hesions. Abdomen closed without drainage. Advised intensive hygienic anti-tubercular treatment. Convalescence uninterrupted. Patient is at present in the navy.

Case 4: Mrs. T, age 30, housewife. First seen December 7, 1920. Family and past personal history negative. Present illness: Pain of a constant achy variety, present in the lumbar region, epigastrium, and lower right abdominal quadrant, with associated nausea and vomiting, vaginal bleeding and amenorrhea for the past two months and a half. Patient had had five previous miscarriages.

Examination abdominally showed pain and tenderness over the right lower quadrant. No masses felt. Vaginal examination showed a bilaterally lacerated cervix of normal consistency, uterus forward and enlarged. Blood count normal. Slight elevation of temperature, and increase in the pulse rate.

A diagnosis of extra-uterine pregnancy was made and operation advised.

Operative findings: Both Fallopian tubes showed the presence of many tubercles about the size of a ce pill. They were also small and very friable. A few cobweb-like adhesions were present. Uterus enlarged to the size of a two and one-half month's pregnancy. Peritoneum not thickened. Two weeks later the patient aborted, and has been perfectly well as far as I know ever since.

Case 5: Mrs. A, age 34 years, housewife. First seen October 27, 1920. Family history, one sister died from pulmonary tuberculosis. Personal history, negative. Patient complained of abdominal pain, backache, headache, leucorrhea, since birth of first child, 10 years ago, and loss of appetite, loss of weight, night sweats, productive cough, general weakness, all present during the past three

tainable. Past personal history, unhygienic home surroundings. Tonsillectomy April 19, 1921.

Admitted to the surgical clinic complaining of presence of a tumor mass in the right upper abdominal quadrant. Examination revealed a mass about the size of an orange, apparently attached to the liver and the right costal margin. No tenderness, but slightly reddened, with infiltration of skin and some fluctuation.

A tentative diagnosis of granuloma of the rib was made. Massermann, negative. Von Pirquet positive. Aug. 1, 1921 mass still present, broken down and discharging from three sinuses. Chest negative. Sinus (lower) probed and found to extend to the rib margin. Operation advised following diagnosis of tubercular ribs,

Operation Aug. 22, 1921. Incision over the above described area obliterating the sinus openings. Ribs exposed, but with no pathology present. At the costal margin, however, in the lower part of the wound, a sinus large enough to admit the index finger leading into the peritoneal cavity was found. Exploration revealed presence of cobweb-like adhesions around the gall bladder, pylorus, duodenum, intestines, and post surface of the liver. Pertitoneum was studded with tubercles and thickened to about one-eighth of an inch. The sinus was closed with plain catgut, the fascia overlapped with chronic catgut, and skin closed with silk worm. There was considerable discharge three weeks, when it finally cleared up and wound began to granulate. Healing was stimulated by applications of silver nitrate and exposure to concentrated electric rays from a 100 cp electric light, held six inches from the wound under a canopy. Patient has gained ten pounds in weight and looks better, wound has healed completely, and patient is back in school,

Most authorities concede that tubercular

and caused her to seek medical aid. Temperature 101, pulse 100 at first examination. Advised hospital for observation.

Abdominal examination showed presence of pain and tenderness in both lower quadrants. Vaginal examination, showed cystocoele, rectocoele, bilaterally lacerated cervix, tenderness in both adenexa. Patient's P. M. temperature while in hospital, ranged from 99.6 to 101.6. Chest examination

chronic. The acute may or may not be associated with fluid, the former case being true of the miliary form. The chronic may be characterized by large growths which tend to caseate and ulcerate. The exudate is purulant or sero-purulant, and may be sacculated or localized. Or, it may be the

The abdomen rapidly filled with fluid until the patient became very uncomfortable and dyspuoic. Paracentesis removed six quarts of straw-colored fluid, and was followed by improvement for 10 days prior to laporotomy under local anaesthesia Nov. 26, 1920.

Operative findings: Peritoneum much thickened and studded with many small tubercles. Intestines matted together firmly with dense adhesions. Two quarts of straw-colored fluid evacuated from many pockets. ConExploration impossible. valescence was slow but steady. At present the patient is doing her own work.

Case 6: J. P. age 13 years, Fairview school. First seen June 21, 1921. Family history unob

acute from the onset, or which may represent the final stage of the acute miliary, with many adhesions to the matted intes- ' tines, and fluid. The acute type may assimilate acute peritonitis, acute appendicitis, acute cholecystitis, intestinal obstruction, strangulated hernia, and other acute abdominal conditions, and is often diagnosed as such. Very often in the chronic forms with fluid, it is hard to differentiate from an ovarian cyst, but most of these patients have a little elevation of temperature in the afternoon or evening, or a subnormal temperature in the morning, and if a careful record of the patient's temperature has been taken throughout the period of the illness, the condition would probably be found at some time. The laboratory findings, together with the history, make an almost positive diagnosis in both the acute and the

chronic cases. You are well acquainted with the usual laboratory procedures at our disposal in this condition. They consist of cytological examination of the aspirated fluid, which shows frequently lymphocytes in varying numbers present and fibrin. Injection of this fluid into a guinea pig produces the disease there. The tuberculin

test, and the Von Pirquet, and finally the blood count, which shows a normal or decreased number of cells with an increase in the lymphocytes.

The presence of a distant focus of infection should be borne in mind, for example, the tonsils, prostate, epydilymus, seminal vesicles, and the Fallopian tubes. We believe that the disease is secondary and frequently associated with chronic pulmonary tuberculosis, pleurisy, or pericarditis. The Germans contend that tuberculosis is primary in the gastro-intestinal tract. It occurs at all ages, but is most common in children and adults between the ages of 20 and 40 years. Some of the predisposing factors are cirrhosis of the liver, abdominal trauma, ovarian cysts, and in hernial sacs. I believe the disease to be more common than is commonly supposed, 6% in my small series.

The predominating symptoms are abdominal pain and tenderness, severe or mild, depending on whether acute or chronic, tympanites, in the acute cases being due to loss of tone in the intestines owing to inflammation, or in chronic cases with adhesions between the visceral and pareital layers. Fever may reach a high point in the acute cases, slight or subnormal in the chronic cases. Ascites is frequent in both forms.

The treatment of this condition has swayed from medical to surgical and back again many times, good results being obtained from both. The results from surgical treatment briefed in this paper have been good. All cases, particularly the acute, I believe should have the benefit of hygienic treatment for a period of from two to four months, and if this fails, or if there is an excessive amount of fluid formed which is of marked disturbance to the patient, the surgical treatment is indicated. However, operation is not always essential, as often the fluid will disappear as the patient's resistance increases. Always remove the focus of infection if possible. An organ affected with tuberculosis, if its removal can be accomplished without undue traumatism to the peritoneum or intestines, should be removed. Statistics from large series of cases show 50% cures and most all patients helped. It has been advised that operation.

should not be performed too early in the attack, because recurrence is more likely in cases where the operation is performed before the tubercles are fully developed. The cure is attributed to the secretion of an immune serum which is claimed is not produced before the tubercles have been fully developed.

CONCLUSIONS

1. Patients suffering from tubercular peritonitis should be subjected to careful hygienic treatment which should be continued if the patient's condition improves.

2. Abdominal section is indicated in patients in which the condition becomes worse, does not improve, or where ascites to a distressing amount forms, removing the focus if possible to do so without injuring surrounding structures, and if it can be done easily.

3. Aim to arrive at an early correct diagnosis.

4. Never operate on an acute case which has been diagnosed as such.

5. Continue hygienic treatment after operation.

6. Never disturb peritoneal adhesions in patients suffering from tubercular peritonitis, for fear of producing fistulae. I would

also advise closure of the abdominal wound following such operations, for the same

pedicle of an ovarian tumor will also cause pain and possibly collapse.

Distention of a hollow viscus or unrelieved tension will produce pain. Every one has presumably experienced this kind of pain in the over full urinary bladder. Relief may succeed a painful distention owing to paresis of the muscular structures.

The colics or spasmodic pains are due to forcible contractions of the unstriated muscular structures of the hollow viscera.

It is a startling fact to realize that with the exception of forced emesis we lose conscious control of every particle of food and drink as soon as it passes the pharynx until it reaches the sphincter of the anus bladder. Between these points the food is under control of an autonomic system of nodes akin to the blocking system of a railway.

or

I regard it as a wise provision that in the creation of both animals and man the di

gestive functions are almost "fool proof" and work automatically and without the control of the cranial nerves except in the reception of food and in defecation. It is a subject for conjecture if many of the neuroses and neurasthenic states are not traceable to the attempt of the central nervous system to gain ascendency over the autonomic system.

Physical diagnosis of the abdomen is almost a "lost art." I never knew the reason for it, but it is nevertheless a fact, that teachers of physical diagnosis confine themselves to the chest and do not pretend to make or teach physical diagnosis of the abdomen. In spite of that the clinician fails to make a complete and thorough examination who does not make use of inspection, palpation, percussion, and, in certain cases, of auscultation. They may advantageously be combined with fluoroscopy and the latter with pneumoperitoneum. No abdominal examination is quite complete without binamual examination, rectal examination and cystoscopy.

of medicine or any desire to know internal medicine. It is to me a subject of wonderment how any one can make a satisfactory diagnosis or even a physical examination to say nothing of conducting the post-operative treatment of a case without the ex

perience acquired in a general practice. We talk about team work, a combination with which I am in hearty accord. It is a serious question, however, whether we as surgeons seek consultations with either internists or other surgeons as the cases demand. It is a fact that errors occur and such cases sometimes come within the notice of the court. They result from insufficient observation, which calls to mind the remark that "more mistakes are made in diagnosis on account of lack of observation than on account of lack of knowledge." To me a real surgeon means more than a mere technician who operates after a ready made diagnosis. by an internist or a laboratory expert. He is master of the situation.

Roentgenology is becoming one of the most valuable aids to diagnosis. Carmen reported last year correct diagnosis of peptic ulcer in 98.21 per cent and localized the ulcer in 95 per cent of cases. He made also negative Roentgen diagnoses in 336 out of 351 cases or 95.76 per cent. Valuable data can be obtained also in chronic obstructions, in urinary cases and in determining adhesions by pneumoperitoneum.

Laboratory examinations of the secretions, excretions, blood, tissue, and bacterial infections are invaluable as aids to diagnosis but are not intended as diagnostic unless supported by clinical evidence.

ADRENALIN AND P. D. & CO.

Up to 1900 the medical profession had to be content with extracts and other preparations of the suprarenal gland that contained, besides what was wanted, a good deal of inert and possibly irritating material,

One manufacturing house at least was engaged in making a discovery-the isolation of the active principle of the suprarenal gland, or, if it is not quite accurate to speak of it as "the active prin

ciple of the gland. For it was known that such a principle was contained some where in the gland

It seems to be no longer the fashion of the surgeon or the specialist to evolve from the general practitioner. More than that we sometimes hear the younger surgeons disclaim any knowledge of the general practice

lutions of suprarenal extracts; and it was this principle in pure form that was wanted.

Physicians need not now be told that the manufacturing house alluded to (Parke, Davis & Co.) was successful in its quest, for Adrenalin, the pressor principle sought, has been in use by the profession ince 1901.

FIRST SESSION

The first session of the semi-annual meeting of the Council of the Michigan State Medical Society was held in the Detroit Athletic Club, Detroit, at 7:00 P. M., January 10th, 1922. The Council was the guest of Dr. F. B. Walker, Councillor of the First District, at a most enjoyable dinner.

Present: Chairman, W. J. DuBois; President, W. J. Kay; Treasurer, D. Emmett Welsh; Councillors, Southworth, Randall, Seeley, Holdsworth, Jackson, Clancy, Walker, Stone and Dodge; Secretary-Editor, F. C. Warnshuis; Chairman of the Medico-Legal Committee, F. B. Tibbals; Associate Editor, Guy L. Connor; Secretary of hte State Board of Registration, B. D. Harrison; Ex-Presidents, A. P. Biddle, Angus McLean; Delegates to the American Medical Association, A. W. Hornbogen and J. D. Brook; Chairman of the Committee on Civic and Industrial Relations, G. H. Frothingham and Dr. C. C. Slemons.

ANNUAL REPORT OF THE SECRETARY-EDITOR, 1921
To the Chairman and
Members of the Council.
Gentlemen:

It is once more my privilege and honor to herewith transmit to you and through you to our members my annual report as Secretary-Editor for the year 1921. Precedent, established for many years, exacts that in the submission of his report your reporting officer shall incorporate therein such comments and recommendations as his executive experience and administrative work may indicate. In making such comment it is desired that it be distinctly understood that the comments made or the recommendations advanced are formulated from a conscientious study of the progress of our organization, its activities, its ideals and its obligations to its members and the public we serve. They are based on our sixteen years of administrative medical work in this state, nine years in the House of Delegates of our American Medical Association and as Vice-Speaker and now Speaker of that National body. To suppress the harping critic or the disgruntled we frankly announce that we disclaim all semblance of dictatorship and that there are no concealed ulterior motives. If these years of service, always at the cost of personal sacrifice and financial loss, have produced no constructive results we can state with all frankness that we have sought at all times to remain free from personal ambitions and have ever been motivated by the sole thought of service.

Balance sheet setting forth in detail the assets and liabilities of the society as of the close of business December 31, 1921, is included in and made a part of this report, subject to the following comments:

Cash on deposit at December 31, 1921 was verified by direct communication with the Grand Rapids Savings bank and reconcilement of the balance reported by the bank with the book records.

All recorded cash receipts for the year ended December 31, 1921, were traced directly to the bank deposits and all recorded cash disbursements were found to be supported by cancelled bank checks, invoices or other data on file.

Accounts receivable were verified by trial balance of the individual accounts.

The inventory of paper is as reported to us by the Dwight Bros. Paper company, which is storing it pending the need for its use. The inventory has been valued at cost, which was identical with the market price at December 31, 1921. Securities owned, aggregating $5,500.00, as