imperative, and five drops of croton oil were given at once. I have tried calomel and almost every thing else without benefit, and latterly have used croton oil with excellent results.

Improved Instrument for Operation upon the Tonsils. Dr. S. G. Dabney: Some time ago I read a paper before the society on the subject of diseases of the tonsils, and I think we are all agreed upon the importance of severing adhesions of the tonsils to the pillars of the fauces, which is sometimes not easily accomplished. We are all also agreed upon the importance of surgical treatment of deep-seated affections of the tonsils, of opening the follicles and thoroughly evacuating their contents, and it has then been proposed that we apply the actual cautery.

These little knives which I show you, one for each side, were devised by Dr. Leland, of Boston, as being very useful for these purposes. I have tried several, and believe these to be the best yet invented. I have in the past had some made after patterns of my own, but those devised by Leland are better than any that I have seen.

In a letter from Dr. Leland he suggests a point that I think may perhaps be of some practical use, that is in certain cases of quinzy, which we know is nothing more nor less than peritonsillar abscess, we can evacuate its contents earlier by the use of a knife of this shape going up through the upper portion of the tonsil than by any other means. We occasionally see in cases of quinzy a drop or two of pus oozing down on to the tonsil, and it is advisable to get a free opening as soon as possible. We usually have to wait a few days before we can evacuate the abscess, and then open above and outside of the tonsil. I have not yet tried the knives for the purpose of making a more speedy evacuation of the pus from the quinzy abscess by making an opening at the side, but have tried them for severing attachments of the tonsils to the anterior pillars of the fauces and find them exceedingly useful, and also for opening deep-seated follicles where the tonsil is small in size, but where it is the source of considerable irritation to the throat.

In lieu of a regular essay Dr. A. Morgan Cartledge made the following remarks:

Gall-Stones: Operation under Hypnosis: Osteo-Myelitis: Operation for Tumor of the Breast. 1. The first case has no special interest except to illustrate a peculiar collection of gall-stones. It seems that I am fortunate in getting a great variety of composition and conforma

tion of such calculi. In my collection I have many large and small stones, but none like those I present to-night as regards color; these look almost like mother of pearl.

The patient was a woman who said she was fifty-six years of age, although I am sure she is sixty-five, operated upon eight days ago, with the history of having passed gall-stones and having had biliary colic for ten or twelve years. In the last six or eight months she suffered a great deal of pain in her right side, and six weeks ago became so ill that she had to remain in bed. Fever developed, as did also a large tumor in the right side of her abdomen extending down into the iliac fossa. She was brought here in that condition, the tumor extending up underneath the border of the ribs and could also be felt in the right iliac fossa.

Diagnosis was made of greatly inflamed and distended gall-bladder with probable suppuration, and operative measures advised.

Another interesting feature about the case was the condition of the patient, that is her heart. There was a marked intermission, sometimes as much as three beats, and the heart volume was very weak; there was also considerable dyspnea at times, and it was a question whether it was advisable to give her an anesthestic. The patient was emaciated, anemic, there was great pallor of the skin, and general weakness, and altogether her condition was unfavorable. I first thought that the gall-bladder was adherent, and perhaps I could use local anesthesia (Schliech's solution) and open the gall-bladder, drain it, removing the stones and pus if any present, which I felt certain there was; but after more careful examination I decided that the gallbladder was not adherent. I could move the abdominal wall over the mass, proving that there was no fixation, and I left the question of anesthesia to Dr. Bullitt, who was with me as the anesthetist. He thought he could give the old lady an anesthetic, but the sequel proves that he did not.

Dr. Bullitt went out to give the patient the anesthetic, and when she was brought into the operating-room I noticed the doctor was conversing with her constantly, but told me to go ahead with the operation. I did so, making quite a long incision, as the tumor was large, and immediately isolated the gall-bladder which was greatly distended; it was brought up into the abdominal wall, opened in the usual way, and stitched to the abdominal parietes, these calculi were removed, the sac irrigated thoroughly, the abdomen being completely relaxed. The

old lady threw up her hand once during the operation, but immediately became quiet upon being assured by Dr. Bullitt that I was simply scratching her with a pin. The operation lasted thirty-eight or forty minutes, and when finished the old lady's complexion was rosy and she was perfectly conscious, Dr. Bullitt having been talking to her the entire time. When told that the operation was completed, she was very much surprised and thought we were trying to fool her as she knew nothing about the operation having been in progress. I think we can very well claim that this was an operation done upon the gallbladder under the influence of hypnosis; a long incision was made, the gall bladder incised and evacuated, then stitched to the abdominal wall with five sutures, without the slightest evidence of pain or shock.

I desire to call especial attention to the condition of the heart in this case, and ask whether it has been the experience of other surgeons to find an intermittent heart action in patients who have suffered with biliary colic. I have several times seen patients, the subject of biliary colic, who had suffered great pain, have the most marked heart disturbance of this kind, intermittent pulse, three cases that I can call to mind now, without any valvular lesions. One was a woman who had otherwise a strong heart, but she suffered intense pain in the heart at the time of the attacks of biliary colic, with an intermission which was most marked. Whether or not the situation of the pain, near the celiac axis, whether the diaphragm pressing directly upon the pneumogastric nerve would produce this irregularity after repeated attacks is a question to be settled. Certainly my limited observation leads me to believe there is something in the development of cardiac irritations by intense pain consequent upon biliary colic on account of the location of the pain, especially in repeated attacks.

I will leave it for Dr. Bullitt to discuss the question of hypnosis. Certainly I consider that this is a case in which a capital operation was performed under this influence, as he practically gave the woman no anesthetic.

2. The next specimen is the entire fibula representing an advanced state of osteomyelitis. The patient was a boy, aged thirteen years. His present trouble approximately commenced eighteen months ago. It was at first thought that his left ankle was sprained, but he gave no history of trauma. Finally history as to tuberculosis negative. Pain, heat, and swelling were at first present, but the boy was

led to consult a surgeon for a small abscess which occurred at the ankle. Later inflammation occurred higher up the leg, and spontaneous openings followed which discharged considerable pus. There was no pain in the ankle, and the boy came under my observation on account of the continued formation of pus which discharged at the numerous openings.

Operation, April 21, 1898. This boy had numerous open sinuses, when I first saw him, on the outer surface of the leg (left) which corresponded approximately to the openings which you will observe in the bone presented. I did not probe the bone before the operation, for it was certain that we had to deal with a necrosis of the fibula. A longitudinal incision was made quite the entire length of the bone, and it was enucleated and removed.

Now an interesting question will come up in this connection, that is the possible reproduction of bony structure, etc. The operation was done carefully, leaving the periosteum intact, and of course we know that we will get bony reproduction where the periosteum is left. In this case, however, we can hardly expect to get any longitudinal growth of bone because the epiphyses were removed. I could not get my own consent to even leave a portion of the head of the bone at the ankle; one of these sinuses entered just at the external malleolus, and, as you will see, necrosis exists at that point, so it was not worth while to leave this part of the bone intact, therefore it was entirely removed. I call particular attention to this as the surgeons present might be inclined to criticise the operation upon the ground that the epiphyses should have been left undisturbed. Another point which might be raised is, that the bone might have been grooved and an attempt made to remove the sequestra which was within the involucrum, and this was considered at the time of the operation, but as the entire bone seemed to be involved in the necrotic process, I decided that the wisest plan was a complete excision.

3. The third specimen I am sorry does not show in its present state as it did in life. I wish you could have seen and examined the tumor when it was in situ. It is a breast removed from a patient a few days and presents many features of extreme interest to me. Ordinarily there is little to be discussed about tumors of the breast because they are so uniform in their histological structure and in their pathological significance. There is, therefore, usually little to be discussed except the methods of operative procedure.

The patient is Mrs. H., aged forty-four years, well developed and well nourished. About two years ago in lifting a heavy stove she bruised her left breast. Early last summer a small area of irritation was noticed at the site of the bruise which occasionally gave rise to some pain. Four months ago a small furuncle developed just below the nipple which soon broke down and discharged; following this four or five other furuncles developed, the last two weeks ago, each in turn discharging; the breast became very much swollen, inflamed and painful.

The family history is negative as regards tuberculosis or cancer. Operation, April 20, 1898. Several enlarged glands found in the axilla, others not perceptibly involved. These glands were very smooth and easily enucleated; they have not become matted to the tissues, and are not so much indurated as we ordinarily see in carcinomatous glands about the axilla. From the appearance of the specimen, and from the clinical history, we would at once say that this is a case of suppurative mammitis diffusa, the glandular area becoming involved secondarily; but I am sure, if you will take the breast up between the thumb and fingers, it will give you the impression of malignancy. You observe that there are numerous sinuses at the site of the numerous furuncles, many of them discharging a yellowish watery fluid, and beneath all this there is a hard mass which will give you the impression of nothing. else except malignancy, although later developments show that the case is one of diffuse mammitis. The hard mass which can be felt is probably inflammatory in character. I take it the indication for removal of this breast was just as great as though it had been the seat of malignant disease, and am free to confess that in an examination. before the operation it gave me the impression of malignancy. I am also aware that many surgeons have made an incision expecting to remove a cancer of the breast and have cut into an abscess. In this case there was marked retraction of the nipple, as you will observe by the specimen, and every clinical sign pointed toward malignant disease. You can see in addition to the retracted nipple several sinures which exuded a yellowish material, and in addition to that by turning the breast over you can see a large cyst. We can distinctly outline. the abscess cavity from which the exuded material came. In about the center of the breast is a hard mass of substance, probably inflammatory in character, which might easily be mistaken for a malignant growth. The glands which were removed from the axilla do not feel