anything until Dr. Travis took issue with the essayist with reference to leaving the string attached to the tube in the child's mouth. I agree with him that the child is much more comfortable if we remove the string, but unless I am able to stay in the house with my patient I do not remove it. I have never had but one child that did not chew the string in two if they could get it in the right place, and that was a fifteen months old babe. While I was called in consultation in another case, the tube became stopped up, and before a physician could arrive the child choked to

death.

The first case I ever had get well, after I began to do intubation, was a little fellow with whom I stayed almost constantly for about five days. When I left the house and left the string attached to the tube, I gave the mother instructions not to pull on the string unless the child had a severe spell of coughing, and she could see that it could not get its breath, then I told her to run her finger down the string almost to the root of the tongue, and lift it out gently in case severe coughing occurred. One night, at nine o'clock, I had to remove the tube, hoping to leave it out. At three o'clock in the morning, before I could summon assistant, the child became so cyanosed, that before the assistant could get there the tube was replaced by the grandmother holding the child and the mother holding the gag, and the child then began to get its breath nicely, and soon thereafter went off into a sound sleep, and in an hour or two I left the house for home. At nine o'clock, the house being about three blocks distant, my telephone rang, and I was asked to come at once. I ran all the way, and if I had not left the string in, I would have found my little patient dead. The membrane had become detached in a fit of coughing and had worked its way up into the tube as thoroughly as you could put a stopper in a bottle. The mother remembered. what I had said; the child became cyanotic, the mother introduced her finger into the mouth, raised the tube, and the membrane was so thoroughly fixed or pushed into the tube that it was as long as two-thirds of the little finger. I did not have to reintroduce the tube. I never use any force if I can help it. I never saw any membrane so detached as to give trouble; I have never met with the unfortunate occurrence in my own practice, and I hope I never will. I admit, however, that it is possible for such a thing to happen. In the case I reported yesterday, when a paper was read on diphtheria, I said that I kept a tube in a child's throat for six weeks. I know it was fully that long.

With reference to having a light to introduce the tube, I do not think it is of any particular advantage, because we introduce the tube largely by the sense of touch. 1 generally wrap the patient in a blanket or sheet, and have his head held straight or the least bit tilted forward with a gag in the mouth, and I do not know that it is so very important to always hold the tube just exactly in a perpendicular way, or that it is absolutely certain that the tube should be carried in a certain position. In the little patient I speak of, I introduced the tube at three o'clock in the morning, and the next afternoon when I went to see him, he had coughed it up just after I got in the house. I want to emphasize this point, that if we leave a string in the child's mouth, it is necessary to pinion the little fellow's arms for the first two or three days, after which time he will leave the string alone. When we are allowed the privilege of introducing the tube, having obtained the consent of the parents to do so, the child hardly ever resists very much. Parents hardly ever have it done until the child becomes cyanotic. That is one advantage of intubation over tracheotomy, that parents will allow you to do intubation when they will not permit you to do tracheotomy.

Dr. Cox (closing the discussion): It is rare that we have detachment of the membrane in these cases, and fear of this should have very little weight. Sometimes other things occur that are exceedingly rare, and we should not take them into consideration when the pressing issue is life or death from lack of air.

As to the removal of the string, I usually leave it in, largely for the reasons mentioned by Dr. Ross. The tube occasionally becomes obstructed and gives rise to a serious state of affairs unless the attendants can remove it. Children will attempt to pull on these strings for the first three or four hours. After that they hardly ever catch hold of the string. If you use a small string anointed with vaseline, it does not cause much annoyance.

As to the use of a light in cases of intubation, your indexfinger will nearly fill up the pharynx, and you cannot introduce the tube until the finger is displaced so as to lose some of its value as a guide; so that I have found it an advantage to have sufficient light to see that the tube is held true and in the median line.

My hope and endeavor is to arouse the general profession to activity along this line, to cause them to see the subject in its true simplicity and exceeding great importance, and not to intimidate and deter by enlarging on rare possible complications.

ABDOMINAL SURGERY, WITH CASES.

BY F. M. BRANTLY, M.D., SENOIA, GA.

Modera surgery has brought to the test, and dispelled many dogmas of the older schools of medicine, and given new impetus to that branch of science, especially to that region of darkness, included within the abdomen, whose innings were long regarded with sacred reverence The peritoneum is no longer regarded either as the Scylla or Charybdis, except by the plodding dogmatist. Although laparotomy has been successfully performed as far back as 1720, and was taught by Fallopius, yet it has been reserved to modern surgery to shed new and abundant light in that direction. Such men as McDowell, Batty, Lusk, Fowler, Skein, Pilcher and a host of others no less renowned, of our own country, and Lawson Tait, Sir Spencer Wells, and Sir Joseph Lister, of Birmingham and London, who have but recently taught us that laparotomy is no longer the dread of the surgeon. Mr. Tait's success has been so uniform that he does not hesitate to advise in all cases of doubtful character to "cut the patient open and find out." In his hands, scarcely one per cent. of cases prove fatal; he seems not to have the fear of spores or bacteria before his eyes as others do, but only observes strict cleanliness, and always uses pure water freely, while others, who take to the doctrines of Listerism, provide themselves with expensive spray apparatus, and freely use the thousandths bichloride or other spore destroyers, perhaps do not have better if as good success as the great Birmingam operator. With all these lights before us, why need the timid surgeon any longer imagine a bloody and difficult operation, with visions of peritonitis, and perhaps a death for which the operator may be held accountable, either by his own conscience or by the legal tribunals of the country? What surgeon is there who has any great experience, but has been brought face to face at times with grave intraperitoneal conditions demanding an immediate and positive diagnosis, and while palpating and percussing and concentrating his thoughts upon the tactus eruditis and groping in the dark, would fain look or feel inside but for the dread and timidity that he feels. So the question between a guess and a certainty is settled by his folly, perhaps at the expense of the life of his patient, or a provisional diagnosis on his lips and a tentative course of treatment in his mind. The day is at hand when the folly is on the side of the surgeon who does not find out. And here we find room and grounds for missionary work among the laity. It is a maxim in the law that the accused shall have the benefit of the doubt; even so should the afflicted have a like benefit. The surgeon who would stand quietly by and witness the agonies of a patient dying from para- or perityphlitis, intussusception or volvulus, or external strangulation, when he knows that an operation would be the means of rescuing him from death, feeling and knowing his responsibility must be conscienceless and callous, and a very coward and unworthy the title he bears, or ever feel remorse like Banquo's ghost that will not down at his bidding. Diagnosis, the sine qua non of success, is sometimes had too late, and often at great risk, but better late than never; early diagnosis has saved its thousands, while late or no diagnosis has lost its thousands. Our admiration knows no bounds when we consider the courage and skill of our countryman, the Kentucky pioneer McDowell, who