This lesion, as many other acute abdominal emergencies, may present anything but the classical history and appearances of organic disease. Just as in gall bladder lesions, and especially in acute inflammations dependent upon gallstones, where there is no previous history of gallstones themselves upon which to base a guess, so in gastric lesions there may have been a lifetime of perfect digestion. It may be stated that as a rule an ulcer in the pyloric regions will be found to have given at some time or another signs of its presence. A history, even if obscure, may furnish the missing link in the chain of evidence.

The most important symptom of pyloric obstruction is vomiting or regurgitation of food some hours after it is taken. The more complete the obstruction the more food will be regurgitated, until practically all that is swallowed will be returned. If the food is retained long enough it will be decomposed and offensive. Pain may or may not be present. The stomach may be dilated or even contracted. Its walls may be hypertrophied. At exploration the peritoneal surfaces are reddened and its vessels injected. If dilated the stomach will present the usual characteristics of dilatation. One may think before operation that he detects a tumor. It seems hardly necessary to say that gastric tumors cannot be felt unless they are at the pylorus or in the anterior walls, except when they are very large and project forward.

With characteristic vomiting, with or without pain or dilatation, progressive emaciation adds the required evidence for a reasonable diagnosis of pyloric stricture. If the vomitis contains blood, changed or unchanged, the question of an acute process, whether ulcer or cancer, must be considered. The opinion inclines toward carcinoma if the blood is changed, if there is cachexia, if the patient is over 35. It becomes a conviction if there is tumor. If the patient is under 35, if he is anemic rather than cachectic, if the blood is bright, the opinion must incline toward ulceration.

The stomach presents a field in which surgery may achieve some of its most brilliant results. From the anatomical, the physiological and the pathological standpoints this field is a most attractive and encouraging one.

In stricture of the pylorus of benign ori

When, however, there is a wide annular ring of cicatrix at the pylorus the method is faulty and unsatisfactory. The operation consists in converting a longitudinal slit in the wall of the duodenum and stomach with its center over the pylorus into a transverse one, by bringing the extremities of the wound in the stomach and pylorus in contact with each other. This approximation of the surfaces is satisfactory when the cicatricial ring is narrow, or when the cicatrix is confined to the posterior wall of the pylorus; for the new channel is then bounded everywhere except behind by normal mucous membrane. When, however, the cicatricial ring is broad, the new wall

Surgical Treatment of Uterine Displacements Resulting From Laceration of the Pelvic Floor.

C. K. Flemming (Journal of the American Medical Association, November, 1899) says: The uterine displacements which may demand operation are retrodisplacements and prolapse. Prolapse follows retrodisplacement, as the uterus in all cases, before it can become prolapsed, must be in a state of retroversion. We shall confine

our remarks to radical treatment of retro

displacement of the uterus. The principal operations devised for this condition are ventro-suspension of the uterus and Alexander's operation.

The indications for radical treatment of this condition are where the subjective symptoms are to be directly traced to it, as all retrodisplacements do not produce symptoms, and therefore do not demand treatment.

Ventro-suspension: The field of this operation is larger than that of any of the others. Its indications are a retrodisplaced uterus, adherent or not, producing symptoms; when the uterus is large and heavy, and particularly when complicated by unilateral or bilateral pelvic disease. The advantages of the operation are that it requires but one incision; it is easily performed and takes but a few moments, and the adnexia can be examined or removed if necessary, or treated according to indications.

The objections to this operation, increased danger of abortion and difficult labor, are without much foundation. The

A

percentage of abortions in women who have not received such operation is large enough as we find mentioned in various books on obstetrics that at least 20 per cent of all pregnancies end in abortion. In statistics of 75 cases operated on at Johns Hopkins Hospital, 14 became pregnant afterward and only one is reported as having miscarried, and that after violent dancing. number in this series had abdominal pain during the months of gestation, but am`unable to say whether it was due to fixation or not. Probably the best and most satisfactory method of performing ventro-suspension is that advocated by Dr. Kelly, but slightly modified, in which, after the preliminary work, the uterus is suspended from the peritoneum by two chromicized catgut sutures, which pass through the uterine muscle just posterior to the crest of the fundus. The mortality from this operation is nil, as it is by far the most simple abdominal operation to perform.

Operations on Round Ligaments: Alexander's operation is also a suspensory operation, the normal ligaments being used to hold the uterus in permanent anterior position. The round ligaments normally are simply guy ropes, preventing too much backward movement of the uterus and are in no way suspensory until the uterus has become prolapsed. Alexander's operation is becoming more popular every day as operators become acquainted with its advantages. The indication for the operation is clearly defined and is a pathologically retrodisplaced uterus, which is not adherent and in which there are no complica

tions, such as a tumor of the uterus or adhesions and inflammations of the uterine appendages. The operation should be performed as recommended by Edebohls, who has probably practiced it oftener than any other operator in this country. Some of the disadvantages of Alexander's operation are the difficulty of isolating the round ligaments, the inequality and possible friability of the ligaments, the two incisions, thus a double liability of hernia. The round ligaments are also shortened by intra-abdominal operations, which were devised by Wyley and Dudley, both of these consisting in making a median incision. The round ligaments are found within the abdominal cavity and folded on themselves and held in this position by suitable sutures. Neither have any advantage over either of the above-mentioned operations. Supra-Vaginal Hysterectomy.

M. Tuffier (Paris) says that he prefers supra-vaginal hysterectomy and that he employs the American method. He has modified the American method only by preserving the ovaries and by uniting by one ligature the two utero-ovarian pedicles. As ligature material he uses, with success, reindeer tendons.

He most always selects the abdominal route. If the fibroma be small, he may resort to the vaginal route.

Myomectomy has not given him remarkable results. He has been better pleased with the atrophying ligature. Bi-lateral cas

tration can be of service.

In cancer uteri he operates even if the process is advanced. In these cases the atrophying ligature gives only deceptions. The important step of the operation is the thorough removal of the canceric lymphatics in the broad ligaments.

In acute puerperal infections there are some forms in which the infection is localized to the uterine tissue. In these cases total hysterectomy can be of use.

Abdominal Hysterectomy in Treatment of Cancer of the Cervix Uteri.

M. F. Legueu (Paris), owing to the insufficiency of vaginal hysterectomy, owing to the defective results which it has given him, now treats cancer of the cervix uteri by abdominal hysterectomy.

He has performed this operation in two different categories of cases-complicated cases (they are the most numerous) and simple cases. By complicated cases he un

derstands extensive cancers associated with infiltration of the broad ligaments, appreciable glandular enlargements, and all other conditions that make the operation through the vaginal route impracticable.

Simple cases are young cancers not associated with peri-uterine infiltration, not extending beyond the vagina.

He sees no advantage in the preliminary ligature of the hypogastric arteries. He has abandoned the practice. He makes a systematic search for the lymphatic glands along the pelvic wall. In nine cases of advanced cancer, with infiltration of the broad ligaments, upon which he operated, the neoplasm recurred in all but one case. He believes that as abdominal hysterectomy is a more complete operation than vaginal hysterectomy, it is preferable to it. However, in advanced cancers, with infiltrations of the surrounding tissues, it is only a pal-. liative measure. The risks associated with the operation more than overbalance the benefits to be derived therefrom. He shall in the future consider these cases inoperable.

But in cancers limited to the cervix, with no apparent involvement of the broad ligaments, abdominal hysterectomy permits radical operating. He thinks that this operation is the therapeutic agent "par excellence" for these cases.

In the treatment of fibroids vaginal hysterectomy is also losing ground.

He has not abandoned vaginal hysterectomy in the treatment of inflammatory lesions of the adnexa. He has performed this operation for lesions of this nature ninety times. He has had four deaths and eightysix recoveries. What makes him prefer the abdominal to the vaginal route is that with the latter one cannot always do just what he wishes. Often one does too much; often not enough.

Induction of Abortion or Premature Labor in Pregnancies, Complicated by Nephritis.

The induction of abortion or premature labor in pregnancies, complicated by nephritis (be the nephritis of the gravidaric, parenchymatous or interstitial form), will, according to M. J. Lvov (Kazan), when timely performed, often be the means of saving the life of the mother, and in premature labor, also that of the child.

The procedure is indicated in the following conditions:

1. The kidney of pregnancy, when even under appropriate treatment the condition.

must furthermore be added, that there are no reliable data that it is harmful in the sense that it excites a more disastrous course in the sympathetically affected eye. This is more likely due to the inherent degenerative activity which varies in each case, so far as its destructive fatality is concerned.

Strong Sublimate Solutions in Treatment of the Eyes.

E. Guttmann writes to the Deutsche Med. Woch., Nov. 2, recommending the instillation once a day of six to ten drops of a 3 per 1,000 solution of sublimate on the inferior conjunctiva and conjunctival fold, avoiding the cornea as much as possible, the eyeball turned up. His experience with. several thousand cases thus treated at Magnus' Clinic has established its great efficacy in catarrhus muco-purulentus with severe symptoms-the mild forms do not require energetic treatment. It is also very effective in trachoma, but treatment must be continued longer than in cases of catarrh; the simple trachoma does not need it. It cures chronic gonorrheal dacryocystitis without the necessity of a sound, except in extremely old cases. The instillations smart for an hour or so, but not seriously unless the nerve terminals are exposed. The more intense the catarrhal symptoms the less subjective reaction and the more brilliant the results. No indications of intoxication have been observed in any case, and the immediate dilution of the solution by the secretions of the eye, precludes the possibility of intoxication. The solution must always be ordered sine spiritu, and the instillations made by the physician, at whose hands they will prove as "harmless as they are effective."—(Jour. A. M. A., Dec. 9, '99).

A New Intratympanic Masseur.

W. H. Weaver (Laryngoscope, Nov., '99) describes an intratympanic masseur composed essentially of a tube fitting between the cut-off and the catheter in which is placed a valve that cuts off the current once in each revolution. The valve is kept in motion by the impact of a small jet of air against a fan-wheel attached to the stem of the valve. It is capable of making from 4 to 20 revolutions of air puffs per second, according to adjustment. The sensation produced is rather agreeable and it can be tolerated from 2 to 10 times longer than Politzerization'. Tinnitis is rapidly re

Brunson (Op. Rec., Nov., '99) has collected the histories of 1,500 cases each of syphilis and rheumatism, and finds that iritis occurred in a little more than three per cent of the former, while in rheumatism the percentage was about one and one-half. He believes that if active heroic treatment is instituted when the initial syphilitic lesion is first seen, iritis will not occur once in 500 cases. The following table showing the differential points of diagnosis between iritis caused by syphilis, and iritis caused by rheumatism, is appended:

RHEUMATISM.

1. History of acute or chronic rheumatism, or some evidence of uric-acidæmia. 2. Photophobia, lachrymation, and pain well marked.

3. Condylomata never observed on iris. 4. Iris often bright.

5. Exudative changes slight.

6. Posterior synechiæ long, thin, and not pigmented.

7. Very little tendency to formation of pigment on anterior capsule of lens.

SYPHILIS.

1. History of syphilis, either acquired or hereditary.

2. Photophobia, larchrymation, and pain not well marked.

3. Condylomata present in every case. 4. Iris often very dull.

5. Exudative changes very extensive. 6. Posterior synechiæ short, broad, and pigmented.

7. Very marked tendency to formation of pigment on anterior capsule of lens.

Quinin Instillations in Suppurative Affections of the Anterior Segment of the Eye.

J. de J. Gonzalez (An. de Oftalmol: Jour. Am. Med. Asso.) announces that he has found neutral quinin hydrochlorate in a I per cent solution-ten drops three times a day-extremely effective in curing corneal ulcers and abscesses with purulent infiltration in the early stages, and hypopyon if not very large. He explains its efficacy by its mild bactericidal action, combined with its paralyzing effect on the leucocytes.