every case. It is true that some of the allied species have in a few instances given this reaction, especially the bacillus coli communis. Achard and Bensande found that prolonged expo. sure to a temperature of 60° C. did not affect the reaction, but that it was considerably diminished at 100° C., and was lost. entirely after boiling for fifteen minutes.

To obtain the serum, the method employed is to asepticise the end of the finger, ear or elbow; then make a small puncture, receive the blood and allow it to clot. Then decant the serum from the clot and add it drop by drop to the culture. If the serum is taken from a case of typhoid fever, the reaction begins at once. But if, on the contrary, it is taken from individuals in health, or from persons suffering from diseases other than typhoid fever, the reaction will not occur. That this reac·

tion does occur, and in the manner and way described, is admitted by all, but at what time in the course of the disease this agglutinating property appears in the blood in sufficient quantity to produce the reaction, is by no means settled.

By some

it is claimed to have been found to exist in such quantity as early as the second day of the disease. If the case be found by further trial to be reliable, Widal's serum test will be of very great practical value in the diagnosis of typhoid fever. But on the other hand, if it is found not to appear in such quantity until the fourth or fifth day, its value will be greatly diminished.

From what can now be ascertained the preponderance of testimony is in favor of its not being found earlier than the sixth day, and by this time usually the symptoms of this disease have so fully developed that a diagnosis may be made.

Biggs and Park, of New York, report 432 analyses made by Widal, Achard, Johnston and others, and make the number of successes 95 per cent. on the first examination.

DISCUSSION.

Dr. Massie being invited to take part in the proceedings said; I am very grateful to the Society for their courtesy, and I appreciate being with you in North Carolina. There has been a great deal written on typhoid fever and especially along the line of blood exrmination. The microscope has come into use within

the last ten or fifteen years and has been the means, as you know, of aiding surgery and medicine more than any other thing. The fact that when a man gets up to read a paper now, unless he goes into microscopic work his paper does not have the same amount of interest that it otherwise would demonstrates this advance. Our schools and colleges have established separate chairs for the teaching of microscopic work and the young men as they come up now are much better equipped than they have been heretofore. I do not know that the medical board has a separate chair but the Virginia Board established a separate chair of Histology, Pathology and Bacteriology. I do not know gentlemen that I can add anything to this paper as I have done no special work on typhoid in particular, though I have along other lines.

Dr. Long: If I am correctly informed, microscopic work is connected with our present examining board.

Dr. Duffy: In that paper there is a very useful thought-that of the influence of the typhoid serum upon the typhoid bacillus. It puts me to thinking somehow or other, that in the administration of the coal tar antipyretics we interfere with the power of the blood to manufacture the antitoxin which destroys the bacilli. I merely throw out this suggestion, it may be that in our efforts to cure, we hinder the destruction of the typhoid bacilli.

Dr. O'Hagan: I suppose he means that fever instead of being a destructive process is really a method of liberating and expelling these toxins from the body and should be encouraged.

Dr. Duffy: While my suggestion was that the reduction of temperature by chemicals might prevent the production of antitoxine in the blood, I would certainly be unwilling to make the patient hotter. We have not yet learned the process by which this antitoxin is produced which has the power of destroying the life of the bacilli, but we hope that the aid of the microscope may bring us to the attainment of this knowledge.

Dr. Register: I would like to ask the doctor if the cold water bath would have the same effect on the patient.

Dr. Duffy: In answer I would say by no means. In the first place, it is conceded that the main object in applying cold water is not to cool the patient but for its effect upon the nervous

system. Still, if to cool him were the only object, we do not introduce something into his blood which produces chemical changes and reduces the temperature. We do it either by the

influence upon the heat forming center by the effect of cold on the peripheral nerves, or by cooling him as we would a piece of iron, and not chemically.

Dr. Register: Dr. Duffy suggested that cooling the fever to a certain point might prolong the fever. I ask if reducing the fever with cold water would not have the same tendency to prolong the fever as cooling with drugs.

Dr. O'Hagan: I belive that the cold bath is universally admitted to be a great success, and that in applying it to the body, it is not for the cooling effect, but the tonic effect on the nervous system. The danger of using coal tar preparations has been pointed out years and years ago, I believe that the danger consists chiefly in its effect upon the process of metabolism. The more advanced physicians have now discontinued the coal tar preparations as of no value in the treatment of ebrile diseases. We all know this, that the labors of Pasteur-that greatest of all great men in his particular department-have proved the value of these antitoxic serums. In the production of that seram we are entirely unable to explain the vital process going on. We can know this, that the use of the serum has been attended with very beneficial results. We have not been able to diminish the mortality more than one-half, but I believe that the time is not far off when the serum treatment will be applicable to quite a number of diseases. I can only say, then, that I was very much interested in the Doctor's paper. I am perfectly willing to confess my ignorance of bacteriology, still I bow my head to those who do know something about it and are instructing the older men.

Dr. Poole: I have been using Ehrlich's tests for the diagnosis of typhoid fever through the urine now for four years, and it has not failed me in the four years. Diagnosis by the microscope is very nice and very true, but, as is known, not everybody has a microscope, and not every one is capable of using one if he has it. This diagnosis by Ehrlich's test, as you know, consists of applying a strong solution of sulphanilic acid to an equal amount of urine, and to that add a weak solution

of nitrite of sodium, agitate it and add a few drops of aqua ammonia. When this is done the reaction comes at once.

If we have typhoid fever, the reaction is such that it must become a blood-red color. The only objection that might be raised is that several other diseases will react just as typhoid fever. Fortunately, they are such diseases as any practitioner ought to be able to differentiate between without any test, such as inflammatory rheumatism and several others. I might add that the test must be applied between the fourth and fourteenth day.

WHEN TO OPERATE.*

BY JOHN C. RODMAN, M. D. Washington N. C.

'HE "When to Operate" in contra-distinction to the "How to Operate," or what to operate upon, shall be the subject of my remarks, and let me assure you gentlemen that it is no easy matter, with the necessarily limited experience of a country physician, to so elucidate these facts and theories, that it will be to you improving as well as interesting.

I shall begin with the following hypothesis, that it is just as important, if not more so in the majority of instances to know "When to Operate," as it is to know "How to Operate". Though the greater number of our text-books assume the case to be one in which only an operation is admissible, they teach us the technique, the mechanical part, and how to avoid the Scylla and Charybdis of our perilous course; yet fail to emphasise with the same care, the equally important question of "When to Operate”. This question of "How to Operate" admittedly is necessary and proper as a requisite to our career as successful surgeons. But in the intrest of our patients and our own reputation it behooves us at the same time to prepare ourselves for that all important step of "When to Operate," for the time when must be fixed in all operations of election before operative measures begin. And *Read before the North Carolina Medical Society June 8, 1897.

most frequently the correct answer to the question when? means a life saved or much pain. That point of time when taken into due consideration has saved many a woman from months of agony and an untimely end in mammary cancer. In this disease, "Time When Operated Upon," controls the prognosis. It is comparatively a simple matter to amputate a breast, though I must confess that in no disease is the old maxim more appropriate "What is worth doing at all is worth doing well" and thoroughly. Though the earlier an operation is performed in this disease, the less is this of vital importance and vice versa. I am happy to to say that there are very few physicians in this enlightened surgical age that do not in this disease advise an early operation and do a thorough one. That there are some who are tardy in this respect is to be deplored. To what degree "Time When Operated Upon," controls the prognosis in mammary cancer is as clearly shown in an article by Professor Frederick S. Dennis before the American Surgical Association some few years ago as in any literature I can find. Not only is this true of mammary cancer but of uterine cancer and all other operable malignant neoplasms. We can readily see, that if the inaccessible glands. are involved, and the cells of the growth are scattered in inoperable regions, that no matter how beautifully and skillfully the operation may be performed, it is all for naught, or at best for temporary benefit. While to the contrary, if it is performed at its proper time, viz, in the incipiency of the growth, even if the technique is faulty and the operator not so skillful, we give our patients a good fighting chance for life and health.

In appendicitis "The When to Operate" if at all, is the absorbing question, before which medical treatment, manner of surgical treatment etc., descend to a secondary place. Certain of our leading lights in the surgical world have said "The When to Operate" should be goverened mainly by pulse, some by pain and tenderness, and others by temperature, and still there are others who viewing the field with a broader .nd more extended vision have not attempted to formulate any set or fixed rules, by which an operation shall or shall not be performed in every case of appendicitis; but rather do they, and it is with this latter class that I most heartily agree, decide by the clinical phenomena presented in each individual case taken in toto.

We see cases