ANTI-TYPHOID VACCINATION:-In a very excellent article on this subject in the Pennsylvania Medical Journal, January, 1915, E. R. Whitmore, M.D., U. S. A., gives the following conclusions:

1. Anti-typhoid vaccination protects as well as does smallpox vaccination.

2. There is no danger from a negative phase.

3. Anti-typhoid vaccination does not increase tuberculosis of other disease.

So, anti-typhoid vaccination is definitely indicated: (1) In the Army, Navy, National Guard; (2) among the personnel of all hospitals; (3) in schools, asylums, prisons, workhouses; (4) in camps of all kinds; (5) among travelers; (6) among young persons; since typhoid fever is a disease of youth and early life; (7) among persons living in cities or districts where the typhoid fever rate is continuously high; (8) among the members of a household where a case of typhoid fever occurs; all contacts; (9) as voluntary vaccination of the non-immune population on the occurrence of an epidemic of typhoid fever.

EMETIN IN THE TREATMENT OF TRAUMATIC HEMOPTYSIS: -The virtues of emetin have been emphasized before Indianapolis physicians and the Indiana University Medical School students by Dr. S. E. Earp on frequent occasions. We note from the Paris letter on the war in the January 16 Journal A. M. A. that Drs. I. Dupont and J. Troisier, in view of the good results from emetin in tubercular hemoptysis, are arresting bleeding wounds of the thorax due to bullet wounds by one or two injections under the skin of 40 mg. of emetin hydrochloride. The dose may be safely

doubled.

Not severe vascular hemorrhage but the pulmonary bleeding in men who may be removed to hospitals. This observation may be observed in civil practice.-A. W. Brayton, in Indianapolis Medical Journal.

BY C. N. COWDEN, M.D., F.A.C.S., OF NASHVILLE, TENN. The excuse I give for this paper upon this time-worn subject is because it is one that confronts the surgeon almost daily in his routine work, and only by a more thorough appreciation of the condition upon the part of the internist can we hope to improve our present mortality results in the treatment of this malady.

The majority of cases are first seen by the general practitioner, and the safety of the patient depends upon his quick decision and hearty co-operation with the surgeon. It is quite a problem and one requiring the highest degree of skill as a diagnostician to be able to decide that this case will require an operation and the other one be subjected to medical treatment. The time has almost arrived when the public realizes that surgery is for the sick and not for the dying, and many patients are aware of the great

*Read at regular meeting of the Nashville Academy of Medicine, Tuesday, Jan. 19, 1915.

danger of a delayed operation. The death rate in every community is still inexcusably too high and an early diagnosis is the only way to lower it; the great difficulty is to get the men who see only one or two cases a year to recognize the danger signals before it is too late.

A few years ago the patients or the laymen were as a whole very much opposed to any operative procedure whatever, and the general practitioner halted to see what the result of general treatment would be; to-day the very word "Appendicitis" is beginning to mean to them an operation as the only safe and sane method of treatment. They have advanced far along the line toward the ideal treatment of the disease, and many of them recognize the symptoms that make the diagnosis. There was a time when fate vested the ability to recognize early peritonitis only in surgeons, and in a very few of them, but now every practitioner should be able to make the diagnosis, and he can do it if he will but try.

The charge that I bring against the general medical man is not incompetency, for they can almost to a man make the diagnosis and reach a correct conclusion. The fault lies in the fact that a careful examination was not made. The patient was not gone over systematically, one organ after another, section after section, after he had gotten a reliable history of the case; hence, a snap-shot diagnosis was made, and death from an unloaded, empty gun is the verdict. As an illustration, a short time ago I was asked to see a patient in consultation with one of those busy men. The patient had an uncontrolable diarrhoea of four weeks' standing that had resisted every kind of a Bismuth mixture with the opiates and all. I turned down the bed linen for an examination of the abdomen and found what? Elephantiasis of the scrotum in the ulcerative stage with general sepsis, and death the next day. This man is a good doctor; he just simply had failed this time to even look in the direction of the patient.

The surgeon has known all the time where the cause for the high mortality in peritonitis lies; but for fear of offending one of his friends, one who refers his work to him, he is content to accept the responsibility and meet the conditions as best he can. Far better would it be if he would be candid and frank with the physician, and show him wherein he has failed to interpret aright the symptoms of danger. He only sees a few cases each year perhaps; and he is not on the lookout for this condition that is so much dreaded by the surgeon. The symptom complex is nearly always a typical one; and if we would go over them with him, in connection with the case in hand, it would be a mutual benefit to all, and could not help but result in greatly reducing the mortality and the morbidity of this disease. My limited experience has been that they can make the diagnosis; but like they are in regard to cancer, they don't want to call it that until the last moment; peradventure that it might be something else.

Peritonitis is not an obscure or mysterious disease, but is one with which anyone can become acquainted, not only with the symptoms and diagnosis, but with the pathology and treatment as well. We hear much said about two classifications of the disease, local and general. When the real facts are, that one is only an early or late stage of the other. In other words, one might almost venture an opinion that no peritonitis is general in its origin. There is a focus from which the disease proceeds; and whether that focus is to remain localized or become generalized must depend upon accidents associated with the nature of the infecting agent and the rapidity with which it progresses -the less acute the one and the slower the process of advance, the more likely is the result to be localized peritonitis.

The real point of confusion enters when the peritonitis at the focus of infection advances considerably before a limiting check is reached; so that, for instance, it might

happen that, in certain cases, a considerable part of the lower peritoneal cavity would be involved. In many appendiceal affections, and in inflammatory diseases of the female pelvic viscera, this more extended involvement of the peritoneum is met with; and when so encountered is frequently described as a case of general septic peritonitis. It is not easy in many cases of this class to say beforehand that the case is not one of general peritoneal infection, for the whole abdominal parietes may be rigid and tender to pressure.

These cases are very amendable to treatment, and if the abdomen should be opened we would find that the process had been walled off and confined to the pelvis, and these local conditions are held in check by the limiting adhesion and never involve the entire cavity, while others begin at a focus and spread unchecked until the entire serous surface is involved. The local slowly merging into the general are at times so rapid, the virulence of the infection being so great or the defensive action of the patient so slight, that no limit or check of the disease can be noted. Hence, we will have to admit that it is impossible to make the distinction between the two, but they will have to be treated as different stages along the progress of the disease.

The peritoneum is practically an analogue of the skin, and has been computed to be about equal to it in surface area. It covers, to variable extent, almost all the abdominal viscera; and so provides a protection for them, and a means by which those that are mobile can harmlessly move the one over the other. In the male the peritoneum forms a completely closed cavity; in the female the Fallopian tubes open into it.

The peritoneum is abundantly supplied with blood vessels and nerves; but its degree of sensibility to mechanical and chemical impressions varies considerably. Thus, the peritoneum forming the mesenteries, mesocolon, and that lining the abdominal parietes is very sensitive. The peri