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oughly carried out over an area of about one third the circumference of the anus, the catgut suture tied in place is used to sew up the incision, care being taken to accurately coaptate the margins of the same. After this suture is in place, and before it is finally tied, with a large needle and a large catgut — of the size usually employed in cervix operations a single suture is passed well within the anus in such a way that it completely surrounds the cavity which has been undermined beneath the membranous covering. Before this is tied, all blood which has oozed into the cavity is carefully expressed; and then this interrupted suture is snugly tied in place. The effect of this is to control the hemorrhage by stopping it, and also to prevent the dilatation of the artificially formed sac by oozing. If the hemorrhoids are confined, as sometimes happens, to one half the area of the anus, all of the sub-membranous dissection can be accomplished through one incision ; if the hemorrhoids are in the form of pediculated tumors, the latter can be snipped away so closely at the base as to leave an elliptical opening, through which the adjacent tissues can be excised. This will require a continuous suture for each mass removed. If the hemorrhoids are diffuse in character and completely surround the anus, I have found three incisions at symmetrical parts of the anus sufficient to accomplish complete excision of the hemorrhoidal mass throughout the entire circumference. After these incisions are closed their long diameters are all parallel to each other and to the long axis of the bowel, and there are no contracting cicatrices to cause subsequent trouble. Some care and judgment are necessary in order to know how far to carry the excision externally upon the skin. If enough is not removed, after the healing takes place tabs of superfluous tissue may be left behind, to which some patients will object. A little attention at the time of operating will usually obviate this difficulty. It is no unusual thing to have union by first intention take place, and I have had these patients discharged, in favorable cases, in eight or nine days. The after suffering is usually confined to forty-eight hours, and is no more acute than after other operations for hemorrhoids. The relief has always seemed to me to come more promptly than after other operations which I have attempted. It seems to be permanent in character, for, not to my knowledge, has any one of the cases operated upon by myself required a second operation. One of my earlier cases, operated upon seven years ago, I still have access to, and although it was a typically bad case, up to the present time there has been no rectal symptom of any kind. In many of the cases operated upon by this method it was difficult, if not impossible, within a short time after the operation to discover that any operation had taken place.

To summarize the benefits of this method : first, it can be readily performed; second, there is a minimum loss of nondiseased tissue; third, the pathological tissues are radically removed; fourth, it is next to impossible for a recurrence to take place, since the hemorrhoidal tissue is so thoroughly removed ; fifth, union by first intention frequently takes place; sixth, all cicatrices are in the long axis of the bowel, and are of such a character that a minimum amount of contraction takes place; seventh, the cure is radical.



BY FRED S, PIPER, M.D., LEXINGTON, MASS, [Read before the Boston Homæopathic Medical Society, June 1, 1899.) Convulsions are abnormal spasmodic movements of muscles, whereby the whole or a part of the body is affected. They may consist of alternate contractions and relaxations or a more or less continued rigidity, to which conditions the names of clonic and tonic are respectively applied. Clonic convul. sions are spoken of as epileptiform, and as a rule originate in the cerebral cortex, while those of the rigid class originate in the motor tracts of the spinal cord.

(H. 453) It is chiefly to this former class or clonic convulsions, so far as they arise from disturbances or the commoner diseases primarily affecting the brain and spinal cord, that I ask your attention.

Convulsions are not a disease, but a symptom, and as such they are a prominent feature in several diseases, and to the fond parent they are a most frightful and distressing mani. festation. If the disease of which convulsions are a symptom is not of a serious type, the temperament and nervous status of the child are such that it makes the condition serious.

A convulsion is the result of a sudden explosion of nerve force or energy which, properly expended and controlled, would give rise to no abnormal manifestation.

It is like a thunderbolt or an explosion from a surcharged battery as compared with the carefully managed and utilized electric current.

The nervous system is more sensitive, reflexes more active, nervous phenomena more common, and inhibition of the will is less potent in children than in adults. (R. 724.)

Symptoms are less reliable as suggestive of lesions, unconsciousness and convulsions are more frequent, on account of this hypersensitiveness; and diseases of nervous types are said to dominate all others in childhood. (R. 594.)

Convulsions are so well known in appearance that description is scarcely necessary. They may be local or general. By some observers much importance is placed upon the clinched fist with thumb beneath the fingers.

Respiration may be greatly diminished or interrupted. The face may be congested, pale ; or cyanosis, due to spasm of the glottis, may add to the unpleasant spectacle.

Convulsions coming on soon after birth are usually due to congenital disturbances or injuries during parturition, causing cerebral compression. Reflex convulsions are rare at this period. (F. 324.) Death may take place in the first convulsion, but this is rare. Occurring in the latter part of cerebral disease, convulsions are of more significance, while recurrence is almost always followed by dissolution. (S. 482.)

Strabismus and inactive pupils are always of bad import. (S. 482.) All convulsions of serious nature are followed by sleepiness or stupor. (S. 485.)

Heredity seems to play a part in convulsions, at least giving temperamental predisposition. Bouchut mentions a

family of ten persons who all had convulsions in infancy. One of these ten married and had ten children, nine of whom had convulsions.

Further than these general hints in studying convulsions we must consider the diseases or morbid states giving origin to convulsions, and dwell briefly on the diagnosis of each, for much depends, both in prognosis and treatment, upon understanding the pathology so far as possible.

Exposure to the sun or high temperatures may cause cerebral hyperæmia and convulsions, and is naturally more common and serious in the large cities. Fatal cases are recorded, but with glonoine, aconite, and belladonna at our service, the prognosis ought to be more favorable than some old school writers advise. Convulsions due to anterior or polio-myelitis are so rare in children that consideration at this time is unnecessary. (Colby.)

There seems to be some existing relationship between rickets and convulsions, particularly what has been spoken of as internal convulsions or laryngo-spasms, even where cranio-tabes is not present. Laryngo-spasm appears to be purely a reflex neurosis, is usually without fever, and it is not confined to the rachitic. Rachitics are more prone to convulsions than healthy children, and yet organic brain charges are seldom found. (S. 131.)

By cerebro-spinal meningitis is meant an acute infectious disease characterized by lepto-meningitis of the brain and cord. (R. 692.)

It varies much in appearance and duration. It may be epidemic or sporadic, and is probably a germ disease, though apparently not contagious. It may occur as a primary disease or complicate some other disease, showing a noticeable affinity for pneumonia. The cerebral and spinal pia mater, the structure chiefly involved, may go on to serous or even purulent exudation ; but where death results early in the disease there may be no macroscopic changes. There seems to be no difference between the sporadic and epidemic cases.

The symptoms are intense headache, fever, hyper-ästhesia of nearly all the special senses, with marked photophobia,

vomiting, convulsions, opisthotonos, strabismus-delirium, and coma.

Opisthotonos and sensitiveness along the spine help to distinguish this disease from cerebral meningitis, but in young infants fever and convulsions may be the only symptoms. (R. 695.)

Another disease productive of convulsions and of probable central origin, but at present but little understood, is hysteria. (R. 723.)

Inherited nervous temperament, irritating environment, and lack of discipline are predisposing factors. It is not confined to either sex or to any period of life, though among children it appears more commonly in later years. The diagnosis is not always easy. There may be paralysis, anästhesia, and in children it may closely resemble serious spinal or joint disease.

The convulsions of hysteria are not serious as regards life, but they are extremely annoying. They usually follow emotional excitement, such as laughter or prolonged sobbing. Globus hystericus is usually present.

The movements seem purposive in character, and seldom result in bodily injury, like biting the tongue.

They do not completely destroy consciousness, and are not followed by sleep, as in epilepsy.

Meningitis is probably the cause of convulsions in a larger number of patients than any other cerebral disease. It may not produce as many convulsions as epilepsy, but it affects a greater number of patients.

As in the infectious cerebro-spinal meningitis, the pia mater is chiefly affected.

It is divided into tubercular and non-tubercular, and this fact shows a great prevalence of cerebral tuberculosis.

The non-tubercular may occur in the healthiest as well as in debilitated children. It is found at all ages, though it is comparatively rare during the first year of life. (R. 595.)

The existence of primary or idiopathic meningitis is doubted by some observers and asserted by others, while a great majority of all cases are secondary to traumatism or some

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