dilated; in compression it is almost always dilated and insensible; sometimes unequal on the two sides.

Treatment.-Shave the head and examine it carefully; if there be no sign of fracture or injury, treat the case as one of apoplexy; the indications are to lessen hemorrhage and arrest inflammation by cold applications and purgatives.

If insensibility continues and the patient grows gradually worse, it is recommended to trephine him, in the hope of letting out the blood that has extravasated underneath, and thus relieve the pressure.

FRACTURES OF THE SKULL.

These are caused by great violence, such as blows or falls on the head, and gunshot wounds.

The symptoms and consequences of fractures of the skull depend on the conditions which accompany it, especially the amount of concussion; the forcing in of portions of the bone; the complication with scalp wounds; the situation and the inflammation excited.

Simple fracture with depression may be ascertained by examination of the shaved scalp; there will be a depression at one part, with a corresponding edge or projecting ridge around it.

Treatment. In a case of simple depressed fracture, if there be no symptom of compression, and if the patient is conscious and rational, he should be kept on the strictest regimen; lying down, head raised; cold water to head and aperients are the remedies. If there be slight symptoms of compression the same plan will answer.

If the fracture be compound, with slight depression, it is best not to trephine unless the symptoms are urgent.

If comminuted, and it is probable splinters are sticking into the brain or its membranes, the bone must be elevated. If possible, it should be done with the elevator alone.

Fracture of the inner table.-The inner table may be extensively splintered by injuries which perforate or slice through the outer table; such as cuts from sabres and blows with heavy weights. If after careful examination it is found that depression exists, the trephine should be used to raise or remove splinters.

Fractures of the base of the skull may run in various directions; they are most frequently found passing through the petrous, squamous and sphenoid bones.

The diagnosis will be founded on the nature of the injury; the patient will probably be injured from having been pitched on his head; there will probably be bleeding from one ear; after the bleeding has ceased a most significant symptom is the draining through the ear of a clear fluid; symptoms indicating damage to the nerves that escape from the base of the skull may be noticed; bleeding from the nose and mouth will show the direction of the fracture.

Symptoms and prognosis depend on the amount of injury to the brain; stupor, dilated and unequal pupils, with rapid pulse, hot skin and dry tongue and delirium are unfavorable symptoms.

Treatment.-Absolute repose, low diet, giving the patient a purge, ice or cold water to the head, are the remedies.

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Trephining.-The pericranium being raised, by means of a blunt scalpel, from the part which is to be perforated, the surgeon applies the trephine with the point of his forefinger protecting the crown, and working it with an alternate pronation and supination of the wrist; and when it has made a circular groove deep enough to work it steadily, he must take care to withdraw the centre pin. He must saw steadily and cautiously, frequently examining the groove, to ascertain whether he has reached the dura mater, and when he has he introduces the broad curved forceps, to

raise the circular piece of bone. The greatest care must be taken to fix the centre pin and the greater part of the circumference of the instrument on firm bone, and by no means press heavily while sawing on any piece of bone that is loose or yielding. When the saw reaches the diploë there will

FIG. 10.

HEY'S SAW.

be an escape of blood with the bone dust, but there is no diploë in either children or aged persons,

When the piece of bone is removed the surgeon must gently insinuate

FIG. II.

ELEVATOR.

the point of the elevator under that which is driven in, and using his finger, or the edge of the firm bone, as a fulcrum, slowly raise it to its proper level. All loose fragments having been removed and the wound sponged, the scalp must be carefully laid down.

GONORRHOEA.

Gonorrhoea is a contagious purulent inflammation of the mucous membrane of the genitals of both sexes.

The time at which the disease usually appears after contagion, is from the fourth to the fifth day; the later it appears the less severe it generally is.

The patient first experiences a sense of titillation in the urethra, as if a drop of urine were contained in it. Upon examination, he finds that the lips of the urethra are red, and that there is a slight mucous discharge. Soon the urethra begins to be affected with considerable heat, and pain is experienced in voiding the urine, which is called ardor urinæ. The pain in many cases becomes excessively severe; there is an appearance of threads mixed with the urine. The next effect is a considerable diminution in the stream of urine, the swollen state of the urethra contracting the size of the canal; it is often discharged in two or more streams, becomes

forked, in consequence of the irregular and contracted state of the urethra, and is passed with much straining, pain and scalding. At first the discharge is mucous, but after a little time it assumes a purulent appearance. The matter becomes yellow, and in some cases green, and it is frequently mixed with blood, so as to give the discharge a sanious appearance.

The disease does not confine itself to the beginning of the urethra, but extends along the course of the canal, and often produces inflammation of the glans and frænum, occasioning effusion into the prepuce and phimosis. The absorbent vessels on the dorsum penis often become enlarged and hard, and produce little abcesses, which go on to suppuration.

In a first gonorrhoea the glands of the groin are often sympathetically affected, and become enlarged and painful.

Irritation and inflammation also take place in the corpus spongiosum, producing the painful state known as chordee. The penis is sometimes curved, and sometimes turned considerably to one side, and the groins, thighs, perineum and testicles ache and feel tender.

After the inflammatory stage abates, a muco-purulent discharge remains, which, when obstinate and thin, is called gleet.

In the inflammatory stage of the disease there is often irritation or actual inflammation of the urinary organs, causing the most exquisite agony, or complete retention of urine. This inflammation may reach the bladder, giving the patient a desire to frequently pass water, and causing great pain in doing so.

There may be hemorrhage from the urethra; inflammation of the lymphatic glands of the groin, constituting bubo; balanitis, or suppurating inflammation covering the glans penis; phimosis, paraphimosis, or inflammation of the testicle in men, or the ovary in women.

Treatment. The treatment should begin with a free use of a mild sedative injection into the urethra. The bowels should be opened by some saline aperient. Abstinence from all alcoholic liquors should be enjoined; the diet should be very plain, and sleep should be procured by Dover's powder, or other anodynes. The sulpho-carbolate of zinc lotion, applied several times a day, is highly recommended by Mr. Wood.

If the patient is strong and plethoric, and suffers greatly from pain and fever, with pain in micturition, it is well to apply two or three leeches to the perineum.

After the acute symptoms have subsided, the remedies of the best reputation are copaiba and cubebs. It is best to give the copaiba in small doses, and the cubebs in larger doses; the oil of sandal wood also has a high reputation.

The most usual mode of administering copaiba is in the form of emulsion, prepared by rubbing the balsam up with gum acacia, and adding camphor water and spirit of nitrous ether, to which a little tincture of opium may be added; great benefit is frequently to be derived from combining the copaiba and cubebs in the same emulsion. Painful erections and chordee may be relieved by a bag of cold water applied to the part; or, a little mercurial ointment and extract of belladonna may be smeared on the part at bedtime. Hemorrhage may be checked by cold water and ice pressure on the urethra at bedtime.

ORCHITIS.

Acute orchitis, or acute inflammation of the testicle, may be caused by local violence, or may occur in conjunction with gonorrhoea; and it is liable to be induced by employing injections and at the same time neglecting to use a suspensory bandage.

Symptoms.—If the patient is suffering with gonorrhoea the discharge will cease, and he will complain of aching pains in the testes and cord, followed by tenderness, swelling, fever, and frequently by vomiting. The part first and chiefly affected is the epididymis. The swelling arises mainly from an effusion of lymph and serum into the tunica vaginalis.

The symptoms of epididymitis closely resemble those of orchitis; in the latter the constitutional disturbance is greater, the local pain much more intense, and the patient does not assume the erect posture, but walks best with his legs apart. In orchitis the testicle is felt to be enlarged, globular, extremely sensitive and tender. When the epididymis is inflamed it will be found above and behind the testicle, lying like a thick semi-lunar mass, threatening to overlap the testicle above, below and at the sides.

Treatment.-Absolute rest in the recumbent posture; leeches over the cord, and opium at night, to allay pain. Purgatives, warm fomentations, and a suspensory bandage, to elevate the parts on the abdomen.

When the acute stage has subsided, strapping, by the application of adhesive strips, should be employed.

Chronic orchitis (sarcocele) may succeed an acute attack or it may arise spontaneously. The exciting causes are chronic cystitis, hypertrophy of the prostate gland, stricture and gonorrhoea.

If the exciting cause is still in operation it must, of course, be removed; he patient should be confined to his back and put on the use of iodide of

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