Society Reports. NEW YORK ACADEMY OF MEDICINE. Stated Meeting February 21, 1895. JOSEPH D. BRYANT, M.D., PRESIDENT, IN THE CHAIR. Discussion on Amputations: A Statistical Study of Seven Hundred Cases from Eight Hospitals of New York City. Topics: Mortality, Gangrene of Flaps, Secondary Suture, Drainage, Dressings, etc.-The discussion was introduced by short papers upon the several topics named, by Drs. J. F. Erdmann, H. Lilienthal, F. Torek, P. R. Bolton, C. C. Carmalt, and S. Tousey. DR. B. F. CURTIS, Chairman of the Section on Surgery, under whose auspices the meeting was held, said that the subject of amputations had been chosen for discussion in preference to abdominal surgery and some other topics, because of its more general practical importance. The original object had been to collect statistics of the city hospitals in their bearing upon primary union of amputation wounds, and union with or without sinus, and only incidentally upon the mortality-rate, etc. DR. ERDMANN's paper showed that of 703 amputations in eight city hospitals, forming the basis of his and the other papers, there had been a total mortality of 109, or 15.5 per cent. These were divided as follows: Of the wrist, 7 cases, no deaths; of the forearm, 74, with 1 death; of the elbow, 6, no deaths; of arm, 88, with 16 deaths; of the shoulder, 24, with 6 deaths; of the foot, 64, with 5 deaths; of the leg, 156, with 19 deaths; of the knee, 46, with 6 deaths; of the thigh, 223, with 48 deaths; of the hip, 18, with 8 deaths. The general mortality, therefore, was 15.5 per cent. In 31 cases death was due to general shock ; 51, to septicemia existing previous to the operation; 18, to constitutional causes; 27, to operative shock; 1, to secondary hemorrhage; 3, to sepsis following the operation; 3, to complicating nephritis or pneumonia; 1, to poisoning with bichloride. Under fresh or primary cases there were 270, with a mortality of 21.4 per cent.; non-primary or old injuries and disease, 433 cases, mortality of 11.7 per cent. Dr. Erdmann then divided the cases into those operated upon between 1884 and 1889, and those operated upon between 1889 and 1894. The fresh traumatic cases showed an improvement in the mortality during the last period of five per cent. These statistics were then compared with some given in The Lancet and with those reported in the MEDICAL RECORD recently by Dr. Estes. The great superiority of the latter was to be accounted for in part by the fact that they were in a degree select, and also by the younger age of the patients. DR. HOWARD LILIENTHAL stated the results as to gangrene of the flap, by which was meant extensive sloughing or marginal necrosis. The latter, marginal necrosis, was not opposed to good surgery. Of 367 cases where the flaps consisted of skin alone, 69, or nineteen per cent., sloughed in whole or in part, while of 216 cases of musculo- cutaneous flap, only 41 sloughed, or nineteen per cent.-showing the comparative advantage of the musculo-cutaneous flap as to vitality. The skin flap was also found to be more easily killed by sepsis. The statistics showed further that constitutional disease was a frequent cause of flap necrosis. Great judgment was required in deciding as to the viability of tissues through which amputation was done. The tendency to flap gangrene was greatest below the knee. Musculo-cutaneous flap was to be selected wherever possible. DR. TOREK had found that out of the 703 cases secondary suture had been employed in 37 ; in 20 of them the wound was closed in forty-eight hours; in 17 later. DR. P. R. BOLTON, writing of drainage and dress- The question of whether drainage should or should not be employed must be decided in most cases by the disease or injury for which amputation was performed. It could be dispensed with in many cases of amputation for tumor, also in some cases of joint disease, trauma, etc. DR. C. C. CARMALT had found details with regard DR. S. TOUSEY read regarding shock and other in cases with shock of like degree, but treated only three or four hours before amputating. The other subject which he had studied at Roosevelt was the circumstances affecting the frequency and duration of sinuses. Age had little to do with it, while the site of the amputation had a great deal to do with it. Sinuses occurred oftenest in amputations of the upper extremities, especially at the shoulder, but the duration was greater in the case of the lower extremities, and greatest of all in the foot. It made little difference in the duration whether bone-tube or rubbertube were used for drainage, the advantage being a little on the side of rubber. The age of the patient had much to do with the mortality. General Discussion.-DR. CHARLES MCBURNEY was asked to open the general discussion. The subject, he said, was too vast to attempt to cover it in a systematic manner. Therefore, he would refer only to a few points suggested by the papers. He thought the mortality at present would be much smaller compared with that of ten years ago, if amputation were done as frequently. With improved antisepsis, etc., surgeons now tried to save many limbs severely injured, which some years ago would have been sacrificed at once. The speaker seldom saw gangrene of the flap. It was not infrequently due to bruising and injury inflicted by the operator, especially when the flap consisted of skin alone. Particular attention should be given to the condition of the circulation at the proposed point of amputation. If it were in a doubtful state, amputate higher. If the foot were gangrenous one could easily tell whether it were safe to amputate at a given point by making a transverse incision and observing whether hemorrhage followed. If not, the circulation at that point was poor, and one should go higher. Dr. McBurney was in accord with what had been said with regard to the value of secondary suture in decreasing the mortality. He would include it under the head of drainage. The only objection to drainage consisted in leaving it too long. If the wound were aseptic, the tube ought certainly not to be left in longer than forty-eight hours, probably not longer than twentyfour hours. Much could be said with regard to shock. A loosely attached limb could be snipped off with the scissors, the wound treated by open tampon, the patient allowed to go without further traumatism until shock was recovered from, secondary amputation being done later. He had saved several patients by pursuing this course when primary amputation would probably have ended fatally. In the speaker's opinion, many cases of shock, so called, were cases of hemorrhage. The amount of blood lost was a matter of very great importance, and one should, at a very early period, make use of active measures to overcome its bad effect. For this purpose he had found of greatest value hot saline solution thrown into the blood-vessels. The infusion might be made before, during, or after amputation. A quart or quart and a half of normal salt solution could thus be injected. Point for Amputation Determined by Esmarch's Bandage.-DR. L. A. STIMSON thought it not unlikely that the greater mortality attributed by one of the speakers to waiting twelve hours or longer on account of shock was due, not to the waiting, but rather to presumably greater severity of the injury in those cases. He had been taught by Dr. Van Buren not to amputate during shock; that amputation would be safe as soon as the temperature began to rise again from subnormal. We owed much to Dr. McBurney for calling attention to the value of injections of saline solution. Regarding necrosis of flaps, he had seen many cases at the Chambers Street Hospital and elsewhere in which doubt existed as to the vitality of parts through which it was proposed to amputate, and he had found the best means for determining that point to be the application of the Esmarch bandage three to five minutes. After its removal there would be a blush in the blanched healthy skin not seen in the diseased or non-vital portion. Follow the outline of the parts which had been white. The knife should be carried down close to the fascia in all skin flaps, as it increased the chances of survival of the flap. Loose suture and snug bandage would give all drainage required in most cases, thus doing away with the drainage-tube and with the necessity for change of dressing called for by other plans. DR. ROBERT ABBE emphasized a few points, the first being the importance of using muscle and skin flaps instead of skin alone wherever possible. The skin flap sloughed because of tendency to fall in folds and because of pressure on harder parts. Another point was the value of deep-buried suture in muscle over the end of the bone. Regarding drainage, he had been surprised that so much had been said about sinuses resulting. There might be a little sinus for a while, but this was unimportant, while drainage was very essential. As to gangrene, it was apt to occur in amputations through the foot, because bone immediately underlay skin, whereas, in amputations where muscle as well as skin and subcutaneous tissue overlay the bone, there was better nutrition. Besides, amputations through the middle of the foot did not leave a serviceable limb because of painful scars, etc., and it was better to cut through the lower third of the leg if possible, or through the lower third of the thigh, points at which instrument-makers found it possible to apply the most serviceable artificial limb. Amputation through the lower third of the leg was to be preferred even to Symes's amputation, although this gave an admirably bearing stump. He thought shock was due largely to hemorrhage. DR. F. H. MARKOE thought the cases divided themselves into two classes naturally-amputation for traumatism and amputation for disease; again, into amputation for septic conditions and for non-septic conditions. In non-septic conditions amputation should be done through healthy tissues and the wound closed. By using buried suture, accurate apposition, and careful dressing, he had had no occasion to regret omitting drainage. In traumatic cases he agreed with Dr. McBurney that we should cut away waste tissue and wait until after shock had passed before amputating. In certain of the remaining cases gauze drainage might be used twelve to thirty-six hours, and in the others secondary suture and tamponade. DR. F. W. MURRAY thought it had been definitely shown that since the introduction of antiseptic surgery the mortality from amputations had been decreased, and it was destined to be decreased still further. He always drained the first twenty-four or forty-eight hours. He had great faith in secondary suture in certain cases. He, too, had had opportunity to save the lives of several patients by hot saline infusion. It was very necessary in amputations to shorten anæsthesia as much as possible, and this was one important reason for using tamponade and secondary suture. Drainage or no Drainage.-DR. B. F. CURTIS said it had been hoped to show the comparative advantage of drainage and no drainage in amputations, but a fair conclusion could hardly be drawn from the statistics given, since drainage had been practised in over five hundred cases and omitted in only about fifty. With drainage there had been absolute primary union in thirty-seven per cent. of the cases of amputation of the upper extremity, thirty-three per cent. of the inferior extremity, or thirty-four per cent. altogether; and primary union including sinus in seventy-two per cent. of the upper extremity, fifty-five per cent. of the lower extremity, or sixty per cent. altogether. Against this, without drainage there had been absolute primary union in sixty per cent. of amputations of the upper extremity, seventy-one per cent. of the lower extremity, altogether sixty-seven per cent.; and primary union including sinus, in seventy-three per cent. of amputations of the upper extremity, seventy-seven per cent. of the lower extremity, or seventy-six per cent. altogether. Dr. Curtis thought New York surgeons did not appreciate as much as they should the advantage of getting rid of drainage, since it would exclude danger of introducing sepsis with the drain, and again with the second dressing. While a sinus, usually due to the drain, might not be serious, yet it was very disagreeable, and kept the patient in the hospital for days when the space was desired for new patients. One cause of gangrene of the flaps had been cutting them too short, so that there was tension on the sutures which held them over the ends of bones. He did not think all would agree with Dr. Abbe in his condemnation of amputations through the foot, especially in workingmen, who could not meet the expense of renewing costly artificial legs. There should be improved methods of keeping records of cases in our hospitals. Some important details were lacking in these statistics. NEW YORK COUNTY MEDICAL ASSOCIA TION. Stated Meeting, February 18, 1895. S. B. W. MCLEOD, M.D., PRESIDENT, IN THE CHAIR. Annual Address by the President. - DR. MCLEOD chose for the subject of his address, "The Place and Influence of the Medical Profession in the Progress of Civilization." His remarks referred not alone to members of the profession, but equally to many outside the profession who had done much to further its efforts in elevating the human race. Among these were Benjamin Franklin, Stephen Girard, the Vanderbilts, and many others. It was not easy to define the word civilization. While in its full sense it meant advancement, yet it was attended by certain disadvantages unknown in the savage or uncivilized state. Some of these were the accidents attending the introduction of the industrial arts. The profession was called upon to treat the injuries resulting from railway travel, to cope with the spread of contagious diseases through modern facilities for travel. The organization of a meteorological bureau and the establishing of boards of health were features of modern civilization, and promised much for the promotion of human health and happiness. The question might well be asked, what next should engage our attention, and how with our improved means were we to meet our present responsibilities? A few of the many questions of lively interest were, the eradication of tuberculosis; prevention of spread of disease in schools; greater widening of the field of usefulness of orthopedics; the further perfection of electro-therapeutics; prevention and treatment of ophthalmia neonatorum; should criminals by heredity be unsexed; improvement in relation to expert testimony. Dr. McLeod referred also to the prosperous condition of the Association, and said it was a duty and a pleasure to enter upon the new year with energy and determination in the purpose to consider such subjects as were practical and calculated to improve the profession and promote the public health. The great work accomplished by the late Dr. William Detmold, the first president of the Association, was placed before the members, young and old, as a most worthy example. The Neuroses of Women.-DR. T. J. MCGILLICUDDY read a portion of a long paper which he had prepared on this subject. Every woman, he said, suffered more or less, and many almost constantly, from functional derangements of some of the organic structures of the body. Many simple deviations from the normal were really precursors of conditions of a most serious nature. But calling them minor ailments, there was still every reason to investigate them, because of their great frequency and the important bearing which they had upon our success as practitioners. Our first duty was that of healing, and not altogether that of trying to solve scientific problems. Old ladies and lay persons generally were loud in their praises of irregular practitioners, simply because they had given attention to their minor ailments. Among the more important of these lesser derangements were the reflex neuroses. Some seemed to consider them insignificant, and some even appeared to doubt their actual existence. By the generic term neurosis was meant a hyperesthesia or disturbance of the nervous system which simulated disease in an organ that was healthy, or without evident lesion of any of its parts. It might be general or local. The specialist who saw such patients must have the knowledge of the general practitioner, otherwise many mistakes would be made in diagnosis and treatment of chronic ailments. If the confiding and unsuspecting patient with a run-down constitution, the result of anxiety, bad air, and a worse diet, and with a headache and some abdominal or uterine symptoms, should stray into the office of an enthusiast in ocular tenotomy, he would probably want to relieve her distress by dividing the rectus muscle for eye-strain. If, however, she should strike a surgical gynecologist of a certain class, a symptomatic uterine catarrh, an unoffending laceration, or a harmless, retiring cystic ovary would be pounced upon by this enlightened specialist, and receive most vigorous treatment; and if he did not always carefully sterilize his instruments he would probably succeed in sterilizing his patient. Or her destiny might lead her into the office of a digestive specialist, who, of course, would diagnose stomach trouble as the cause of all her ills, and proceed to lower several feet of rubber hose into her surprised stomach and treat that organ to a wholesome bath. If our specialism was allowed to run into exclusivism, very shortly the only safe man for a patient to consult would be the old-fashioned general practitioner, with all his faults and deficiencies. There was much difference of opinion with regard. to the causation of the various neuroses, but many cases had been recorded illustrating the fact that peripheral irritation was a very decided factor in their production. Irritation might be set up in any part of the body, and result in a reflex disorder in a distant organ. Some of the sources of irritation which might be noted were The digestive organs-indigestion; a, stomach -gastric catarrh; b, intestines-parasites, ulcers; c, hæmorrhoids, thread worms, pruritus ani. The genito-urinary organs-inflammations, internal ; a, kidneys calculus; b, bladder calculus, catarrhal states; c, ovaries-inflammation, morbid growths; d, uterus-inflammation, morbid growths. External; a, vulva-pruritus, herpes; b, clitoris-adhesions. The respiratory organs-inflammation, irritation (catarrh), new-growths-the eyes-eye-strain, errors of refraction and accommodation. The ears-abscess, impacted rectum cerumen. This, the author said, was by no means a complete summary of the causative factors which operated in the production of reflex disturbances, yet they were fair examples of what we should look for when searching for some peripheral irritation to assist us in the diagnosis and treatment of disease. Strong mental impressions stimulated the vesical and rectal nerves of the young soldier when going to battle for the first time; the uterine nerves in the young female emigrant produced amenorrhoea, from the excitement incident to leaving home and going to a new country. The differential diagnosis between a severe reflex headache depending upon uterine or digestive. trouble, and beginning exophthalmic goître where a rapid pulse and swollen thyroid were among the earliest manifestations, was often exceedingly difficult, as the mere fact of entering a physician's office for examination would often produce in nervous young women a great amount of excitability, giving rise not only to a rapid pulse, but also globus hystericus and temporary congestion of the thyroid. The following classification of the neuroses suggested itself: The neuroses of the nervous system; of the circulatory system; the respiratory system; the genitourinary system; the glandular system; the cutaneous system. The spinal and cerebral centres were not alone implicated, but the ganglionic and vasomotor nerves probably even more. The cardiac and solar plexuses in particular, took an important part. A further division of the neuroses with regard to the parts affected might be made as follows: cerebral, spinal, cardiac, vascular, pharyngeal, laryngeal, bronchial, gastric, intestinal, renal, vesical, genital, glandular, ophthalmic, aural, lingual, articular, dermal. Many of these were combined, as in the cerebro-spinal, gastro-intestinal; while two or more might exist at the same time, as vascular and glandular. The author had time to read further only about the cerebral neuroses or psychoses. Among peculiar mental conditions depending upon morbid conditions of the abdominal and pelvic viscera, were mental depression; loss of memory; excessive irritability; wakefulness; intense lethargy and drowsiness during the day; morbid fears, as of death. Under the head of cerebral psychoses fell catalepsy, trance, hypnotism, somnambulism, neurasthenia, anæsthesias, amenorrhoea, enuresis, dyspepsia, and diarrhoea coming on from bad news or hard times." Also all the hysterical symptoms depending upon the emotions, such as hysterical aphonia, hysterical apnoea, hysterical laryngismus, hysterical suffocation and strangulation. More severe types were melancholia, mania, and convulsions. The cerebral neuroses often occurred in neurotics from the mind being directed to a particular part. This was seen in patients who were familiarly known "womb cranks," who imagined they had uterine disease, and were sometimes readily cured by almost any simple manipulation of the uterus. The author related a case of migraine, hemiplegia, case of migraine, hemiplegia, and chorea depending upon uterine irritation. The symptoms came on after an attack of diphtheria, but as she had suffered from disordered menstruation and hysterical symptoms, and the hemiplegia disappeared from the left side and later appeared on the right, it was evidently of a hysterical nature, starting, with her other hysterical symptoms, from pelvic disturbance. Like chorea-which was also present in this case-functional hemiplegia was found during periods of develop production of neuroses or psychoses. For instance, he believed that in connection with gynecology there had been a tendency to attach too much importance to conditions of the uterus and ovaries in the causation of neuroses. An experience of two or three years in an asylum had convinced him of the correctness of this view. DR. NATHAN G. BOZEMAN mentioned a case of enuresis in which it was possible to make very accurate observations, since the woman had a vesico-vaginal fistula. She was suffering from an irritable condition of the organs of the pelvis, which was not relieved by the treatment which a physician, who had previously seen her, had directed to the uterus. On one occasion the urine was collected every hour for thirteen hours. During the first twelve hours she passed only one ounce of urine, while the next hour she passed fifteen ounces. DR. ACHILLES ROSE mentioned as an example of the influence of emotion on the gastro-intestinal functions, the fact that, as Napoleon's army was going through Poland in 1812, all the soldiers had dysentery from drinking stagnant water, but the dysentery ceased during a battle of three days' duration, and returned at its close. DR. J. BLAKE WHITE emphasized the statement that one should practice general medicine before entering upon a specialty. DR. LEONARD LANDES pointed out the difference between exophthalmic goitre and myxedema as described by German and French writers, having mistakenly understood the reader of the paper to say they did not differ. DR. BROTHERS said a word as to the treatment of neuroses, and particularly of the necessity for checking sexual excesses and errors of diet, which were among the most potent causes. Calisthenics should be practised. Arsenic occupied about the first place among drugs. DR. FRANK VAN FLEET thought there had to be an idiosyncrasy, else patients with uterine disease, ocular trouble, etc., would not suffer from reflex neuroses. When that idiosyncrasy did exist, he thought the exciting cause was no more likely to be in the uterus than in the eye or other organs, and it might be necessary to send the patient to several specialists before relief could be given. DR. MCGILLICUDDY, in some concluding remarks, said he thought general practitioners should know enough about medicine to treat the neuroses without sending the patients to specialists. Paroxysmal Hæmoglobinuria.-DR. BISHOP reported a case in which the urine on certain occasions contained blood-pigment, but which upon careful and repeated examination had not been found to contain blood. The patient was a sailor, and had begun to pass colored urine from the time of great exposure on shipboard. He could bring on an attack at will by exposing himself to the cold, and it was only after exposure to cold that the urine was colored. In the summer he had attacks-apparently replacing the paroxysmal attacks of hæmoglobinuria-of cerebral symptoms coming on at night, during which there was fright, especially fear of being enclosed in a small space, as a barrel. Dr. Bishop had advised the patient to take up his residence in a warm climate, but such advice, he said, might prove disastrous should the cerebral symptoms become more frequent in the absence of attacks of hæmoglobinuria. A New Diagnostic Sign of Carcinoma of the Stomach consists, according to Boas, confirmed by Dr. D. Stewart (Medical News) in the presence of lactic acid. By giving a test-meal (flour soup) quite free from any lactic acid this acid was never found in any conditions except those of carcinoma. THE NEW YORK PATHOLOGICAL SOCIETY. Stated Meeting, January 23, 1895. GEORGE P. BIGGS, M.D., PResident. Primary Tuberculosis.-DR. E. HODENPYL presented three specimens of tuberculosis, illustrating some rare conditions. The first one was from a case of primary tuberculosis, with volvulus and perforation of the intestine. He was indebted for this specimen to Dr. Sanger, house physician of St. Francis Hospital. The patient was a fairly nourished man, forty-five years of age, a baker by occupation, who gave a history of the bowels not having moved for two weeks previous to his coming to the hospital. On admission, the abdomen was distended, and his temperature was 99o. A large dose of calomel failed to relieve the constipation, and on the following day several enemata were given without result. After this he was given a large dose of croton oil with negative result. The temperature then rose, an intense peritonitis developed, and he finally died. The autopsy showed a general peritonitis, and at about two feet from the ileo-cæcal valve a volvulus which completely constricted the intestine. Above this point the intestines were considerably distended. Here there were also two perforations of the intestine, and another perforation was found below the point of constriction. The intestines were covered with a rather large number of tubercular ulcers. Microscopical examination confirmed the diagnosis of tuberculosis of the intestine. The speaker said that this was the first case of primary intestinal tuberculosis he had met with, and so far as he could ascertain none of his medical friends had seen such a case. There was nothing in the history to give a clew as to how he had contracted the disease, and there were no evidences of tuberculosis in other parts of the body than the intestine. Healing Tubercular Ulcers of the Colon.-The second specimen presented had been removed from a man who had suffered for a number of years from pulmonary phthisis. In the small intestine were a moderate number of small tubercular ulcers, while in the colon there were a number of ulcers with irregular margins and smooth bases. Microscopical examination of these ulcers showed some remnants of tubercular disease, but the bases were covered with new connective tissue. It was certainly rare to find a case in which tu'bercular ulcers of the intestine were healing. Tuberculosis of the Bladder.-The third specimen was more interesting from a clinical standpoint than from a pathological one. The specimen had been taken from an old consumptive, who had been in the hospital for three months before his death, and yet no bladder symptoms had been detected. The autopsy showed advanced tuberculosis of the lungs and two or three small tubercular abscesses in the kidney. The bladder was quite small and contracted. In the fundus were a number of irregular ulcers, and toward the edge a few miliary tubercles. Section of the walls of the bladder showed tuberculosis and considerable round-cell infiltration. DR. WILLIAM VISSMAN asked if in the second case the patient had been treated with tuberculin, as the condition in the intestine was very much like that found in patients who had been treated with tuberculin shortly after its first introduction. DR. HODENPYL said that he did not know how the patient had been treated. THE PRESIDENT said that the specimen recalled to his mind one recently added to the museum of the New York Hospital, the clinical history of which he did not for the moment recall. There were characteristic tubercular ulcers presenting distinct evidence of attempts at repair. DR. SAMUEL ALEXANDER, referring to the third specimen, said that the position of the ulcer, so high up in the fundus of the bladder, was a very unusual feat ure, without any ulceration in the trigone. If we were to hold to the theory that tuberculosis of the bladder was due to an extension from the urinary tract below, usually beginning in the seminal vesicles or the prostate, it would seem strange that the bladder should escape so completely. Such a condition, he thought, was almost unknown among clinicians. DR. HODENPYL asked if Dr. Alexander had found in his experience that tuberculosis of the bladder was usually attended with great pain. DR. ALEXANDER replied in the affirmative. At Urethral Stricture, Cystitis, Suppurative Nephritis. -DR. FARQUHAR FERGUSON presented the bladder, urethra, and kidneys from a male, fifty-six years of age, who was admitted to the service of Dr. L. A. Stimson on January 17th. He had had gonorrhoea twelve years before. During the past five years there had been difficult micturition; the stream of urine had been small, and the urine had contained mucus and pus. He had been obliged to get up several times during the night, the pain being greater at night and when the bladder was full. During the three weeks prior to his admission to the hospital he had had more pain, micturition had been more frequent and difficult, and the urine had contained both blood and pus. the time of his entering the hospital the urine was dribbling away constantly. Dr. Stimson performed supra-pubic cystotomy under cocaine anesthesia, and the bladder was continuously irrigated. After the operation the urine had a specific gravity of 1.010, contained five per cent. of albumin, and the microscope showed numerous pus-cells. Although the bladder was constantly irrigated, the patient's condition steadily grew worse, and he finally died on January 21st. At the autopsy, the supra-pubic incision was found to communicate with the bladder through an opening 12 ctm. in diameter. In the perinæum were three sinuses leading toward the urethra. After the removal of the bladder it was found that the sinuses communicated directly with the membranous portion of the urethra. At the junction of the membranous and penile portions of the urethra was a tight stricture. In front of the stricture the canal was narrowed and its wall thickened for a distance of five centimetres. This portion presented evidence of previous inflammation. Behind the stricture the urethra was greatly dilated, dark in color, and necrotic. The wall of the bladder was greatly thickened, and in its walls were numerous pouches containing pus. These varied in capacity from one to fifty cubic centimetres. mucosa of the bladder was softened and discolored. A probe two millimetres in diameter passed through the stricture. The pelvis of each kidney was dilated. and the left kidney contained numerous purulent foci. Purulent Pericarditis.-Dr. Ferguson also presented The a remarkable specimen of purulent pericarditis. patient was a male, twenty-two years of age, who had been admitted to the hospital on January 7, 1895. He had previously had two attacks of la grippe, and was an alcoholic subject. Five days previously his illness had begun with severe pain in the right side and in both knees, an aching in the lumbar region posteriorly, and dyspnoea. He had not had a chill or cough, nor had he been very feverish. He had had no headache, and had not been aware of any heart trouble. His dyspnoea had grown steadily worse. On admission, his pulse was 122, respirations 48, and temperature, 100.8° F. Physical examination showed friction sounds in both axillæ, and abundant sibilant and sonorous rhonchi scattered over both sides of the chest. There was dulness at both bases posteriorly, and also diminished respiratory murmur. Just below the spine of the right scapula was an area of diminished resonance, and over this portion were distant bronchial voice and breathing. Respiration was labored and rapid. The cardiac area appeared to be normal. The first sound of the heart was somewhat valvular and |