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the septum or inflammation within the septum, as noted in a child suffering with congenital syphilis, and hypertrophy of the turbinates, are causative factors. A strumous or uric-acid diathesis may predispose to perichondritis and subsequent deflection. The author. showed different forms of deflection by passing around diagrams.

Speaking of the surgical treatment, he mentioned the operation of Asch as be ing the most popular, and believes it will bring about a positive result.

REMOVAL OF CERVICAL SYMPATHETIC.

Dr. Emory Lanphear, St. Louis, Mo., contributed a paper in which he dealt with the removal of the cervical sympathetic for epilepsy, exophthalmic goiter, and glaucoma. He mentioned the work of Jonnesco and other surgeons along this line, saying that this field of surgery was worthy of further study and investigation.

Dr. Harold N. Moyer, Chicago, said that the benefit to be derived from operation in exophthalmic goiter is not very promising. However, the subject was worthy of further experimentation. He believed the same thing applies to epilepsy. Some benefit might be accomplished by operating on these cases at an early date. If the operation is late, very little, if any, benefit will be derived from it.

SURGERY OF THE TURBINATED BONES.

Dr. J. A. Stucky, Lexington, Ky., read a paper on this subject. The author did not discuss operative procedures on the turbinated bodies, nor on any of the soft tissues covering the bone, but rather the bone itself. While it is true that the tissues covering the bone are far more frequently found in a pathologic condition, and require surgical treatment, it is also true that the bone itself in many instances is at fault. When this is the case, the mucous membrane and turbinated bodies may be entirely obliterated by chemical and electric cautery or scissors, forceps and snare, and the latter condition of the patient be worse than the former, because of the remaining cicatricial tissue and unnatural dryness of the parts.

The author then called attention to what seems to him to be the best methed of removing a part or whole of the bone. The first and most important desideratum in all intranasal operation is to remove only just as much tissue as is absolutely necessary. The crushing or punch forceps, spoke-shave, and snare should only be used in exceptional cases. In removing a part or the whole of the middle turbinate, correctly shaped scissors are the only instrument needed. For this purpose he has found none equal to those devised by Dr. C. R. Holmes of Cincinnati, one for each turbinate, right and left. For turbinectomy or turbinotomy of the lower bone, the narrow-bladed scalpel. and strong straight scissors are needed. An incision through the soft tissues is made along the edge of the bone; this is peeled back with the back of the scalpel and the bone exposed. Should this be too firm to cut with the scissors, a narrow, thin saw is used.

saw

In cases where the knife, saw and scissors cannot be used to complete the operation, on account of the size, depth and conformation of the nasal chambers. the snare is used to complete the removal of the posterior portion. Little or no dressing is needed after the operation, except when the lower turbinate has been entirely removed; then strips of gauze placed smoothly over the wounds are allowed to remain twenty-four or thirty-six hours, then carefully removed, after thoroughly softening with 50 per cent hydrogen dioxid The subsequent treatment consists of keeping the parts clean until union is complete.

Dr. William L. Ballenger, Chicago, concurred with the essayist as to the method of operating. He has seen the type of osteitis mentioned follow the use of the snare, and the wound persist in discharging pus. An instrument that has a greater cutting surface than the snare for operating on the turbinates is certainly desirable.

Dr. A. J. Stein, Chicago, said the av erage rhinologist has a tendency to ig‐ more the bone in operatting on the turbinals, that is he uses the snare or some other instrument to remove the soft tissues, but ignores the bone, which is of more importance.

MAMMOTH OVARIAN TUMORS: REPORT OF A CYST WEIGH

ING 245 POUNDS.

Dr. James B. Bullitt, Louisville, Ky., presented this paper. Only growths weighing 100 pounds or more have been considered as mammoth tumors. A search through literature has developed reports of 23 such tumors. Brief summaries of these cases are given. The. largest of these tumors weighed 202 pounds.

The essayist adds a twenty-fourth case by reporting in detail the case operated on by Dr. A. M. Cartledge, Louisville, in May, 1897. The tumor sac and contents together wighed 245 pounds. There were a great many adhesions encountered and the operation was prolonged. The woman rallied from the shock and was in good condition at the end of five days, when obstruction of the bowel beame manifest, the patient dying on the seventh day.

In considering the twenty-four cases. it is observed that twenty-one cases were operated on. Of the fifteen in which recovery took place the average tumor weight was 129 pounds; while of the six in which operation was followed by death the average weight was 181 pounds.

I.

There are manifestly but three methods of dealing with these tumors: immediate extirpation; 2, preliminary tapping, followed in a short time by extirpation; 3, tapping repeated as often as necessary to relieve uncomfortable distension.

To illustrate that life may be long sustained by constant tapping and withdrawal of fluid, the case of Dr. Ap. Morgan Vance is cited, where the woman was tapped 179 times between the ages of 34 and 80 years, it being computed that in this time 21,480 pounds of fluid were withdrawn.

In so far as any conclusions can be drawn from the study of these 24 cases the following are submitted:

1. The fatality from such tumors is directly proportioned to the size of the

tumor.

2. Extensive adhesions to the parietes and viscera militate, against successful operations, but are second in importance to the size of the tumor.

3. Preliminary aspiration followed by extirpation in a few days is apparently no safer than immediate operation.

4. Marsupialization is contraindicated in tumors of mammoth proportions.

5. Successive tappings are sometimes tolerated over a long period of years, but lead ordinarily to exhaustion and death in a comparatively short time, a few years.

6. When death occurs after operation it is most apt to be immediate, within a few hours, as the result of shock. If this first danger is passed safely, the fatal issue is apt to be the result of obstruction of the bowel, especially in those cases where extensive adhesions are present.

Dr. A. H. Cordier, Kansas City, Mo., mentioned the case of a woman, colored, 43 years of age, who had carried an ovarian cyst for eleven years. The cyst with its contents weighed 160 pounds. The patient died on the ninth day following operation from exhaustion. OBSTIPATION AND ITS RADICAL TREATMENT.

Dr. Thomas C. Martin, Cleveland, Ohio, read a paper with this title. He said that the rectal valve is an individual anatomic organ in itself, and must now be reckoned with in studying the operations of the integral mechanism of defecation.

When the muscular elements are relaxed and the gut is either greatly dilated or else is even in lesser measure distended, the valve is passively supported by its fibrous band across the channel to resist the hurried or uncontrolled descent of the feces. The presence of the band of fibrous tissue under the free margin of the valve provides a control to receive or retain a bolus, or, it may be said, the several valves receive a series of boluses till a sufficient pressure is made to stimulate the complex involuntary mechanism of defecation to further propulsion of the feces or to a reversed peristalsis. The presence of feces or the involuntary movements incident to their presence signals the consciousness to co-operative voluntary expulsory effort or give warning of the necessity of voluntary resistance. The valvular arrangement of the rectum provides for the minimum expenditure of energy on the part of the voluntary forces, for the reason that the gut's contents are collected on the surface of the

unyielding sarcum and steadied there to receive the pressure of the really expul sory voluntary effort. Such an arrangement of the feces further facilitates defecation for the reason that the entire contents of the rectum are not rushed on the anus at once.

If it be the function of the normal rectal valve to beneficently retard the descent of the feces, it is obviously true that it may be the especial property of the valve, in certain other than normal conditions, to maliciously obstruct the descent of the feces.

The patient is the subject of more or less chronic irregularity of defecation. He some days makes frequent partially successful attempts to evacuate the rectum, but may experience an unrequited desire for stool. The patient acquires the reprehensible physic habit. In time the periods of obstipation are interrupted by diarrhea. There is commonly an ineffectual straining at stool except for fluid feces.

The writer described a method for division of the obstructing valve and presented cases.

[TO BE CONTINUED.]

THE MISSOURI VALLEY MEDICAL ASSOCIATION. This society held its annual meeting, under the presidency of Dr. B. F. Crummer, of Omaha, in Council Bluffs, Iowa, on Thursday, September 21st, with a good attendance of members. An excellent programme was presented, consisting of the following papers :

President's address, B. F. Crummer.

Tropical Dysentery, Mary Strong, Omaha, Neb.

The Treatment of Hernia in the aged, C. C. Allison, Omaha. Nebraska.

Spina Bifida, W. O| Henry, Omaha, Neb.

Pulmonary Tuberculosis Treated by Collopsing the Lung with Nitrogen Gas. Report of a case, John Hiatt, Beaver Crossing, Neb. Infantile Scorbutis, H. M. McClanahan, Omaha, Neb.

Aortic Aneurism, J. P. Lord, Omaha, Neb.

Iowa.

Hemorrhage after Tonsillotomy, F. W. Dean, Council Bluffs

Severe Recurrent Hemorrhage for past Twenty-two Years in a Woman Seventy-eight Years of Age, Rebecca Hanna, Red Oak, Iowa.

What Should be the Position of the Surgeon Relative to the Treatment of Appendicitis, J. E. Summers, Omaha, Neb.

Diagnosis in Neurotics, Inez C. Philbrick, Lincoln, Neb. Bronchial Calculus, LeRoy Crummer, Omaha, Neb. Some remarks on death by Electricity, F. E. Coulter, Omaha, Nebraska.

The amendment of the By-laws, making the annual meeting migratory, as well as the semi-annual meeting, was adopted, and we predict will give universal satisfaction. The selection of the next meeting place was left to the president and secretary to decide. The following were elected to membership:

Dr. David Williams, Treynor, Iowa.

Dr. William Besore, Macedonia, Iowa.
Dr. Clinton E. Soff, South Omaha, Neb.
Dr. A. A. Ashley, Red Oak, Iowa,

Dr. J. C. Anderson, Omaha, Neb.
Dr. James Cole, Thurman, Iowa.
Dr. J. M. Aikin, Omaha, Neb.

The meeting closed with a sumptuous banquet at the Grand Hotel, which proved a pleasing climax to a most interesting and instructive meeting. Dr. R. M. Stone, of Omaha, occupied the head of the table, and as toast master filled the position to the emminent satisfaction of those present. Those who responded to toasts were Drs. Jacob Geiger, Donald Macrae, D. C. Bryant and William Jepson. The following officers were elected for the ensuing year: President-Jacob Geiger, St. Joseph, Mo.

First Vice-President-J. P. Lord, Omaha, Neb.
Second Vice-President-C. C. Allison, Omaha, Neb.
Treasurer-T. B. Lacey, Council Bluffs, Iowa.
Secretary-V. L .Treynor, Council Bluffs, Iowa.

AN INTERNATIONAL CONGRESS OF THE MEDICAL PRESS.

Plans are being perfected for the organization of an International Medical Press Congress next year during the Paris Exposition. Prof. Cornil and Mr. Marcel Baudouin are at the head of the movement and have requested the American Associations to send delegates to the Congress. Prof. Cornil, Senator, has been selected President, Messrs. Lucas-Championniere and Laborde, Vice-Presidents, and Dr. R. Blondel, Secretary General. The date for the organization of the Congress will be determined later. Dr. I. N. Love, President of the American Medical Editors' Association has appointed the following delegates to the Congress :

Dr. J. M. Mathews, Dr. Horace Grant, Louisville, Ky.
Dr. Geo. F. Butler, Dr. Geo. H. Simmons, Chicago.

Dr. C. H. Hughes, St. Louis.

Dr. C. F. Taylor, Dr. H. A. Hare, Philadelphia.

Dr. Dillon Brown, Dr. Daniel Lewis, New York.

Dr. Thos. H. Hawkins, Denver, Colo.

Dr. Henry W. Coe, Portland, Ore.

Dr. William Warren Potter, President of the American Medical Publishers' Association, has appointed the following delegates to represent this organization at the Congress.

Dr. J. C. Culbertson, Cincinnati, Ohio.
Dr. Ferdinand King, New York City.
Dr. Landon B. Edwards, Richmond, Va.
Mr. J. Macdonald, Jr., New York City.
Mr. Chas. Wood Fassett, St. Joseph, Mo.

A meeting of the above named delegates will probay be called at an early date to decide upon plans and select a route to the Paris Exposition.

THE PARIS EXPOSITION OF 1900.

The Paris Exposition will open April 15 and close Nov. 5, 1900. United States Day will be July 4th, when the Lafayette monument will be unveiled. Arrangements are being made for a party of physicians from Iowa, Illinois and Missouri to visit the Exposition, with their families, at small expense. Two hundred physicians have already registered, thus assuring the success of the excursion. The object of the registration is to learn, approximately, how many to make arrangements for, and that information may be mailed from time to time relative to rates, itinerary, acommodations en route and in Paris. The trip will be made from Chicago or St. Louis to New York, thence via the most direct route to Paris. Tickets will be good returning any time within one year, via London, Liverpool and New York.

Physicians desiring to register should send their names to Charles Wood Fassett, care of the Medical Herald, St. Joseph, Mo.

PENN'S SUCCESSFUL DOCTORS.—The result of the examination by the Pennsylvania Board of Medical Examiners, through which alone graduates in medicine may be permitted to practice in the state of Pennsylvania, has just been announced. The University of Pennsylvania makes the same extraordinary showing in 1899 as was the case in 1898. Of one hundred and forty-three students examined, only one failed, and the general average of the whole was 86-an average far in excess of that obtained by students of any other school of medicine. The graduating class in the School of Medicine at this institution numbered 218, of whom about 135 resided in Pennsylvania. The fact that some men from other states wil remain here to practice their profession or to become resident physicians in the various hospitals accounts for the greater number who took the examination than who reside here.

The fact that the University of Pennsylvania furnished about thirty-four per cent of the entire number of candidates for the board's certificate and less than two per cent of the number of failures, makes the record all the more remarkable, especially when the exceptionally high average obtained by all the men is taken into account. The details of the examination are as follows:

No. Ex'd No. Failed P. C. of F. Gen. Av.

Colleges

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