to the economic importance of getting people out of the hospitals quickly. I wish to emphasize this point. Our hospitals at the present time are crowded. Nurses are scarce and are becoming scarcer as the war depletes their ranks. The withdrawal of physicians and surgeons from private practice will bring more people to the hospitals. The withdrawal of attending physicians from hospitals for the war will further complicate matters. It is then of the utmost importance to evacuate hospital beds as quickly as possible. I have roughly calculated what an economic saving the procedure of Dr. Shea's meant.

He saved approximately fourteen days on each case. As he had thirty cases the number of days saved is 520, roughly speaking, a year and a half occupancy of one bed in a hospital. You can readily see what an important item this would become to a hospital of 100 beds should we succeed in shortening the occupancy of all of our appendicitis cases to a nearly like amount.

DR. BILL (Bridgeport): I should like to emphasize one point that Dr. Shea brought out about operation. It is not a question of differential diagnosis; we all know how difficult it is in a great many cases to decide whether a case is appendicitis or one of a number of other things as Dr. Sullivan has suggested. The point is this, that after the doctor has made the diagnosis of appendicitis the thing to do is to have his case operated on, not to treat it medically nor to go home and wait two or three days to see if the thing will resolve. After the diagnosis is once made of appendicitis have it operated on.

DR. TAFT (Hartford): I want to congratulate Dr. Shea on his admirable paper. I was quite interested this noon in looking over some old statistics of operations in cases of gangrenous appendicitis, not acute catarrhal cases, but gangrenous cases and I was much startled at the mortality records. I found that in the first 100 gangrenous appendices which I operated on I had a mortality of fourteen per cent. In other words, I lost fourteen cases. In the last 100 I lost three. I then commenced to wonder just what there was about my former method of operating which might have produced that high mortality in the early stages of my operating career. As I looked back I found the amount of drainage material I put into the abdominal cavity was excessive. In the old days I was very fond of putting in what we called a big handkerchief drain and stuffing that with gauze. Some of my cases developed an ileusrather a large proportion. I didn't succeed either in shutting off as many cases of general peritonitis following the operation as I have in recent years with less drainage. I think, although I can't say this from statistics, that I had more shock and consequently a lowered resistance to infection following the greater degree of manipulation of earlier cases than I have

had recently. Lately it has been my custom to do away with gauze drainage as distinguished from tube or gauze wrapped up in rubber. Probably in the majority of cases to-day where I use drainage at all I use the so-called cigarette drain. I believe that in the vast majority of cases where we use a drain that if we use one fair-sized cigarette drain placed in the lowest point in the pelvis with the patient in the so-called Fowler's position, or something approaching it, that our cases do quite as well as where we used multiple drainage. That conclusion is arrived at from my own personal observation of cases rather than from the experience of other men.

I think the individual factor enters so largely into one's results or success that it is very difficult to lay down a standarized rule for operations. It has been my custom to remove the appendix in every possible case. I don't recall in recent years of but one abscess that I drained. That was a child and he had had an abscess for several weeks, perhaps a month, and that appendix I subsequently removed.

I don't believe it adds materially to the risk to tear apart tissues provided it is done carefully and provided the operator can operate by touch. I think it is essential in doing abdominal work to be able to separate your adhesions by touch rather than by sight. We ought to have an educated finger to do the work successfully. I believe we keep drains in too long. There may be cases where it is wise to keep them in eight or ten days, but I think I agree with Dr. Lampson as to the usual length of time they should be left in. I think the time should be shortened rather than lengthened. In some cases I take them out the second day. I don't know but as large a percentage of them get well if the drain is left in longer, but I wouldn't care to say they do. I believe I have been quite as successful personally in taking them out the second day. To-day I do not apply drainage to cases of gangrenous appendicitis where there is no pus. In some of those cases I put a drain through the abdominal wall down to the fascia. They get well far more quickly than when the drain is put down into the pelvis. I believe we are going to gradually do away with drainage except in a small percentage of cases.

DR. OSBORNE (New Haven): Just a medical word. Suggestion was made by the last speaker of less shock occurring now than formerly. Sometime ago we had everybody giving the anaesthetic. I believe that there is less shock now because of the greater care before the operation, the greater care after the operation, and the less amount of the anaesthetic. Also, when the patient is not knocked out that means his whole metabolism is better, his blood is in better condition to fight toxemias, his kidneys work better. I think these facts have a great deal to do with the better prognosis of surgical operations.

DR. SHEA (Bridgeport): Just a few words as to the fever noted in acute appendicitis. There is always a temperature sometime during the first twelve hours. I cannot recall a single case of acute appendicitis, coming under my observation, during the past five years, where there was no elevation of temperature. Usually the temperature ranges from 99.5 degress to 101.5 degrees. When you encounter an elevation as high as 103-105 degrees you better look elsewhere for the trouble.

As to the diagnosis, I wish to emphasize that it is the order of symptoms that enables one to make a positive diagnosis in practically every case, pain, nausea or vomiting; abdominal sensitiveness, fever and changes in the blood; that is the order in which the symptoms occur and if you will question your patient he will tell you that exact order of occurrence of symptoms.

To-day, in speaking of acute appendicitis, it should not be a question of mortality, but how long were you confined in the hospital. Nobody should die of acute appendicitis. If they do, somebody is at fault, either the doctor or the patient, more often the former. I think I might again repeat that an early operation lessens your patient's stay in the hospital eleven days; that is of certainly greater importance to the patient and surely a question of economics to our present overcrowded hospitals.

In speaking of drainage, Í did not say you could not remove them in three days, but I do say you must have more to go on, than the mere number of days they are to be inserted. You must follow a definite rule or key, and that key is normal temperature, active intestinal peristalsis and good bowel action. It has been our custom to gradually shorten the drains, taking four to six days for their entire removal, rather than completely removing them at the one sitting.

Tuberculosis of the Lungs with Especial Reference

to the Importance of Adenopathy.

JAMES A. HONEIJ, M.D., NEW HAVEN.

In general with tuberculosis of the lungs emphasis should be laid on two types of cases (1) early tuberculosis with positive clinical findings, but which upon radiological examination show greater involvement than the signs and symptoms would lead one to suspect; (2) advanced tuberculosis with signs and symptoms which are masked or difficult of interpretation, but which give the general impression of advanced tuberculosis. There is a third type of case, in reality not a true pulmonary tuberculosis, which presents no definite signs, but usually shows inflammatory changes, mainly around the hilus and in the peribronchial tissues. The latter should be included among reportable cases, for parenchymal involvement may follow. The diagnosis is dependent chiefly upon the shape and size of the chest, the shallow breathing, the small movement of the diaphragm and the inflammatory changes. Such cases, especially when they show glandular involvement, should be classed as early cases of tuberculosis.

From a roentgenological point of view tuberculosis may be divided into parenchymatous and peribronchial tuberculosis. The latter type deserves consideration especially because it is often associated with tracheo-bronchial gland involvement, though it is also true that with rapid, acute pulmonary tuberculosis the glands often enlarge and sometimes become an index of the acuteness and duration of the attack. All the classical clinical signs occur in parenchymatous more frequently than in peribronchial tuberculosis. It is also noteworthy that greater accuracy of diagnosis obtains in pulmonary cases where the process is unilateral; and this is particularly true, if there is no gland involvement.

Naturally tuberculosis of the hilus region-which means tuberculosis of the lymphatics and glands-affords fewer clinical

signs than does pulmonary tuberculosis. In the examination of children for tuberculosis, notwithstanding many well described signs aimed to secure accurate diagnosis, the question of the extent to which the glands are involved is always difficult to answer. For the moment we may assume that if there is fever and the ordinary physical signs are insufficient to warrant the diagnosis of pulmonary tuberculosis, the involvement of a group of glands is responsible for the symptoms-but this is not a diagnosis.

In adults, tracheo-bronchial adenopathy is not uncommon and I have been particularly interested in the question, whether it affords sufficiently early and adequate evidence of pulmonary tuberculosis, and, if not, what is its significance. Now, experience teaches that swelling of the lymph glands is characteristic of primary, not of advanced tuberculosis. Furthermore, a diagnosis of tracheo-bronchial adenopathy is of considerable importance in children; not only in infants, but also in children to the age of ten or more years, because in the large majority of children the lymph nodes are tuberculous and pulmonary tuberculosis frequently is associated with gland tuberculosis.

Two types of hilus involvement are recognized: (1) a definite pulmonary, peribronchial and gland tuberculosis, and (2) hilus gland and tissue involvement without indication of pulmonary tuberculosis. The first is best illustrated by cases of unilateral, definite parenchymatous tuberculosis; the second by cases in which the hilus region has become affected before signs appear in the parenchyma, though later pulmonary changes develop and may be readily diagnosed.

Obviously, then, from a pathological point of view the hilus region is important. A number of investigators have shown that frequently the earliest lesion occurs in the hilus glands and later they are affected more intensely than the lungs. Thus Ghon states that alterations in the lymphatic glands of children are never absent on the side of the lung focus; and Parrot, on the basis of post-mortem material, says that the primary lung foci in children are practically always accompanied by tuberculous changes in the lymphatic glands adjoining the lungs.