chill and temperature, so regular often in its periodicity, to such a cause when it at once puts the onus on the patient, or previous surroundings, while the dear surgeon has done a most successful, beautiful, and aseptic operation. The cases of post-operative pneumonia, pleurisy, meningitis and joint affections are in a large measure due to infection of this character; that is, there are septic emboli carried to these distant organs, and they are truly metastatic processes. A toxemia or septicemia is a usual concomitant of peritonitis, which latter may be of several varieties. Thus we may have a mild septic (not purulent) peritonitis with increased pulse and temperature which subside after free drainage by the bowel. Or, again, we may have septic non-suppurative peritonitis, violent in its character, leading to death in a short time.

Such a one was the case of E. T., aged eighteen, a prostitute, who was operated on for a double pyosalpinx. The patient was anemic, run down, and gave a history of having had a child ten weeks before, followed by a probable puerperal fever of mild grade. During the enucleation pus escaped into the cavity from a rupture of the tube. Went off the table in good condition; in twenty-four hours temperature went to 103.5° F., pulse 140. Belly distended. Died six hours later.

Autopsy: Belly contained some serum; serum with few flakes between coils of intestine.

Bacteriologic examination: Shows streptococci in tubes, in bloodvessels, and in fluid in belly.

Again, we may have a more rapid or virulent infection, resulting in pus formation in the belly and death in less than twenty-four hours, as the case of F. B.; operation for double pus-tubes. Post-operative temperature 99° F., pulse 80. Eight hours later temperature 101° F., pulse 120. Belly not distended, but tympanitic. Restlessness. Forehead bathed in sweat. Face pinched and drawn; some muttering, later delirium; no vomiting nor pain. Death in twenty hours. Post-mortem: Pus in incision and along sutures; about a pint of free pus in pelvis, and pus containing fibrinous flakes in belly. Micro-organism present. Staphylococci also found in veins and in arteries. Culture confirms finding of staphylococcus pyogenes aureus.

The other variety is classical and so easily recognized as to leave no doubt as to the condition, which is not true always in the above forms of poisoning, particularly if there is little or no temperature and much

shock, as is often the case from the severity of the infection itself. This latter group includes the cases which are slower, less virulent, but none the less serious. The symptoms develop more gradually and slowly. There is usually more marked distension, persistent vomiting of bile, or bile mixed with blood; the face becomes yellowish, pinched, the conjunctiva even jaundiced; usually obstipation. Temperature may range from 100° to 104° or 105° F., pulse ranging to 130 until the third or fifth or even sixth day, when death closes the scene from heart failure due to the sepsis.

Some of these slower forms of infection may even present diarrhea, as one with which I am familiar following a curettage, the patient dying on the seventh day. Never much temperature; pain not very marked, but distension, vomiting, and gradual sinking. Death may even in this class of cases be attributed by dishonest surgeons to gastritis, diarrhea, yellow atrophy of the liver, typhoid fever, or other causes equally as far removed from the true cause. This fools the public, it fools many general practitioners, but it does not fool the surgeon, nor such men as I have before me in this Society.

4. Among my fourth group of causes I would include the cases due to bad after-management. These we never see except in the hands of occasional operators. It has been said, and I know truly, that bad management may be the cause of many fatalities, no matter how skillful or perfect the operation itself. Personally my opinion is that sweet milk has done much harm to laparotomy cases. I almost lost a case after strangulated hernia from injudicious feeding with solids on the fifth day after operation. The overtaxing of the intestines is often more than they can stand. Distension or meteorismus with interference of cardiac function or paralysis therefrom may ensue, or intestinal toxemia of sufficient intensity to cause death in a weak patient.

5. Finally I would mention miscellaneous causes; those due to accidental obstruction from Murphy's button, for instance, or to a true hypostatic pneumonia, as occurred in a patient of mine sixteen days after operation. The case was one in a fat woman, weighing 275 or 300 pounds, who could lie no other way than on her back. Death resulted on the nineteenth day. We would have allowed her up in a few days more, but on account of the thick and fat wall and her size, fear of a subsequent hernia kept her in bed with the result mentioned.

Then complicating troubles may come up through the action of the nervous system, possibly on the kidneys of patients in rare cases, or a

heart the subject of a fatty degeneration or brown atrophy as is found in large tumors may quit and cause death from a true heart failure, though probably some of these cases of sudden death or more prolonged development ending in death may be due to an embolus, which should. not be overlooked in accounting for the fatal termination. Then in gall-stones with long-continued jaundice, blood changes may occur, or a condition of bile poisoning may exist with subnormal temperature that may result in death from a true exhaustion or rather cholemia. As stated, however, among all these causes we find that sepsis in one of its various manifestations still claims most victories.

Could we do away with sepsis or always combat it successfully, I think our mortality would be less than one tenth of one per cent; and all this goes to show, as my friend McMurtry said in his paper before one of our local Societies a short time ago, "That while we may seem to have attained the ideal we have not done so, and surgery is still an art and not an exact science."

LOUISVILLE.

Reports of Societies.

THE LOUISville medICO-CHIRURGICAL SOCIETY.*

Stated Meeting, February 15, 1901, John G. Cecil, M. D., President pro tem., in the Chair.

Continued Report of Supposed Sarcoma of the Forearm. Dr. A. M. Vance: I have here a specimen which is of some interest in connection with the continued report of the case. Two meetings ago I exhibited a boy sixteen years of age who was supposed to have, and gave all the gross appearances, a sarcoma of the forearm resulting from traumatism, a nail which was in a board. It was then the consensus of opinion that the boy had a malignant growth, and I was of the same opinion. The advice of the Society was that the boy should be put under the influence of chloroform, an incision made, and the tumor examined; that the operative procedure should depend upon the findings at that time.

I studied the case carefully and concluded to wait a while. I put on a compression bandage and waited. It is now four or five weeks

* Stenographically reported for this journal by C. C. Mapes, Louisville, Ky.

since the boy was exhibited. Two days ago a small opening appeared at the site of the original wound, and these two pieces of wood came out; so I am inclined to think now that the whole thing was inflammatory, due to the foreign body, though the fluoroscopic examination failed to show this. I think there is probably still some pieces of wood in the arm. If you will recall my report of the case you will remember that the wound primarily healed, and the boy went for four months without a sinus or other evidence of trouble; at the end of four months the enlargement began. It was rather tender; there was no heat, no redness, and the wound of entrance had thoroughly cicatrized.

Discussion. Dr. Louis Frank: I remember the case distinctly. Of course the fluoroscopic examination would not show a piece of wood in the arm. The suggestion offered when the boy was before the Society was that the arm be opened, a section of the enlargement submitted to microscopical examination, and the nature of the operation would depend upon those findings. I think the plan Dr. Vance pursued has proven to be wiser than the plan suggested would have been, because this is one of the cases where the microscopist might have erred, as the great amount of cell infiltration might have given a typical picture of round-cell sarcoma.. This was supposed to be a sarcoma, and the microscopical findings would have probably verified the clinical history and diagnosis, and an operation would have been done accordingly. Dr. Vance is to be congratulated upon his conservatism in this case; it teaches us that these cases do get well, and that nature is a wonderful doctor.

Foreign Body Removed from the Nose. Dr. William Cheatham: I have a foreign body removed from the nose of a patient to-day. There is nothing especially interesting about the case except to illustrate the simple method we have of removing these foreign bodies. It is quite a large bean, probably having become larger since it has been in the nose, and the patient's nose was very small. It is a great mistake, when the foreign body is of a smooth variety, to attempt to remove it by means of forceps. My method is to ask the mother or some other member of the family present for a hairpin, bend the end of it over in the shape of a hook, and with this instrument the foreign body can be easily removed. Forceps are usually dangerous on account of their slipping, and thus pushing the foreign body further in.

Discussion. Dr. B. C. Frazier: I would like to ask whether or not it would be advisable to introduce a catheter from behind to push out the foreign body from the nose when it was found that it could not be extracted anteriorly?

Dr. William Cheatham: This might be done with a catheter having a proper curve. We blow them out sometimes by compressed air

through the other nostril.

Double Salpingo-Oophorectomy. Dr. Louis Frank: These specimens themselves are not of much interest, but are shown as I desire to give the history of the case. They consist of the tubes and ovaries from a patient operated upon yesterday, February 14th-a double salpingooöphorectomy. The history of the case is of some interest as bearing upon a subject to which we have lately given considerable attention, and which has caused some discussion, namely, the condition of retroflexion or retroversion.

The patient from whom these specimens were removed is a young woman twenty-six years of age; she gives a history of having suffered for the last three or four years with pelvic pain, but more severely with pain in the back and rectum. She had never borne a child, and had been under the observation of two excellent surgeons in the city, both of whom at different intervals of a year-the last one about twelve months ago had curetted her for an endometritis. She came to me with this history.

After a careful examination I made out the uterus, which was movable to apparently the normal extent; it was retroverted, with the cervix pointing almost directly upward toward the symphysis pubis. It could be brought down by means of a tenaculum forceps to the ostium vaginæ, and could be replaced without great difficulty, but would not maintain its normal posture. With an intact perineum this was rather difficult to understand. There was much tenderness in the left side, and I thought at this point I could make out a prolapsed ovary, though of this I was not certain. On the other side the ovary and tube were easily palpable, perfectly movable, and did not seem to be bound down. With a history of prolonged suffering, however, I advised her to have an exploratory incision made, telling her I thought she would lose one ovary and tube, and possibly both. The operation was purely exploratory in the strictest sense of the word.

Upon opening the abdomen I came down upon the fundus of the uterus lying above and completely covered by the summit of the