tion, the skin being loose, and in many places, especially on back and thighs, so natural as to require close examination to discover its artificial

nature.

SURGICAL SUGGESTIONS. Syphilis of Larynx.-An early diagnosis of syphilis of the larynx is important, as in this stage it can be satisfactorily treated, while neglected tertiary lesions are often incurable, except, perhaps, by radical surgical measures. -ANDERSON.

Examination of Virgines Intacte.The bimanual examination of virginis intacte should always assume the form of a recto-abdominal palpation. There is no need in these cases of a vaginal examination; the finger in the rectum will teach us all we wish to know concerning uterus, tubes, and ovaries. The only difficulty to be overcon e is to identify the cervix; a little practice will enable us to master this detail.-EDEBohls.

Intra-cranial Hemorrhage. - Intracranial hemorrhage is regarded as a very natural accident in Bright's disease, atheroma, and hemorrhagic pachy meningitis.

Tuberculous Iritis.- -1. Tuberculous iritis must be distinguished from other varieties of iritis. 2. This form of iritis is premonitory of the appearance of tuberculous nodules elsewhere. 3. Its invasion is insidious, slow, and with but little local reaction, bnt is accompanied by numerous posterior synechiæ. 4. The absence of pathognomonic symptoms

makes the diagnosis difficult. 5. The tendency to spontaneous healing of miliary tuberculosis of the iris depends upon the natural resistance of the iris tissue. The encapsulation of the tubercle and the rapid obliteration of its nutrient capillaries favor its isolation and the protection of the healthy tissues.—VIGNET.

Shock is a disturbance of the functions of the nervous system, induced suddenly by a violent stimulation made directly on the nerve-centres, or indirectly through the peripheral nerves, whereby the harmony of action of the great nervous centres, more especially of the sympathetic ganglia, and through them of the various organs of the body, becomes deranged. It is essentially a depression of nerve-force, and bears in effect the same relation to the nervous system as syncope to the vascular.CONNERY.

Black Eye.--There is nothing to compare with the tincture or strong infusion of capsicum annuum mixed with an equal bulk of mucilage or gumarabic, and with the addition of a few drops of glycerine. This should

be painted all over the bruised surface with a camel's-hair pencil and allowed to dry on, a second or third coating being applied as soon as the first is dry. If done as soon as the injury is inflicted, this treatment will invariably prevent blackening of the bruised tissue. The same remedy has no equal in rheumatic stiff neck.

Dislocation of Ulnar Nerve.-Dislocation of the ulnar nerve at the elbow

is a comparatively rare affection, occurring independently of fractures or dislocations of the bones of the elbow, and may result from direct violence, or from muscular effort or violent flexion of the arm at the elbow, causing laceration of the fascia which holds the nerve in its groove at the back of the inner condyle of the humerus. The symptoms resulting from this injury-pain, tingling in the parts supplied by the ulnar nerve, and a certain amount of disability of the elbow-are usually more marked immediately after the injury, but the symptoms usually become less marked in a short time, in many cases very little permanent disability seems to follow, the nerve accustoming itself to its new position. Very rarely a neuritis is developed. In view of the possibility of the development of a neuritis, it seems wise to replace the dislocated nerve and fix it in its normal position as soon as possible after the injury. The most satisfactory method of securing the nerve seems to be that practised by Mr. MacCormick, who exposed the ulnar nerve, and having made a bed for the nerve by dividing the fibrous structures behind the inner condyle of the humerus, fixed it in its usual position by two kangaroo-tendon loops passed through the inner margin of the triceps tendon and somewhat loosely around the nerve; several sutures were also used to unite the divided margin of the fascial expansion of the triceps tendon superficial and the

cur, and in no case is it recorded that neuritis developed in the nerve as a result of of operative treatment.WHARTON.Medical Record.

RECENT ADVANCES IN CEREBRAL SURGERY--Von Bergmann (Centralblatt für Chirurgie, No. 27, 1895), at the German Surgical Congress, brought to notice certain advances that have recently been made in the department of cerebral surgery.

In cases of tumor of the brain, surgery has, of late, done very little beyond facilitating a correct diagnosis, and rendering operative interference less dangerous. In Jacksonian epilepsy surgical treatment is usually followed by a relapse, and a certain cure can only be effected in which the convulsions are due to the compression of a circumscribed cortical motor centre, as by tumor or cyst. On the other hand, decided progress has been made in the operative treatment of different forms of intracranial suppuration of otitic origin, such as cerebral abscess, epidural suppuration, infective thrombosis of the lateral sinus and leptomeningitis. The most dangerous forms of chronic aural suppuration, which is usually excited by a collection of cholestomata in the interior of the ear, are indicated by intercur rent acute and subacute attacks with fetid discharge, and by the presence of polypoid granulations in the tym panic cavity and the auditory meatus.

The extension of the inflammation through the thin and carious ligamentum tympani sets up a pachy meningitis, which in turn gives rise to an extradural or epitympanic abscess, or

As

to intradural or cerebral abscess. The cerebral abscess, when small, and in an early stage of development, is situated on the surface of the brain, but as it enlarges it sinks into the substance of the affected lobe. the diagnosis between a superficial and epitympanic abscess on the one hand, and a cerebral abscess on the other, is attended with much difficulty, the author holds that in performing an operation it is necessary to expose both the extradural abscess and the part of the temporal bone most likely to be involved in the extension of the suppurated process. An operation is described by which the upper and anterior surface of the petrosal bone through a quadrangular opening made in the squamous portion of the temporal bone, just above the line of the zygoma, and between a line in front drawn directly upward to the sagittal suture from the tragus and a parallel line behind carried upward from the posterior border of the mastoid process. By this wound the mastoid antrum and cells may be opened when necessary and the sigmoid fossa reached. In conclusion, the author alludes to the successful surgical treatment of infective thrombosis of the lateral sinus.

Exposure and incision of the sinus with ligature of the internal jugular vein proved successful in six out of thirteen cases treated by Jansen, of Berlin. These cases added to those of Macewen and other surgeons showed that the operative treatment resulted in recovery in twenty-seven out of forty-five patients. Thrombosis of the lateral sinus is often associated with an extradural abscess

In ex

on the roof of the tympanic cavity, and in most cases of cerebellar abscess forms a communication between this collection of pus and the suppuration in the middle ear. posing the outer surface of the mastoid process and the bone lying behind this, search should be made for the mastoid emissary vein. Not only is the orifice a good guide to the sinus, but in addition, the state of the vessel may aid in the diagnosis. If it contains pus, suppuration in and about the lateral sinus is indicated, if it be blocked by a thrombus, this will be a sure sign of thrombosis extending into the cavernous sinus. The author attributing much of the recent progress in cerebral surgery to improvements in technical details and in the instruments, makes use of an electric circular saw with which he divides the outer table, while the inner table is divided by the careful use of a chisel.—University Medical Magazine.

TREATMENT OF DIABETES.-Robin (Bulletin de l'Académie de Médecin, No. 23, 1895) employs what he terms an "alternating treatment" in diabetes. He believes that in this disease there is an increased activity of the chemical changes of general nutrition, and of the hepatic cells in particular, which is the result of increased activity of the nervous system. Hence he recommends drugs which diminish the activity of these general changes by acting primarily on the nervous system. The treatment is divided into three stages: (1) For four days a powder, containing about fifteen grains of antipyrin and ight grains. of sodium bicarbonate, is given twice.

a day. In addition cod-liver oil is taken twice a day, and Seignette salt as a morning purgative. (2) At the end of four or five days the antipyrin is discontinued, sulphate of quinine prescribed, six grains in a cachet at the mid-day meal. This is taken for six days, then discontinued for four days, and afterwards taken again for six days. Before the morning and evening meals a cachet is recommended containing arsenate of soda, ca: bonate of lithium, and codeia. (3) After fifteen days these drugs are discontinued, and the author prescribes, for ten days, a pill containing opium, belladonna, and valerian. The cod-liver oil is discontinued and the patient is allowed to drink a weak solution of bicarbonate of soda 1 in 125. In the case of nervous women, or if there should be intolerance of the opium and belladonna pills, fifteen grains of potassium bromide are given two or three times a day for eight days. In addition to the medical treatment the diet is regulated. On account of the loss of inorganic salts in diabetes the author recommends the food to be well salted; to supply potassium salts he advises green vegetables, especially cabbage and endive, and also a weak solution potassiom tartrate to dilute the wine taken at meals; and to counteract the loss of phosphates of magnesia. He also recommends bouillon on account of the inorganic salts which it contains. If sugar is still present in the urine after the third stage of the medical treatment above mentioned the course is recommenced. After a second course, whether sugar has disappeared or not, the drugs are dis

continued for one month. Robin has treated by this alternating method 100 cases of diabetes, in each of which the daily quantity of sugar excreted was 100 grammes or more. In twentyfour of these recovery has occurred; in twenty-five recovery is still doubtful; in thirty-three there has been considerable and permanent improvement; in eighteen the results have been negative. -Medical Recard.

VAGINAL SECTION AND DRAINAGE FOR PELVIC ABSCESS. --Watkins(American Journal of Obstetrics, August, 1895), in a paper read before the Chicago Gynecological Society, May 24, 1895, reports a number of cases where he has performed vaginal section and thus drained a pelvic abscess with the best results. The operation is indicated.

(1) When the condition of the patient is such as to make abdominal section extremely dangerous.

(2) When the abscess is large, of long standing, and situated low in the pelvis, and when the patient gives a history of peritonitis.

(3) When abdominal section reveals extensive and firm intestinal adhesions.

(4) When the abscess is on the floor of the pelvis and is complicated by rectal fistulæ.

(5) Vaginal section may be indicated for the separation of adhesions which fix the ovaries and tubes on the floor of the pelvis, and for examination of the ovaries and tubes.

(6) Puerperal abscess. These abscesses frequently involving the tubes and ovaries, and satisfactory results usually follow through drainage of them.

The writer has done vaginal section for pelvic abscess nineteen times, and in every case the result has been relatively satisfactory. In two cases operations for secondary abscesses were required; in one case abdominal section was necessary to complete the operation. Excepting in the two cases which developed additional or secondary abscesses, the temperature became practically normal within a short time, and the patients have been out of bed at the end of two weeks. Many of the operations are of too recent date to permit a satisfactory report of the ultimate success, but some date back three years. None of the patients, to his knowledge, suffered especially from pelvic disease after the operation. Three have some enlargement to the left of the uterus, which may later on require abdominal section, and two of them have a sinus. The advantages of the operation

are,

(1) It is not dangerous to life. (2) It is followed by little or no suffering.

(3) Recovery is rapid.

(4) No raw surfaces are left in the abdominal cavity to cause adhesions. The objections to the operation are,

(1) It is applicable in only a small per cent. of the cases of pelvic ab

scess.

(2) Diseased tissue is not removed. The tissue may, however, become normal after the abscess is opened and drained, as has frequently been the case after spontaneous rupture or puncture of the abscess. The nature of the abscess must be considered in

selecting this method of treatment. For example, tubercular or gonorrhœal abscesses indicate excision more than abscesses due to some other infection. Watkins believes this operation should take the place of vaginal puncture or aspiration, since there is less danger of injury to the bladder, rectum, or some other portion of the intestinal tract. He has seen two cases where large blood-vessels have been injured with a fatal result. He advises vaginal section rather than celiotomy and secondary vaginal puncture, saying that celiotomy could be immediately performed if necessary. Vaginal section is performed as follows: The uterus is dilated, the uterine cavity explored, curetted, irrigated, and packed with gauze, if indicated. An incision about one inch long through the vaginal wall is made near the cervix, opposite the most prominent point of the tumor, -usually posteriorly. All connective tissue between the vaginal wall and the abscess is separated with the finger, or it may be necessary to divide some of the fascia with scissors. Careful exploration is then made determining whether the peritoneal cavity has been opened, and if so, it should be carefully walled off with gauze packing. The finger is then passed directly into the abscess, using a blunt instrument, if necessary. All pus is removed by thorough irrigation with sterilized water. Two drainage-tubes sutured together, one large and one small, are inserted and fastened to the cervix by sutures. Drainage should be continued as long as there is any discharge.