diagnosis. Both tubes and ovaries were removed, but were bound down by very strong adhesions; right ovary enlarged and cystic; left atrophied; tubes closed and fimbria destroyed. Irrigation with hot distilled water; drainage tube inserted; peritoneal toilet aseptic; recovery complete. Disease of the tubes was of gonorrheal origin. Length of incision was one inch and a half; three peritoneal and two superficial sutures. CASE 2. Mrs. W, white, aged about twentyeight years; pale; gives the history of constant pain over both ovaries; dysmenorrhea. Pain is increased by constipation, going up and down stairs, riding on the street cars, and by pressure, and has continued seven years. On digital and conjoined manipulation masses of considerable size were felt on both sides of the womb, much larger on the right than on the left side. Abdominal section was advised and accepted by patient. Pathological specimens removed; the tubes were thickened and shortened, closed; ovaries scirrhotic; there was also a cyst of right broad ligament, which was ruptured by breaking through the numerous adhesions. Glass drainage tube inserted; removed in twenty hours and a rubber substituted; peritoneal toilet, aseptic; origin of disease gonorrheal. Irrigation with hot distilled water; length of incision one inch and a half; recovery complete. CASE 3. Negress, aged between twenty-five and thirty years; has had disease of the uterine appendages more than three years, also the sequelæ. The disease dates from a former gonorrhea. Large mass on right side of uterus, and a smaller one detected on left side; on section the tubes thickened, closed, and hypertrophied; ovaries atrophied; cyst of right broad ligament; appendages imprisoned in firm adhesions were removed; peritoneal cavity irrigated with hot distilled water; drainage-tube left in twelve hours; peritoneal toilet made aseptic; length of incision one inch and a half. In all of these cases suction of the drainagetubes was practiced every two or four hours by hard, black rubber syringe with a long nozzle; recovery complete. Mrs. X, white, aged thirty years; has had cystitis three years; was an inmate in the gen eral hospitals more than a year, then an outdoor patient for months, though a cure was not accomplished. Under rest (irrigation of the bladder with hot and saturated solutions of boracic acid an hour at a time three or four times a day) Dr. Penrose made a vesico-vaginal fistula to aid rest and drainage. In the bladder was found an ulcer an inch or more in diameter; this and the bladder were coated with phosphatic deposits. Since the operation the bladder and vagina have been given complete rest and irrigated as already described. The cystitis was cured in three months and patient got to be a strong, healthy woman. The vesicovaginal fistula was closed by Drs. Penrose and Price. The edges were uniformly pared down to the mucous coat of the bladder at least half an inch in width. The opening was closed by twelve silk-worm gut sutures held securely by compressed shot. This material seems by far superior to silk or silver, and doubtless will be the favorite material for fistula in the future. The writer never witnessed an operation done with more ease, skill, and rapidity than this by these experts. Recovery was complete in ten days. The study and observation of these cases, with many other similar ones, will convince the practical mind how important and essential abdominal section is, and also prove the folly of attempting a cure by electricity of pus tubes, pelvic abscesses, and deformed appendages, encapsulated in strong and old adhesions; while to one who has seen the abdominal specialist and general surgeon operate,it is self-evident that the general surgeon should not do or should have special training in abdominal surgery before assuming its responsibilities. Specialists seldom make an incision over an inch and a half; it is the exception for them to see the abdominal contents; the tactus eruditus is developed to an almost marvelous ex tent. Hot distilled water is the only antiseptic used to irrigate the abdominal and pelvic cavities. Asepsis is pursued in all the details of the operation, both as concerns patient, nurse, operators, instruments, and assistants, and the room and contents. The specialist intrusts the details (before and after) during operation to no one, superintends every thing, sees his patient every few hours after the abdominal section to ascertain the condition of patient and prevent complications, and if the nurse is giving the necessary attention; does not give opiates, but gives the patient every chance to get well; makes short incisions, enters the abdominal cavity in one or two minutes, completes the operation in from six to thirty-five minutes (it is seldom an abdominal section lasts an hour); rarely uses more than two or three sponges, two three fourths of an inch apart, in his eagerness to get done he breaks one or more of the sutures in tying, lets the wound gape, takes a superficial suture or puts on a strip of adhesive plaster, but never replaces the broken peritoneal suture; besides, he has to use half to a dozen or more peritoneal sutures to close the wound in the abdominal wall. STANFORD, KY. BY T. B. GREENLEY, M. D. The character of the present epidemic seems to vary somewhat in its peculiarities from those prevailing heretofore. In the first place, it has spread more rapidly than any epidemic. we have a history of. It is not positively determined where it had its origin. From the best account we can obtain, it commenced at Kalomna, about twenty leagues southeast of Moscow, Russia, while others claim that it had its origin at Wassali, Ostrow, some distance southwest of St. Petersburg. Nevertheless, by the middle of October nearly one third of the population of the capital was smitten with the disease. This was within a few days after its appearance at the above-named places, and so rapid was its extension that by the middle of December it seems to have been epidemic in the principal cities and towns of continental Europe. hemastats, one bistoury, one pair of scissors, LA GRIPPE, OR EPIDEMIC INFLUENZA.* closes the wound with three peritoneal and two superficial sutures, irrigates with hot distilled water, and does not use, as a rule, sponges to cleanse the abdominal cavity. When necessary, he makes the most thorough drainage and prac tices the most complete asepsis from the purgation and hot water and soap bath before operation until recovery of patient. Shock from prolonged operation, etherization, and exposure of abdominal viscera is avoided. Nothing is left undone. The general surgeon makes the abdominal incision large enough not only for his hand but his foot, the specialist uses one or two fingers in the abdominal cavity, the general surgeon the whole hand for diagnosis and intra-peritoneal operation. He also opens the lips of the wound to the utmost, looks into the abdominal cavity with both eyes, plays "peek-a-boo," encounters a Cerberus or pathological condition that frightens him, and makes a hasty retreat and leaves patient to his fate and early death. The specialist would overcome the complication, if it were possible, and prolong the patient's life months or years, and would not open and re-open the abdomen several times to learn the patient's condition. The general surgeon enters the abdomen in from ten to thirty minutes, prolongs the operation and etherization one or two hours, allows the intestines to extrude, all of which increase the shock; besides, chemical antiseptics are used in the peritoneal cavity which are irritants; antisepsis is relied on for success, asepsis being scarcely considered, whereas if thorough asepsis was used antiseptics would not be necessary. After the general surgeon has dwelt specifically upon the importance of placing thoroughly in apposition similar tissues and uniting the peritoneal surfaces, the sutures having been introduced It made its appearance in Boston about the middle of December, and in a few days we had accounts of its presence in New York, Chicago, Omaha, and other places, seeming to take its course at first in a westerly direction. It is now prevalent over the United States as well as most of the western hemisphere. As before remarked, no epidemic that we have a record of ever made such rapid progress in its extension. It might be regarded as pandemic. In less than three months from the time it made its appearance in Russia it spread over the continents of Europe and North America. We have accounts of influenza prevailing as far back as the twelfth century. The last one *Read at a meeting of the Hardin County Medical Society, March, 1890. in this country was in 1873. In that year it seemed to affect horses more severely than the people. In some cities horses were disabled to such an extent that it became necessary to substitute cattle to do the hauling. The epidemic, however, was mild as far as it pertained to the people. We also had an epidemic of the so-called grippe, or influenza, in 1843. The writer resided in Louisville at that time, and well recollects it, having had personal experience of its effects. The prominent symptoms were those of common coryza, with severe bronchial irritation. The etiology of the disease seems to be somewhat shrouded in mystery. Some claim that it is due to a micro-organism, while others charge it to the unusual warm fall and winter just passed. When we study the rapid manner with which it has extended in every direction, making as rapid headway across the ocean as it does over land, and affecting large numbers of a population simultaneously without time of incubation, we must concede it can not be due to microbic origin. And as it frequently prevails in cold as well as warm weather, it can not be regarded as dependent on temperature. It is doubtless due to meteoric or atmospheric influences, but what changes or special conditions are necessary for its production perhaps will never be solved. Dr. Rauch, of the Illinois State Board of Health, is of the opinion that it may be caused by the high temperature and heavy rainfalls during the past fall and winter. These conditions may have had a tendency to cause its more rapid extension over this country; but as it is not essentially a winter disease, and as we frequently have as much or more rainfall during the spring and summer months without developing the disease, the past winter weather could not have been a prominent factor in its causation. It can hardly be regarded as being entirely due to conditions of the atmosphere, unless those conditions could be the same all over the countries where it may become prevalent. It seems to prevail independent of any special conditions, either hygrometric, thermometric, or barometric. Neither can it be of mias matic or telluric origin, as it has attacked ship's passengers in mid-ocean, where telluric influence would be out of the question. As before remarked, it has by some been regarded as being due to a species of bacteria that has the power to multiply rapidly in the atmosphere. It was recently announced that this specific organism had been discovered in Vienna by Dr. Jolles, but the British Medical Journal has received a dispatch from the doctor stating its falsity and giving a true statement of his experiments, upon which the editor of the Journal remarks: "We have now before us the original preliminary communication by Dr. Maximilian Jolles, the reputed discoverer of the microbe of influenza, and well might we exclaim, 'Parturiunt montes, nascetur ridic ulus mus!' After all, the dust raised about the discovery of the microbe of influenza vanishes into air on perusing the statements made by the discoverer himself." Several objections might be urged against this theory. In the first place, the same character of microbe would not be likely to multiply with equal rapidity in all countries and in all grades of temperature at the same time, as it seems the disease has no choice as to prevalence between extreme degrees of low or high temperature. In the second place, as before remarked, all known bacterial diseases have a certain time allotted them for incubation or latency; but in this disease large populations are attacked at once, allowing no time for communication from person to person. And in the third place, it would be a matter impossible for microbes to make headway, in their passage over the ocean, against contrary winds, sometimes blowing more than fifty miles an hour. Influenza, unlike some other epidemics, ignores all hygienic laws and observes no respect to sanitation whatever. It may be said it has no regard for persons or localities, and attacks high and low, rich and poor alike; in a word, it seems to be a democratic disease. Then the question may be asked, what is its etiology? This problem perhaps will, at least for the present, have to be relegated to those things which in our philosophy we are unable to account for. There has been, in many cases, one element prominently manifested, which no doubt was due in a great measure to the character of weather Dr. Roach describes. I allude to the malarial symptoms which seem to predominate in a majority of cases. As an insight to the character of the weather, I give a synopsis of the temperature, barometeric pressure, and rainfall during the winter months. For December: Highest temperature, 71°; lowest, 24°; average, 51.4°; excess during the month, 419°; greatest daily range, 27°. Precipitation, 1.74 inches; deficiency, 2.57 inches. Mean barometer, 30.70. January: Mean temperature, 44.8°; highest, 72°; lowest, 14°; greatest daily range, 35°. Rainfall, 5.73; excess, 1.48. Mean barometer, 30.70. February: Mean temperature, 46.5°; highest, 73°; lowest, 22°; excess, 220°; greatest daily range, 36°. Rainfall, 6.25 inches; excess, 1.77 inches. Barometeric pressure, 30.10. The excess of temperature for the three months was 963°, equal to 11° daily. The excess of rainfall for the three months was 0.68 inches. (See Signal Service reports, Louisville.) These calculations are based on the mean temperature, rainfall, and barometric pressure of the same month for the past seventeen years. The temperature shows a daily average of 11° above, making the past winter the warmest in this latitude of any within the recollection of the oldest inhabitant. In fact, it has not been sufficiently cold to destroy any malarial influence that may have existed last summer and fall. On this hypothethis we can readily account for the cases of intermittent and remittent fevers that have occurred in the mean time. If my recollection serves me correctly, the epidemics of 1843 and 1873 were milder in character than that of the present. They were not so generally in their effects accompanied by such severe neuralgic symptoms nor fever of such pronounced remittent type. The former occurred in June and the latter in October-seasons of the year when we should have had as much or more of the malarial element manifested. To be sure, a great many during the present epidemic have had very mild attacks, hardly severe enough to cause them to take bed or call for medical assistance. As a rule, when the disease occurs only as a coryza, affecting the throat and upper air-passages, it is usually treated with domestic remedies. It observes quite a broad latitude, as far as severity of symptoms. is concerned. It may be as mild as an ordinary cold, with slight aching pains through various parts of the system, or as severe as an attack of remittent fever accompanied with the most intense neuralgic pains. These pains sometimes affect the head, sometimes the lumbar region, and sometimes the other parts of the body. We frequently have severe aching in the lower extremities, and occasionally very severe intercostal neuralgia. This character of pain, in many instances, has been so intensely severe as to cause some writers to regard it in the light of dengue fever. These pains, like the fever accompanying them, are generally remittent in character. It would seem that this epidemic has exerted an unfavorable influence, as regards lung trouble, in both bronchitis and pneumonia, both diseases being more prevalent, especially in cities, and more fatal in character. The mortality in these diseases in Louisville. has been greater than usual in the last few weeks, while, strange to say, that from consumption has been materially less. It would also seem that it has a deleterious impression on old people and those of delicate health. A great many old people have died, especially in cities, since the influenza became prevalent. Whether it has influenced the increased mortality of other diseases outside of those mentioned, we have no record; but we notice the daily mortality lists in some cities, more particularly Boston, New York, and Chicago in this country, and Paris and St. Petersburg abroad, have been greatly lengthened. In Chicago for a short time the usual daily mortality was more than doubled. Another peculiarity of this epidemic is, that the least exposure after a supposed recovery is apt to produce an attack of bronchitis or pneumonia. Two cases of very severe attacks of bronchitis have come under my observation from this cause. I am of the opinion, from observation and from what I can learn from others, that the type of the diseases alluded to is unfavorably affected by the cause of la grippe. Persons affected with this disease seem to suffer from nervous and muscular prostration out of proportion to the severity of the attack. This also may be regarded as a peculiarity attached to the epidemic. As to the management of the disease, I can not say that I have had a large experience, not more than thirty cases having come under my observation. In the country I do not regard it a dangerous disease when we can have the patients properly cared for. There is such a great variation in the manifestation of symptoms in different cases that no special treatment can be laid down that would be suitable in its treatment. In the mild cases, which perhaps constitute the majority, it should be treated as a simple coryza; say at night a full dose of quinine and Dover's powder (quinia, pulvis Doveri, āā grs. v), keeping the patient in bed next day; and as a rule he is relieved. A case assuming the remittent type of fever, with more or less neuralgic pain, would require the same prescription repeated at intervals of four hours, and if the temperature exceeds 102° add grs. iij to grs. v of acetanilide. This plan I have found to break up the trouble in twenty-four to fortyeight hours. Should the supraorbital pain be severe, a small folded cloth wet with aqua ammonia should be applied to the part and well pressed against it for one minute; this may be repeated when necessary. Should the patient from imprudence take pneumonia or bronchitis as a sequela, of course treatment must be used adapted to the case in hand, but at the same time it must be recollected that great debility, especially of the nervous system, follows influenza, which should modify the ordinary treatment for those dis eases. The treatment as advised by various writers differs in some particulars, some recommending the free use of alcoholic liquors with quinine and antipyrin, while others object to the use of alcoholics. I have seen no case wherein I thought alcohol would do good; of course, were I called to an inebriate with this disease I would not withhold his dram; and as to antipyrin, I would be somewhat apprehensive as to its use, owing to its usual depressing effects; nor would I advise as large doses of quinine as some recommend. My special objection in this regard also applies to large doses of antipyrin on account of the general debility resulting from the disease. Influenza, in the estimation of some observers, is in some way allied to epidemic cholera. This opinion doubtless grew out of the fact that it has occasionally preceded that malady in its prevalence over Europe. This has more particularly been the case in Russia. So much are the profession of that country impressed with the probability of its following in the footsteps. of the present epidemic that the authorities are about instituting measures in the way of quarantines, etc., to prevent its visitation. The facts in the case of cholera following influenza are no doubt altogether incidental, and the two diseases bear no relation to each other as cause and effect. WEST POINT, KY. Correspondence. PARIS LETTER. [FROM OUR SPECIAL CORRESPONDENT.] One is always interested in the phenomena of somnambulism and hypnotism, but never so much as at the present time, science having at last dispossessed charlatans of the study of these phenomena, which had been too long relegated to them. Professor Charcot has contributed in a great measure to place the subject in its proper light. In a very interesting lecture on this and allied subjects, lately delivered by him at the Salpêtrière Asylum, he began by stating that he must acknowledge that he was wrong in disdaining for so long a time, and of abandoning to empirics a whole domain of facts which he repulsed, as he was unable to explain them in a satisfactory manner; that he was even obstinate to deny them, for the simple reason that he did not understand them. He next endeavored to determine the psychological character of the state of somnambulism, this character being the abso |