clavicle is very suspicious. If there are several of different sizes the case is settled, especially if they grow and others appear.

We cannot insist too much on care and thoroughness in palpation. We must feel for a thing as though we intend to feel it, and not idly "poke" as patients sometimes call it. Taking the abdomen for instance, begin as high in the epigastrum ás you can feel the aorta; let it beat against your fingers, tossing against them all the intervening tissues and organs; follow it down to the bifurcation and then follow the iliacs as far as possible. This enables one to get an idea of the tissues overlying the great vessels. Then feel deeply alongside the aorta, remembering the masses of glands that lie along the spine there. If they are greatly enlarged they may be felt. Now draw the knees up and so place them that they are comfortably supported without voluntary effort, the epigastrium may then be explored for tumors or tender points. Sometimes patients complain that pressure causes pain when they mean simply the disagreeable sensation we all have on deep abdominal pressure. Asked whether it is only this or a soreness as of an inflamed part, intelligent patients will usually answer correctly. Next feel from the right hypochondrium to the pelvis, feeling every structure between the fingers and the posterior abdominal wall, letting the movable structures slowly slip under the fingers with pressure enough to feel their consistence, and repeat the maneuver until satisfied.

The liver, gall-bladder, kidney, colon, mesenteric glands, appendix and possibly a part of the ureter should be in mind; they are all there and all can sometimes be felt. Afterwards go to left side and proceed as carefully. It was a lesson to see the late Dr. Fenger palpate an abdomen. If he couldn't tell you everything that was there in a favorable case, he could tell you that certain conditions: e. g. a large induration, were not there. In feeling for glands in the base of the neck, one should differentiate every palpable structure before concluding the examination.

A cancerous gland does not feel flat and flabby, but full, rounded and generally hard. Every one should practice on the glands in advanced breast cancer. There is frequent opportunity. Palpation is capable of indefinite improvement if practiced with care and thoroughness.

In doubtful tumor in the epigastrium or umbilical region or hypochondrium, inflate the stomach with seidlitz powder, the parts given separately, and if nothing is gained in that way, inflate the colon with a bulb such as is used in Paquelin cautery. It will sometimes give valuable aid. When a case has been carefully studied from all standpoints and all ascertainable facts are gleaned, and the diagnosis is still uncertain and no improvement in the condition is noted in a reasonable time, we still have the incision; and in view of the certain information it may afford, and the possibility it offers of relieving or curing he condition, it is advisable. Why waste months with medical treatment when it is evidently doing nothing.

After incision, a patient will need about three weeks in bed, and after the first forty-eight hours is comfortable; and the time of enforced rest may be of the greatest service.

Incision is recommended by such eminent authorities as Keen and Kocher. It is the logical result of surgical experience.

Careful manipulation of the organs can do them no harm. It is no small advantage to be able to say to a patient distressed with the thought that he has cancer of the stomach, that he has not. The simple separation of a few adhesions has relieved serious symptoms. Incision enables one to examine the stomach, duodenum, pancreas, liver and gall-bladder, organs which sometimes require inspection and touch to enable one to make a diag nosis certain enough to admit of proper treatment.

If cancer of the stomach is ever to mean anything but a deathwarrant, it must be diagnosed early. To wait until a visible or palpable tumor forms, is often too late for radical treatment.

A definite anatomical diagnosis is of the first importance and can not be made without direct inspection.

Certain ulcers never heal, and these are the ones among which the 5 per cent. of cancers occcur. Surgical treatment of such cases, and of early carcinomas, is already brilliant, and has a promising future.

ary

PELVIC SUPPURATION.

BY A. J. PULS, M. D., OF MILWAUKEE.

In reviewing the cases of suppuration within the pelvis, coming under my observation, I do not intend to follow the customorder of the text-books, to outline first the etiology, next the symptoms, diagnosis and prognosis, and then the therapy, but will confine myself to the causes and pathologic changes, and to the treatment of the various forms of the inflammatory pelvic affections which are familiar to us and are seen by the general practitioner in his daily practice.

Those interested in this line of work will find the books published by August Martin (Krankheiten der Eileiter), Howard A. Kelly (Operative Gynecology, Bk. II, Chapter XXVII, p. 209), very useful; a still more detailed description may be found in J. Veit's Handbuch der Gynickologie, Bd. III, 2, written by A. von Rosthorn, who treats at great length the anatmy and pathology and the inflammatory processes of the interstitial tissues of the pelvis.

The study of pelvic suppuration following inflammatory processes, discloses the fact that the causes are due to infection by the invasion of pyogenic germs. The text-books make mention of the various pus-producing microorganisms, but lay little or no stress upon the fact that traumatism is a potential agent to change latent chronic into acute inflammatory processes.

Another important factor in the etiology of pelvic suppuration may be found in the intestinal tract, on account of its close contiguity with diseased pelvic organs.

The traumatic influence on diseased tissue is shown clearly in a case of catarrhal appendicitis reported by Rose. (Deutsche

Med. Wochenschrift, No. 14, April 3, 1902. Die Untersuchungsmethoden Bauchkranker auf Wurmfortsatzentzuendung). A laborer receiving a bruise over the seat of the appendix, developed a general peritonitis which terminated fatally. No signs of perforation of the intestines or appendix were found. Rose offers this explanation, that the septic germs traversed the diseased appendicular serosa and produced a violent, fatal peritonitis.

Some time ago Fenger opened up a cecal abscess on a patient on whom appendicectomy had previously been performed. He claimed that an infected focus, in this case probably the ligaturestump, becomes the seat of an acute disease by traumatism, such as the action of a cold bath had on this patient. Similarly, exposure to a cold, or local injury, can inflame unhealthy tis

sues.

Both the vermiform appendix and the sigmoid flexure of the colon, as well as other parts of the intestinal tract, when once glued to the adjacent uterine appendages by peritoneal adhesions, may by their contiguity, under the influence of traumatism, give rise to intrapelvic suppurative inflammation. In studying the anatomy of the right uterine appendage, we notice a close association of the appendix to the ovary by means of the appendiculo-ovarian ligament. This ligament, although not sharply marked, is a peritoneal fold covering the ovarian vessels, and from it arises the infundibulo-pelvic ligament. At the third lumbar vertebra in the posterior abdominal wall, it branches off and descends laterally to the iliac fossa, to connect with the appendix. (Ernst Fraenkel. Die Appendicitis in ihren Beziehungen zu den Ekrankungen der wieblichen Sexual organe. Sammlung Kl. Vortraege, 323).

If the vermiform appendix is normally situated, it occupies the pelvic position; its distal half overlies the border of the psoas muscles, also the common or external iliac vessels, and hangs over into the pelvic cavity. (Waldeyer).