gas per anum, are sufficient to indicate immediate operation. In postoperative cases surgeons do not delay, but at the present time, unfortunately, few patients are admitted to the surgical clinic in this early stage. The later symptoms are fecal vomiting, general abdominal distention, continuing absolute constipation, and the signs of autointoxication. Now the diagnosis is simple, but the chances of recovery, even though the operation be performed early in this stage, are few.

In obturation ileus the acute primary symptoms are frequently absent. There is often a previous history of constipation and abdominal colic. In carcinoma of the large intestine there may be a history of blood in the stool or intermittent diarrhea and constipation. In this group of obturation ileus I have been impressed with the history of recurrent attacks of intestinal obstruction, that is, absolute constipation, vomiting (not fecal) and distention, which have been relieved after a day or two by cathartics and enemata. This history of a successful non-operative relief often puts the physician off his guard, and operative interference is delayed. In one of my own cases there was a history of five such attacks, one lasting five days. In obturation from carcinoma of the large intestine the obstruction of the lumen may not be absolutely complete and some little fecal matter and gas may pass, appear in the enema, and if this symptom is interpreted as a sign of relief the necessary operation is often further delayed. When the obturation is in the small intestine peristalsis is a constant early symptom. If the obstruction is high in the small intestine, distention is slight or absent, and vomiting of a forced character early. In obturation the symptoms are more obscure than in strangulation ileus, but the constipation, even though there be no vomiting or peristalsis, should be regarded as suspicious. The following distention, even without vomiting, is still more suspicious. In obturation of the colon the distention may be extreme before vomiting takes place. This clinical picture, with the evidence of some gas and feces in the enema, should be enough to allow a diagnosis of an obstruction of the large intestine. Early vomiting, absolute constipation, sometimes without much pain and little or no distention, indicate an obturation of the small intestine high up. Peristalsis can usually be made out.

I have not mentioned movable dullness in the abdomen. It is practically absent in obturation ileus, and is a late sign in strangulated ileus.

From my own experience in postoperative obstruction and from the few cases that I have seen in the early hours of primary intestinal obstruction I believe that it is not difficult to make a diagnosis at a period in which operative intervention promises an excellent chance of recovery. If the practitioners will avoid giving cathartics indiscriminately, place such patients in bed, give them nothing by mouth, employ the stomach tube and rectal enemata early, make a careful abdominal examination and blood-count, avoid morphia if possible (if the intense agony demands some relief before a decision as to operative intervention can be made, give small doses),

I feel quite confident that they will be able to recognize intestinal obstruction in the early hours. This has been accomplished in appendicitis, in perforated gastric and duodenal ulcer, why not in intestinal obstruction?

The problems in the surgery of intestinal obstruction present increasing difficulties with the duration of the attack and the possible complications. In strangulation ileus peritonitis may take place without gangrene or perforation. Autointoxication must be considered in all late cases.

Before operation the stomach should be washed out. Chloroform may be the best anesthetic. The anesthesia must be very carefully given. The washing out of the stomach does not always prevent vomiting under narcosis, and in such cases chloroform is better than ether. The selection of the position of the incision. varies. If the exact position of the obstruction cannot be fixed, median laparotomy should be performed. In desperate cases a simple enterestomy under cocaine may have to be done. This is only feasible in obstruction of the large intestine or low down in the ileum. If possible the obstruction should be found and relieved. If the intestine above the point of obstruction is distended and filled with fluid contents, it should be evacuated, and if the symptoms have been present over 48 hours, enterostomy should be performed in addition to the relief of the obstruction. The mortality of operation after 48 hours without enterostomy is so definitely higher than with enterostomy that there appears at this time no question as to the efficacy of this additional safeguard. The object of the enterostomy is to aid the patient in immediately disposing of intestinal contents and combating autointoxication. When the intestine is the seat of gangrene the gangrenous loop must be taken out of the abdominal cavity. The surgeon has to decide between fixing the loop outside of the wound with enterostomy above, with later resection; resection at once, with fixation of the ends in the wound, or resection and suture. This decision is reached in individual cases. When there is obturation from a new growth, one must decide between enterostomy or colostomy alone, with a later operation for resection, and immediate resection. The earlier the operation takes place after the initial symptoms the easier to settle these questions, and the more frequently can the lesion of the intestine be relieved completely at one operation with the least mortality. MINUTES OF PRINCE GEORGE COUNTY MEDICAL SOCIETY.

College Park, Md., January 12, 1907.

The Society met at 1 P. M. at the home of Dr. Eversfield. Called to order at 1.30 by the President, Dr. Fox, with 12 members (Drs. Fox, Eversfield, Etienne, McMillan, Taylor, Nally, Birdsall, Latimer, Perry, Willits, Griffith and McDonnell) present, also Dr. S. S. Buckley.

The name of Dr. C. S. Bradfield was presented for membership. Under the rules the application will be considered at the next meeting.

The following was presented by Dr. Latimer:

"WHEREAS, there exists in nearly every community a certain small class of individuals who habitually disregard any and all sense of obligation to reimburse any physician for services rendered;

"Resolved, That the members of this Society in the future shall not attend, professionally, any person or persons who reside in their respective communities who shall not have paid their indebtedness to their last medical attendant for any services rendered after this date if such last attendant be a member of this Society or a subscriber to this resolution. This not to apply to emergency calls demanded in the nature of humanity. And, with the purpose of making this resolution effective, we each exercise every reasonable diligence to ascertain such delinquent debtors."

After considerable discussion the resolution was carried by a two-thirds majority of the members present.

(A recess was here taken for dinner.)

It was moved and carried that every physician in the county and the insurance companies be notified of the action of the Society in opposition of the reduction in fees for regular life insurance examinations and in voting to refuse to make such examinations for a fee less than $5.

Dr. Latimer presented the report of the special committee, which was adopted, as follows:

"WHEREAS, Some of the firms of manufacturing pharmacists are placing directions for administration on their bottles to encourage the laity to prescribe for themselves and thereby injure the patient and make the labors of the physician more difficult, be it

"Resolved, That the members of this Society, so far as possible, prescribe no products of firms following such practices.

"Be it further resolved, That the attention of the various State branches of the American Medical Association be called to this action."

The Society accepted Dr. Perry's invitation to meet at his house on March 9 at 1 o'clock, and also Dr. McDonnell's invitation to meet at his house at College Park on May 11.

A rising vote of thanks was then tendered to Dr. and Mrs. Eversfield for their hospitality.

Adjourned at 4 P. M.

H. B. MCDONNELL, Secretary.

The resolution above referred to is as follows: "WHEREAS, certain life insurance companies doing business in our county have reduced the medical examiner's fee from $5 to $3 by placing the fees on a sliding scale, all cases of $3000 or under being allowed $3, and as ninetenths of our cases come under $3000, this practically cuts the fees for our work down two-thirds; and

"WHEREAS, in our opinion, $5 is the smallest amount for which the work can be properly done; now, therefore, be it

"Resolved by the Prince George County Medical Society, That every applicant for insurance in the old line insurance companies be charged $5, and no less; and be it further

"Resolved, That we, as a Society, pledge ourselves to these resolutions, and also to use our influence with all physicians of this county to carry out these resolutions, whether they are members of this Society or not."

Society Reports.

THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.

MEETING HELD NOVEMBER 19, 1906-DR. BARKER IN THE CHAIR. Cysts of the Breast-Dr. Bloodgood. Cysts of the breast vary from the most benign to the most malignant, and a diagnosis can be made in most instances only at an exploratory incision. Therefore one must be familiar with the differing cysts, the contents, inner wall and the tissue of the surrounding breast.

We have the galactocele in young lactating women, the cysts occurring at or before menopause, those with senile parenchymatous hypertrophy, those formed about papillomata, and malignant cysts.

Galactocele-Cysts occurring in the lactating breast may contain purulent material. They are of some months' duration. It is only necessary to remove the cyst. Carcinoma in the wall is rare.

Cysts occurring at the menopause, which varies in different women, are white in color as a rule, but may be hemorrhagic. It is justifiable to remove the cyst alone.

Simple Cysts-They have been observed in all ages, 30 to 70, and a few in senile breasts. Their walls are smooth, almost like the peritoneum, and they contain clear fluid. In the further development they may be multiple and of the same character. They are usually bilateral, and in 75 per cent. of the cases both breasts must be removed. In multiple cysts the tendency to carcinoma is slight. Small cysts are always lined by epitheleum, which they lose when the cysts become larger. This is a probable explanation of why we so seldom get carcinoma in the larger cysts; i. e., in those over one centimeter in diameter. Small cysts filled with cellular detritus instead of fluid are in 50 per cent. of the cases cancer. Both breasts are to be removed, as the condition is often malignant.

There are two stages in the histology of senile parenchymatous hypertrophy: (1) The adenomatous stage. Here the cells lining the ducts are of a slightly higher type. (2) The acini of the ducts become dilated, probably due to a desquamation of the epithelial cells. This is the stage of ectasia. These dilations may become further dilated, and the lining then is no longer of epithelial cells, but of connective tissue, and is smooth. There may be hemorrhage into the wall, but never into the cyst. In other cases, instead of the cells desquamating and dilating the spaces into cysts, the epithelium of the walls is as marked as in the adeno-cystic stage. The entire breast may be filled with minute cysts. Cancer is common here.

Papillomatous Cysts-The papilloma is usually large; in one case it filled the entire cyst, but this is uncommon. Hemorrhage is quite common. The characteristic sign of cystic papilloma is hemorrhage from the nipple. There may, however, be no hemorrhage, for the duct may be occluded.

The presence of blood in a smooth-walled cyst is a diagnosis of cancer.

Fat in a lymph gland, it is interesting to note, may be mistaken for carcinoma metastasis, for the fat becomes infiltrated with connective tissue. The picture on fresh section may be very typical.

Cysts in Perithelial Angio-sarcomata Recently Dr. Pancoast had a case of a woman with a rapid growth in the breast. On incision a cyst was found containing clear fluid. The wall was soft, rough and irregular, and it proved to be a perithelial angio-sarcoma, which is very rare. The zone of the tumor was sharply defined from the surrounding fat. Cysts are not uncommon in perithelial angio-sarcomata.

Sebaceous Cysts-They are near the surface and contain sebaceous or dermoid material. They may be malignant.

Dermoid cysts may be malignant also. Dr. Bloodgood mentioned a case in which cancer was not found in parts of the wall of the cyst, but on further section was seen with an infiltration of the skin and easily recognized.

The interesting points which we should bear in mind are: Cysts in young women in lactating breasts may be carcinomatous. After 30 we can determine from the wall of the cyst, the contents and the surrounding tissue whether or not to remove the cyst alone or the entire breast. One of the geatest aids for the diagnosis of malignancy is blood without papilloma or broken-down cheesy material.

A number of pictures were shown on the screen illustrating the various types of cysts.

Typhoid Spine-Dr. MacRae. The term "typhoid spine" was introduced by Dr. Gibney of New York in 1889 to designate a certain group of cases, the chief points concerning which are as follows: The condition generally comes on in convalescence not later than three months. Pain is the most marked feature. There is a distinct tendency to recover. symptoms are present.

Certain sensory

Gibney considered it an inflammation of the soft parts holding the vertebra together. Concerning the actual condition, however, there was a difference of opinion, chiefly between two factions.

Gibney declared it to be a definite organic condition, while, on the other hand, there were those who believed it to be entirely a functional disorder without any organic change. The first view was somewhat at a disadvantage, since the condition was never fatal, there were no autopsy findings to confirm their belief, while in favor of the second view there were several points: First, the condition was only one of symptoms; secondly, the patients always got well; suppuration never occurred. This last was one of the strongest arguments against it being an organic change caused by the typhoid organisms, for, as is generally known, typhoid lesions nearly always suppurate.

Later, however, more men becoming interested in the subject, interesting reports of certain changes were made, such as kyphosis, lateral curvature, and signs of local inflammation (there was in no case, however, any report of suppuration), changes in the lower extremeties, such as wasting, changes in the reflexes and sensation, all of which are suggestive of organic changes.