time I was thoroughly satisfied that the epilepsy was of the
Jacksonian type due to traumatism, and that the brain.
centre primarily involved was the motor centre of the leg.
I had him prepared for operation. After putting him on
the table I made my measurements, then making a horse-
shoe incision I removed scalp and trephined over the leg
centre. Rather to my surprise, I found that one side of my
trephine was through the skull, while the other side was
quite far from being through. I broke the button out, en-
larged my opening, and found the upper side nearly as thick
again as the lower side. I also noticed a slight depression
on the skull, which could not be detected until the scalp was
removed, and a pronounced evidence of an old fracture
where spicula of bone had pressed on the duramater.
Directly under this I inserted my exploring needle and
found a cyst which contained eight drams of fluid. There
was a complete sac which I was able to remove. Hemor-
rhage being very profuse, I was obliged to pack the wound.
with gauze.
When patient left the table he was suffering
severe shock, but recovered from this in about an hour. He
had no spasms for about twenty-four hours after the opera-
tion and then he began with a slight twitching of the
muscles, but not all the muscles involved prior to operation.
They continued until I removed the packing, but after the
packing was taken out permanently he had no more spasms.
About four days after this he was able to close his hand and
use his arm somewhat, and at the present time, two weeks
after the operation, he has a good firm grip in the right
hand, can use right leg as well as left, and has no more
spasms or twitching of muscles. A great change has come
over the expression of his face, the look of imbecility is fast
passing away. This case to me is interesting from two
points: first, that he complained of comparatively little pain
for the great pressure which was being exerted upon the
brain; second, that the use of his arm returned in such a
short space of time and the rapidity in which this arm and
hand has gained strength, also the marked difference in his
memory now and before the operation.

1

The types of epilepsy which are cured by operation are those of the Jacksonian order resulting from injury which are not of too long standing and the cortex extensively involved. We are not doing our duty as physicians to those suffering with Jacksonian epilepsy if we do not open the skull and relieve the pressure, so as to give them a chance to recover if it is possible; but in all such cases it is not necessary to do this if the case is properly treated at the time of injury. When a case of injury to the head comes to our notice, the first thing we should do is to explore the wound thoroughly and determine if an injury to skull exists, and if the wound is not large enough, enlarge it sufficiently to make sure that all has been discovered that may exist. I have had two cases wherein no scalp wound existed where there was extensive fracture. So when we get coma after an injury it is always well to shave or perhaps cut the hair very close all over the head and examine very minutely for fracture of some description. Of course when you have hemorrhage from the nose or ears you will be able to arrive at some conclusion, such as fracture at the base; but if fracture exists in the upper portion of the cranium you will not get those symptoms. I observed one case where the fracture extended from the right temporal to the left frontal bones, but the fracture could not be detected until the head had been shaved.

Now the operation of simply opening the skull to relieve pressure is not very formidable; in fact, I cannot see any more danger in making an exploratory opening in the skull than making one in the abdomen, which we often do if we are not satisfied with our diagnosis. If it is done with all the aseptic precautions, the patient will be able to get about in ten or twelve days. For that matter, the same may be said about the operation for the relief of epilepsy, providing the cortex is in fairly good condition.

We have at times injuries involving the cranium from which there is no trouble at first. The wound may seem so small and apparently only the scalp affected that it would seem hardly worth more than a passing notice. Some days.

or possibly weeks may pass before there will be any trouble manifested, then we may get dull pain in any portion of the head, perhaps involving the greater part, with violent lancinating pains in the region of the old wound. We may have vomiting, mental depression with unsteady gait, a slight tenderness in and about the old cicatrix, and possibly find what is known as "Pott's puffy tumor," slight rise in temperature, acceleration of pulse, or possibly normal pulse. There may be several symptoms present pointing to some organic trouble of the nervous system. When we find this trouble we must always be on the alert for suppurative pachy-meningitis. This condition is the result of one of two things: first, there may be a small fragment of bone due to the original injury which has passed unnoticed which is ingrained with dirt and may be ever so small, yet sufficient to produce infection, while if it had been discovered at the time of injury and the bone been chiselled out where the dirt had been ground in, we could have avoided this trouble. It is always necessary where particles of dirt are seen in the end of the bone fragments to use chisel and cut that portion of bone away, as it is the only safe and sure way of getting all the particles of dirt from the fragments. On the other hand, this trouble may arise from a necrosis due to an injury of the periosteum at the time the scalp wound was received.

One other cause must not be overlooked, which is more liable to occur in old people than in young, and that is, erysipelas of the face and scalp, which is liable to set up thrombosis of the veins, which may extend into the cranium, thereby carrying the streptococcus into the membranes and possibly into the brain itself, so we can see how necessary it is to be very careful even in the slight scalp wounds. We should pursue the most profound caution in the treatment of all such cases, as the danger arising therefrom is not to be overestimated.

My aim in this paper has been to point out the importance of making a correct diagnosis of injuries to the head, and second, the vital importance of immediate operation if fracture exists; also of close observation of the most trivial wounds of the scalp.

THE DIFFERENTIAL DIAGNOSIS BETWEEN APPENDICITIS AND INFLAMMATIONS OF RIGHT. OVARY AND TUBES.

BY H. P. PERKINS, M.D.

[Read before the Massachusetts Homœopathic Medical Society.]

The subject of this paper was chosen by the Chairman of this Section as being of interest to many of our members; but in presenting the paper, I ask your indulgence as to its scope. It is not an exhaustive essay to which the fellows. have neither time nor patience to listen. In the briefest possible limits I hope to show what diseases of the right tube and ovary are commonly mistaken for appendicitis, and to determine what points, if any, we can rely upon to assist in diagnosis.

The possibility of mistake is not rare. In a very valuable article, Fowler, of Brooklyn, has shown more than twenty forms of simple and conjoined disease of the right adnexa and appendix in which the diagnosis was incorrect. Primarily, appendicitis is more apt to be mistaken for disease of the tube than such trouble for appendicitis. This fact hinges on what is practically an axiom-that in medicine, as in other pursuits, one naturally looks for the expected. The normal or abnormal woman being more prone to diseases of the appendages than of the appendix, in doubtful forms of inflammation the physician chooses the most likely.

Let it be understood that we are now dealing with those cases in which there is no doubt, for in the majority of cases in women as in men, the diagnosis is fairly easy. Given the sudden onset, the digestive symptoms with the pain, tenderness, and rigidity well marked in the region of the line running from the umbilicus to the anterior superior spinal process, the condition is evident.

A short glance at the topographical anatomy of the appendix, with its normal and abnormal relations, reveals the reason of uncertainty. The appendix may lie in various positions in the abdomen - above or below, in front of or behind

the cæcum, transversely across to the left side of the cavity or at an angle across. In over ninety per cent of all cases its normal base is found within a circle of one and one half inches in diameter external to the rectus on the line drawn from the umbilicus to the anterior superior spinal process. The meso-appendix reflected from the mesentery of the ilium has in the female a prolongation running to the ovary, bringing it at times nearly in opposition to that organ. Through this appendicular-ovarian ligament an extra supply of blood is carried to the appendix, and in its folds a chain of lymphatics has been demonstrated, giving direct communication with the ovary and aiding the possibility of infection.

With the appendix of its normal length of from two and one half to three inches, in most cases the pus of its inflammation lies in the region external to a line dropped from our first line to about the centre of Poupart's ligament. The appendix being of abnormal length, running over the brim of the true pelvis, the pus may be found in various parts of the basin, even invading the folds of the broad ligament or the pouch of Douglas.

It is thus seen how intimate is the relation of the tube and ovary to the appendix, and how the territory of the former may hold the inflammatory products of the latter.

The morbid conditions of the adnexa, which are liable to cause trouble in diagnosis in view of the possibility of abnormal locations of the appendix, are first, the various forms of tubal disorders catarrhal and purulent, pyo-salpinx, hydo-salpinx, hæmato-salpinx, and tubal pregnancy; second, inflammation of the ovary-congestive or cystic.

In catarrhal salpingitis we have increased temperature and pulse range, nausea, vomiting, and abdominal tenderness, with paroxysmal pains, all of which symptoms being likewise characteristic of appendicitis. I ut there are points of difference. The pains are paroxysmal and not the colicky ones of appendicitis. Happening at or during the menstrual period, the flow is likely to cease; if in the interval, there is frequently a bloody vaginal discharge. Painful micturi