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from thirty-five cases were inoculated into guinea pigs, and in seven instances the animals became tuberculous.

Eustace Smith believes that the infection is derived from the pharynx, as a rule, without tuberculous lesion of that part. In closing this paper, which I fear is already too long, I will state that inasmuch as we are not always able to convince the parents of the advisability of an operation, we are forced to try some other treatment. In these cases injec

tions are used.

Schwartz injected a solution of carbolic acid to destroy the tendency to develop.

Reboul reports forty-seven cases treated by camphorated naphthol.

In these cases the glands were hard in eighteen cases, softened in twenty-four, and ulcerated in five. Of the fortyseven cases twenty-eight were cured and nineteen improved. The treatment is reported as harmless and seems to act beneficially both on local and general conditions. The mixture consists of:

Ry naphthol

Camphor āā 10 grams
Alcohol 60% 40 grams.

This is injected with antiseptic precautions, a few drops here and there throughout the mass of enlarged glands.

Lannelogue recommends injections of chloride of zinc in order to transform the tuberculous tissues into a sclerotic mass. He uses two to five drops of a ten per cent solution. Many cases treated showed marked improvement.

Tincture of iodine has been applied on chamois at the negative pole of the galvanic battery while the positive pole was placed at an indifferent point. Six cells were switched on for eight minutes. Much improvement followed its application.

In this paper I have not included those cases which we often see which diminish upon the internal administration of remedies, but have referred only to such as go on to continued enlargement and progressive involvement or suppuration.

REMARKS.

APPENDICITIS: A SUPPLEMENTARY REPORT.1

BY NATHANIEL W. EMERSON, M.D., BOSTON, MASS.

This article is to continue and supplement one published in the NEW ENGLAND MEDICAL GAZETTE in September and October, 1898. It is a report of cases operated upon since that time, and carries on consecutively cases there detailed.

The writer hesitates to emphasize individual opinions, which in some instances are much at variance with those whose work and experience has warranted their writing with authority upon this subject. Individual and dogmatic assertions are very misleading; and in offering the preceding and following opinions upon this subject, and stoutly maintaining them, the assurance goes with them that they are the outcome of practical experience, and are not academical in character for the purpose of supporting any special line of opinion or belief.

Admitting that some cases are operative, and others are purely medical cases, and that many cases recover completely from a first attack under medical treatment - and I think there is no controversy over these statements as here made -the question is continually asked, How are we to tell which is the operative case, and which the one to recover under purely medicinal treatment? To this question one more should be added, How can we tell to which class any given case belongs? By much discussion of the subject, and continuous operating, and actually seeing and handling the appendix in its various stages of degeneration, we have passed a long way on the road to a better understanding, by the whole profession, of the various stages of appendicitis, and this occasion is taken to point out the fact that to the surgeon is due the accuracy of our present knowledge of what takes place in appendicitis. Yet with all our knowledge we cannot always answer correctly the above questions.

A. mistake is often made in intimating that those who claim that the best way to treat appendicitis is by operation

1 Read before the Hughes Medical Club at its February meeting.

do so because they are keen to operate. There is no satisfaction in the operation by itself, and the advocates of the operation are mainly those who see a crisis actually at hand or threatening, but who take the most efficient means so far offered to anticipate or completely control the crisis.

Everybody admits that if pus is present an operation is the best way out of it, but no man living can tell in any given case that pus will not be present. Too much stress is laid upon "dulness" as an indication for operation. Dulness may or may not indicate that pus is present; but in any event it is a sign of an advanced stage of the disease, and should not be awaited. If it is present, many other confirmatory symptoms will also be present with it, and there would seem to be little doubt as to what is the proper course to pursue; but the stage of dulness should be anticipated if the case is early enough under observation. No operator should have cases of dulness developed under his own observation, and should see them only as he finds them already developed. Therefore, the question is not how to deal with pus cases as revealed by well-developed dulness; they must be operated on and have become already questions for individual judgment and management of detail on the part of the operator himself.

Personally I believe that not one per cent of suppurative cases arrive at this stage without abundant warnings. The interpreter is not always at hand, but the warnings are always given in the form of recurrent attacks even of so mild a character that they are overlooked, or professional advice is not even sought.

True it is, previous attacks may have been so mild as to warrant hardly a proper diagnosis, yet had the interpreter been at hand they could and would have been read as warnings. In my earlier practice I was much in doubt about this. class of cases, but am so no longer because again experience proves that removal of the appendix cures the previous slight attacks, even if they had never gone beyond the stage of simple colic. No. 16 is a case in point. There had never been an acute attack of appendicitis. On removal of appen

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