DISCUSSION.

DR. GEORGE C. WILKINS.

The first two cases just read are samples of what is frequently a cause of post-operative treatment, differing in cause, but both requiring operative treatment. The postoperative ileus differs little from the general ileus, except in the causation. This causation may be divided into three things-mechanical, septic and ædemic. In the odemic there is paralysis of the bowels without any mechanical obstruction. The first case cited by the authority was the case of the loss or the absence of any septic infection or obstruction, and the fact that the obstruction relieved itself, practically. The unusual feature in this case was the fact that the obstruction occurred in a case in which the abdomen was not opened, which is unusal. The cedemic and septic types are the types which are most commonly met with immediately after operation; and in the mechanical type of obstruction, the difficulty is usually found at some later period, some six weeks or longer, or even a year subsequent to the operation.

The second case cited by the authority was one of mechanical ileus, and these cases are the ones in which the treatment is more satisfactory and successful.

An early diagnosis of these cases is all important, and once the diagnosis is established, the treatment is determined, since there is only one rational treatment to pursue. Early diagnosis and adequate relief is of the utmost importance. Emptying the bowel of its toxic fecal matter and gas is an important feature in the operative treatment, and, if the condition of the patient will allow it, friction of the bowels adjacent to the part that has been obstructed above the obstruction is desirable. A solution of epsom salts

could do no harm, and might aid in establishing a normal

peristalsis.

The discussion of the third case I will leave to Dr. Kingsford.

In the fourth case, there should be a removal of the appendix subsequent to the original operation. If the appendix had been examined in this case at the time of the first operation the fecal concretions would have been found and the appendix removed; and I think this case illustrates the wisdom of removing the appendix whenever the lower part of the abdomen is opened, provided this can be done without unduly prolonging the operation or handling the bowels unduly.

Now, this procedure of removing the normal appendix is criticised by some physicians, but I think the majority are in favor of it, and I think it is yet to be proven that the removal of the appendix produces any harmful result.

DR. H. N. KINGSFORD, HANOVER.

In regard to the pathological findings in the material removed in this case of suspected tubal pregnancy. The material mentioned by Dr. Stickney, in which it was supposed there was some bone which had resulted from a ruptured pregnancy, in my opinion is simply calcareous deposit, and the formation of true bone in a partially organized clot which came from from a ruptured ovarian hematoma. In this particular ovary, as in many ovaries which we see, the follicles, a great many of them, did not seem to go on to their natural development. In a great many ovaries you see the follicles partially formed and the ovum partially formed in the follicle; the ovum dies, and a certain amount of hemorrhage takes place into the follicle and there is considerable oozing, so that you get at times quite a large hematoma. When this ruptures, it goes into the abdominal cavity, and is moved about more or less by

the twistings of the intestines and by the contraction of the muscles and it acts as a foreign body; it may undergo absorption or organization, or it may undergo calcification with the formation of true bone. Of course, the formation of true bone in a blood clot is not common, but it is a thing that does occur, and that, in my opinion, is what did occur in this particular case. There was a great deal of the calcareous deposit. Some of the sections from this tumor were sent to Drs. Mallory and Nichols, who are interested in this particular condition, and they agreed with me that it was true bone formed in a clot. Oftentimes this calcareous deposit in a clot, even if of small size, gives a great deal of discomfort to the patient, and causes a tumor which sometimes shifts its position, and may obscure the diagnosis in a great many cases. Some of the so-called phantom tumors are due to organized blood clots. They are hard tumors to locate, and cause a great deal of trouble in making a positive diagnosis; and the shape of this particular mass, though, if you should stretch your imagination, it might appear like a temporal bone, is simply the parts of a clot, in which there was a calcareous deposit on one side, only on this particular side it was the most dependent part, and more material was left there in which the calcareous material could be deposited.

I think a careful analysis in every case where blood clots are found, shows very often the beginning of calcareous formation. Of course, the clots are usually taken out and thrown away, and they are seldom analyzed. So that the data in regard to them is really not reliable.

DR. FOSTER.

The Doctor wishes me to say a word or two as a result of my examination of the tissue taken from the third case. I do not wish to enter into any lengthy discussion, but will simply say that an examination disclosed that this growth,

which involved the cervix, had taken a lodgment sometime in the body of the uterus, not taking in the fundus. I was asked by the author what my opinion would be as to an operation, and I would like to say that the subsidiary conditions, of course, had nothing to do with the condition which was found in the uterus and in the vagina.

Closing of the discussion by Dr. H. L. Stickney:

I have nothing to add, Mr. President, except to make reply as to the advisability of removing the appendix at the time of the operation. It has been my custom to remove the appendix when it is convenient to do so, and I had done so up to this time. I read a paper about this time from Dr. Johnson, of Washington, who believed that it was not advisable to remove the appendix in all cases, any more than it is advisable to amputate the second breast when one is diseased; Dr. Johnson does n't think it advisable to remove other healthy members for fear you may have a subsequent trouble. Of course, operators differ in this respect. Howard Kelly believes it negligence on the part of the operator to interfere with a healthy appendix, while, of course, some other operators of equal standing and prominence believe that it is criminal to leave it while you are in the abdomen.

THE LOSS TO PHYSICIANS FROM HOSPITAL

WORK.

A. NOEL SMITH, M. D., DOVER, N. H.

Hospitals are a blessing to the community; indeed, there is very little doubt but that they are a necessity, while they are becoming more and more indispensable. Of course the large cities are quite well supplied with them, but the smaller cities and towns are also getting to be well equipped. The race for supremacy seems to be well on between the Carnegie libraries and the cottage hospitals.

The necessity for hospitals has existed all through the centuries ever since disease has afflicted the human family. About the latter part of the fourth century the Persian empire was for a little while the only place where medicine could be cultivated and be protected by the laws. Certain Christians, called "Nestorians," founded a school of medicine at Edessa, in Mesopotamia. Pupils came from all parts and studied practical medicine in a public hospital. This was probably the first institution for clinical instruction.

In most of our cities the hospitals have been founded and are maintained by private endowments. New York City supports Bellevue and allied hospitals at an outlay of $600,000 a year, which is about fifteen cents per capita. Boston is the most notable of those cities which maintain a general hospital at public expense. Her City Hospital costs the citizens seventy-nine cents per capita, an average yearly expense now of nearly $500,000. The Carney Hospital has done a great work in its forty-three years of existence. It has no funds from which it derives an in