thus far he had done this operation in seven cases, all of which subsequently menstruated but at irregular intervals, and no physiological changes or nervous manifestations resulted. One of his last cases he reported in full. The patient had had both tubes and one ovary removed, and for the relief of her symptoms, hysterectomy had been advised, but to which she would not consent. Operation was undertaken and the ovary freed from its adhesions, but left attached by the ovarian ligament, was implanted directly in the uterine cavity in a space previously gauged out in the muscular substance. Primary union resulted and the woman menstruated three months after the operation, and then, at intervals, every three months. Eighteen months later she developed a severe menorrhagia, and hysterectomy had finally to be done three years after the first operation. Examination showed that the ovarian and uterine tissues had become merged, with Graafian follicles present. He was at a loss to account for the hemorrhages. The specimens obtained from this case were presented at the meeting. The reader doubted the extended applicability of the method, but believed that it might be advantageously employed in isolated cases. A Plea for Conservative Operations on the Ovaries, from a Neurotic Standpoint, with a Report of Cases.-Dr. J. W. COKENOWER of Des Moines read this paper, in which he called attention to the necessity of making a better diagnosis in those cases in which the symptoms presented were ascribed to ovarian disorders. In many instances it was questionable whether the trouble was really due to the ovary. It was much more likely to be an intoxication traceable to the intestinal canal, of which the pelvic disease was the result, rather than the cause. Neurotic cases were rare in which the symptoms were wholly dependent on the sexual organs. It was important to recognize when to conclude medical treatment and institute surgical measures. The consensus of opinion of many observers rather than the statistical reports of a few, should be given preference. Negative results for conservative ovarian operations for the relief of neurotic conditions were common, and between the two extreme views as to the advisability of operating, an intermediate view was the best. He reported four cases in which single or double oophorectomy and hysterectomy had been done, with disappointing results. He thought that in many cases we operated when we should not have done so. Dr. MORRIS of New York opened the discussion on Dr. Dudley's paper. He discussed the advantages of the procedure and the respective value of homoplastic and heteroplastic transplantation. He had made numerous experiments on rabbits, and the latter method was unsuccessful. He thought that it was well to save the ovary in a case of pyosalpinx, and he found that the organs could be kept in hot saline solution for several hours without injury, before being transplanted and while the remaining operative procedures were being completed. In discussing Dr. Cokenower's paper, he called attention to the fact that it was essential to carefully differentiate fundamental psychoses from neuroses. Dr. GOLDSPOHN of Chicago opened the discussion of Dr. Cokenower's paper. He thought the question might be solved by distinguishing between psychical and actual pain. Every other part of the body should be examined before the pelvis. He had also invariably found that pelvic lesions were aggravated by the erect posture or anything else that favored congestion. Dr. HUMISTON of Cleveland found that frequently the pelvic organs were normal and other organs accounted for the neuroses. In discussing operative measures, he stated that he only attained good results from the complete operations. Dr. BACON of Chicago thought that the site of implantation was not favorable, as the implanted ovary might be washed away by the uterine discharges. He believed that the chief object was to secure the advantages of internal ovarian secretion, rather than the possibilities of pregnancy. Dr. MASSEY of Philadelphia considered that in many cases it was necessary to remove the inflammation rather than the organ itself, and in this connection he believed that kataphoresis with the mercuric ions valuable. Dr. CARSTENS of Detroit thought that occasionally in young women a favorable case for the Dudley operation might be found, but that in older women it was best to remove the ovaries if the symptoms were bad. Dr. CRAIG of Boston had observed that the normal Ovary became scarred during middle life from cicatrization of the continually rupturing Graafian follicles, and that many so-called cystic ovaries, without clinical symptoms, contained merely enlarged Graafian follicles. As it was an essential thing to keep up the internal ovarian secretion, he believed that under the proper circumstances, Dudley's operation was favorable. Dr. CHANDLER of Philadelphia thought that Dudley's operation presented many advantages and but few objections. Among the latter were the remote possibility of sepsis, the death of the ovary, the production of malignancy, and the action on the foetus. The main advantage he considered to be the postponement of the menopause. A Series of Mistaken Gynecological Diagnosis.—Dr. T. S. CULLEN of Baltimore reported the following interesting cases: (1) Was diagnosed as a large multilocular ovarian cyst, which at operation was found to be a pedunculated fibroid, partially parasitic The omentum was markedly atrophied and ascites was present. The latter is extremely rare with fibroid conditions. (2) Here the uterus was enlarged, globular, with apparently two subperitoneal nodules. On account of the general history no examination of scrapings was thought necessary. At operation an advanced adenocarcinoma of the corpus was found. (3) Here a globular mass projected from the right side of the uterus and from the vicinity of the right cornu a subperitoneal nodule. Both uterus and nodules were movable and a diagnosis of intraligamentous and subperitoneal myomata made. At operation the subperitoneal nodule proved to be a tense and kinked hydrosalpinx, the intraligamentary growth an adenocarcinoma of the ovary invading the bladder wall. (4) This patient, aged sixty, presented temperatures from 100 to 103°. There was marked pain in the pelvis and slight discomfort in defecation. In the vaginal vault, and apparently attached to the posterior surface of the uterus, was a slightly irregular but globular mass. The diagnosis was between adhesions of subperitoneal myoma glued to the pelvic floor and pelvic abscess. Operation showed an irregular globular tumor involving the sigmoid flexure. This had dropped over to the right side and become adherent to the pelvic floor. Diverticulæ were filled with fecal concretions, and between the floor and the growth was a small abscess due to rupture of a diverticulum from the intestine. The tumor was benign. (5) A case of adenocarcinoma of the kidney had been well for sixteen months after operation. Then a rapidly growing tumor was noticed in the hepatic region, which turned out to be a neoplasm involving the lower half of the liver, but was not a metastatic growth. Injury to the Rectum in Gynecological Examinations.— Dr. H. A. KELLY of Baltimore called attention to the importance of the rectum as an avenue of investigation and the obstacles encountered by this route. A rough examination might readily rupture cystic structures and spread their contents over the abdomen. He had also seen several cases in which the finger was pushed through the rectum and entered the abdominal cavity, necessitating repair by laparotomy. In one instance it was found that a large ovarian cyst had been punctured. The accident depended not so much on the rough handling or carelessness of the examiner, as on the soft and friable character of these tissues. In making a rectal examination, it was always well to recognize, but not to invaginate the ampullæ and to get the finger beyond what might be called the third sphincter of the rectum. During an examination it was most essential that the arm be perfectly relaxed, and the wrist not held stiffly. Distending the bowel with air also greatly facilitated the examination. When injured, the rectum might be repaired through the posterior cul-de-sac, or, if advisable, by the abdominal route. He asked that cases of this kind be put on record. Dr. WETHERILL of Denver called attention to the possibility of injuring the rectum during the conduct of a labor, when the operator's finger was inserted into the rectum to support the advancing fetal head. Dr. CULLEN of Baltimore reported two cases in which the rectum had been injured. Dr. SHOEMAKER of Philadelphia mentioned an instance in which an appendical abscess had been ruptured by the hydrostatic pressure of an enema, and Dr. NOBLE of Philadelphia also reported a case of pelvic abscess ruptured by rectal examination. Some Further Observations on the Use of the Stem Pessary for Scanty and Painful Menstruation. Dr. J. H. CARSTENS of Detroit stated that in a certain class of cases these conditions could only be ascribed to lack of exercise of the uterine muscle. He thought that the organ could be sufficiently well developed by the introduction of a foreign body which the uterus would constantly endeavor to expel. In another class of cases, dysmenorrhoea comes on later, after normal menstruation for years, in which the uterus, and especially the cervix, had undergone premature atrophy. All these cases might be relieved by the introduction of a stem pessary. In one of his cases the stem had been in place for two years, but after removal a gradual return of her symptoms took place, which was finally relieved by the reintroduction of the instrument. In another case of sterility of five years' standing, preg nancy came on after the use of the stem for a few months. The Propriety, Indications, and Methods for the Termination of Pregnancy.-Dr. F. A. HIGGINS of Boston believed that there were evidences of broadening of the indications for the termination of pregnancy, and the wisdom of this could not be questioned. The question remained whether this would lead to ill-advised abortion, but he felt safe in stating that he did not think it would. He discussed in detail the influences exerted by the various acute and chronic diseases. An acute disease was not usually an indication, but if labor comes on, it should be hastened. The religious question was also touched upon. one. As for the methods, he considered bougies favorable in certain cases, but thought it better to employ two than He recommended, however, the Vorhees bag and the colpeurynter. Manual dilatation was accompanied by the danger of rupture. Instruments, he claimed, were under more complete control, and therefore more secure. The dilatation in each case depends on the amount of stretching which the cervix will endure. The Bossi dilator was shown and discussed, and the author's newly modified instrument presented. This was more compact than the Bossi and claimed to be less dangerous. It might also be used for dilating the cervix before ordinary curettage. Dr. HALL of Kansas City said that he thought it was more honorable to suggest methods of preventing preg nancy in questionable cases rather than to devise methods of abortion. He believed that the effect of such a paper might be bad on the public mind. Where the necessity existed, he considered that the instrument was preferable to the use of the fingers. Dr. BACON of Chicago claimed that the social condition of the patient should be largely taken into account in deciding the advisability of abortion. In the case of hydramnion and twins, he advised rupture of the membranes, and the bag, when used, should then be placed within the egg sac. In his opinion, vaginal cæsarean section was to be preferred to the use of instruments. Adherent Uterus as a Complication of Labor.-Dr. J. C. APPLEGATE of Philadelphia discussed the circumstances under which the pregnant woman with adherent uterus should be allowed to go to full term, and the best method by which such complications could be treated. He found that the round ligament suspensory operations had no effect, but that labor quite fully destroyed the results of the previous operation. Peritoneal suspension was dangerous from possible rupture of the uterus. Ventral fixation was unjustifiable before the menopause, except under rare circumstances. Before attempting the latter operation, amputation of the cervix should always be done. In vaginal fixation he believed that labor should be induced. With ventral fixation, pregnancy to full term depended on the mobility of the uterus; if the cervix failed to enlarge and rose posteriorly, labor should be induced. The safest thing for these cases, however, was considered to be cæsarean section. In the reader's estimation the best method of suspending the uterus was by sutures introduced in front of the origin of the tubes instead of to the fundus. Two cases were reported, in one of which the |