able to exert considerable pressure by the bandages, while allowing sufficient play to the movements of respiration and deglutition. After the operation the patient slept well and suffered no pain. The wound was dressed for the first time on the seventh day, and it was found almost entirely united by first intention. There was a little serous oozing, but no pus. The tubes were gradually removed, and by the fourteenth day the wound had united soundly, and the patient felt no inconvenience about the seat of operation. There was no elevation of temperature, except on the tenth day, when it rose to 103° for some reason or other, but fell almost immediately under the influence of quinine, remaining normal.

Since there was nothing about the wound to account for the rise of temperature, and as it yielded so readily to quinine, it was most probably due to malaria. The patient left the hospital to all appearances perfectly cured of his deformity, and, I think, largely secured against the infection of general tuberculosis.

CASE II.-Colored, aged 25; John J., born in Virginia, sailor, parents living. No history of tuberculosis or scrofula; history of syphilis, which he contracted last January. Glands of neck and under chin began to suppurate ten years ago, were opened at the time and afterward healed. Five years ago another one was opened on the right side under the ear. In the winter of 1884-85 quite a number began to enlarge, and some suppurated, and even now sinuses can be observed on the anterior border of the sternocleido-mastoid muscle. After a thorough treatment of two months, with such remedies as were thought adapted to such a case, good diet, etc., with no avail, Dr. Branham removed (in April, 1885), five enlarged glands from the right side of the neck. The wound. kindly healed, but the deep upper cervical glands continued to enlarge, so that by September 3 four or five large lobular masses, appeared freely movable on the subjacent parts. They were mainly below the body of the jaw on the left side, but overlapping the bone considerably, those on the right side beginning lower in the digastric triangle. They extended downward and toward the middle line to within three inches of the clavicle. There was no other enlargement of the superficial glands of the body-spleen normal, etc. September 3, 1885, I made an incision, beginning below the angle of the jaw, along the anterior border of the sternocleido-mastoid muscle down to opposite the cricoid cartilage.

The external jugular vein, which in this case was quite large, owing no doubt to the pressure of the glands upon the internal jugular, was cut and considerable welling up of blood followed. Both ends of the vein were grasped by forceps and ligated and it gave us but little inconvenience. The tumors were now carefully enucleated by dissection with the fingers from beneath the muscle. until the five large glands were shelled out of their bed. Several smaller glands were observed extending along the internal jugular, and their removal necessitated a great deal of caution; notwithstanding this the sheath common to the vessels was opened up for the length of an inch, and the vein, nerve and artery could be readily recognized at the bottom of the wound. In spite of the proximity to the many large vessels of the neck very little blood was lost throughout the entire operation. When both masses from the two sides were removed an opening was made along the posterior border into the resulting cavity beneath the muscle for drainage. This was alike done on both sides and a drainage tube placed. The incisions were then sewn up with silk sutures (carbolized sponges being left to the last moment for the purpose of arresting all oozing), dusted with iodoform and dressed with oakum as in the previous case. Eight hours after operation temperature was 104, pulse 110 and weak. Infusion of digitalis in whiskey, ordered every two hours. Within four hours the temperature had fallen to 100. At this time the patient seemed very comfortable, slept well and had no pain or other subjective symptoms accompanying the rise of temperature. On the 12th day the wound was dressed for the first time and a discharge of a serous fluid found saturating the oakum around the tubes. In every other particular the wound was all that could be desired; there was little or no induration and the parts not even tender. After carefully washing the neck with a solution of bichloride of mercury the tubes were shortened and the same dressing reapplied. September 22, all the stitches and tubes were removed, and the patient was so far improved by the 28th that my notes register-wounds healed up entirely." The patient remains entirely free from the return of enlarged glands of the neck.

CASE III.-C. J., colored, age 25, born in Africa, not married; both parents healthy. General health good until July, 1884, when there began an enlargement of the glands of the neck below the angle of the inferior maxilla on the left side. Was admitted into

the hospital July 20, 1885. On examination the tumor was found to be about the size of an egg, over which there were several sinuses discharging a thin watery pus.

July 25 the operation was done by dissecting down all around the glands, removing them en masse, avoiding injury to the inflamed circumglandular tissues. The glands were removed through an incision running along the anterior border of the sterno-mastoid muscle, beginning at the angle of the jaw, extending down two and a-half inches. The wound was dried, dressed with iodoform and oakum as in the above cases, and healed by first intention without a bad symptom, and the patient was discharged August 7, cured.

CASE IV.-N. V., colored, aged 43; born in West Indies; mother still living and healthy; father died from strangulated hernia. Brothers and sisters healthy as far as known to the patient. Five years ago an enlarged gland discharged itself by suppuration from the right side of the neck. Was healthy from that time till March, 1884, when the glands on both sides of the neck, especially those of the left, began to enlarge.

He entered the hospital March 23. On examination it was found that the glands on the anterior border of the sterno-mastoid were enlarged, nodulated and tender, giving a sense of fluctuation. in points here and there. A fistulous track leads to the lower mass of the glands. This stnus, both from his own statements and from appearance, had existed but for a short time. After an examination I came to the conclusion that there was but one thing to do, which was a complete enucleation of the entire mass of diseased glands, that would give him any reasonable security against the persistence of the fistula, or free him from the considerable risk of generalized tubercular infection.

July 15 the enucleation of the glands was done notwithstanding the strong probability of infection of the lungs, which was evidenced by harsh breathing at the apex of the right lung and prolonged expiration; also, there had been observed a slight tendency to evening rise of temperature. As the patient was very anxious to be freed from his uncomely appearance, and I, fearing the almost inevitable general tubercular infection (if he was not already a sufferer from it), I began to do what might be otherwise thought an unnecessary and almost unwarrantable operation, namely, that of dissecting down, as in the other cases, and removing the

glands en masse, disturbing the inflamed connective tissue around the glands as little as possible. In this dissection the large vessels were exposed considerably, and the planes beneath the sternomastoid freely opened. After a counter opening was made along the posterior border of the muscle, the wound was thoroughly dried and a drainage tube passed beneath the muscle.

The wound was then dressed and treated as in the other cases, and healed readily with scarcely an untoward symptom, so that by August 4 it was entirely healed. It soon became apparent that our suspicion of general tuberculosis was too well founded, for the patient died September 22, of acute tuberculosis.

These cases were noted for the special purpose of demonstrating that the surgical treatment of tuberculous disease of the neck is not of sufficient danger to deter the surgeon from undertaking such a procedure, and if the above cases teach anything, it is that it is safe, justifiable, and in the larger proportion of cases, gives better results in every particular than any temporizing treatment yet instituted.

DISCUSSION ON DR. CHAMBERS' PAPER.

DR. JOHN S. LYNCH denied that the bacillus is the cause of scrofulous degeneration of the glands. He admitted that in every such gland the bacillus can always be found, but only after the gland has undergone degeneration. Before this has occurred it is impossible to distinguish the process from ordinary inflammation. If the bacillus is always the cause, why is it not found in the earlier stages?

DR. CHAMBERS replied, that he had referred to Dr. Lynch's published opinions on the subject in the paper he had just read. In regard to the presence of the bacillus, Koch claims to discover it. But even Dr. Lynch acknowledges, in his published work, the danger there is from scrofulous glands for the development of tuberculosis; therefore the removal of them is important.

DR. RANDOLPH WINSLOW considered Dr. Chambers correct. No surgeon would hesitate to operate. The affections are dangerous and ugly. The glands must be removed, except in cases where there is general tuberculosis.

DR. LYNCH explained, that while a suppurating caseous gland is a source of danger, it is a question whether the danger arises from the bacillus, or from the pus itself. He argued that on account of this danger they should be removed before suppuration has taken place.

TREATMENT OF PENETRATING WOUNDS OF THE

ABDOMEN.

BY RANDOLPH WINSLOW, M. A., M. D.

Professor of Surgery in the Women's Medical College of Baltimore-Lecturer on Clinical Surgery in the University of Maryland.

At the last meeting of this Faculty, I presented some remarks upon penetrating gun-shot wounds of the abdomen, and reported several cases of this character which had come under my care. Certain conclusions were deduced from the study of these and other reported cases, which I believe to be in the main correct. During the year which has elapsed since the reading of my paper, the subject has continued to attract the attention of eminent surgeons in this country and abroad, and what is of more importance, several successful cases of laparotomy for gun-shot and stab wounds of the intestines have been performed and placed upon. record.

The remarkable case of Dr. W. T. Bull, in which seven holes in the small intestines were sutured was alluded to in my paper of last year. It gives me great pleasure to mention here the equally remarkable and no less successful case operated on by Surgeon-General John B. Hamilton, of Washington, in which a pistol wound of the abdomen was received, and laparotomy was performed three hours after the receipt of injury, on July 1, 1885. Eleven wounds were found in the small intestine, two in the ascending colon, and a bleeding artery in the mesentery. The artery was tied and the wounds closed with Lembert sutures. On the seventh day feces passed per anum, on the twelfth the ball was passed with the stools and the patient made a good recovery.*

Dr. Augustus V. Parkt of Chicago, also reports a case of penetrating gun-shot wound of the abdomen in a boy of 16, upon whom he performed laparotomy. The wound was midway between the umbilicus and symphysis, and two inches to left of middle line ;.

*Journal Am. Med. Asso. Vol. V, No. 8, p. 202-1885, Aug. 22d.

+ Jour. Am. Med. Asso., 1885, Oct. 31, p. 494.