which unite at a central bright red nodule projecting a little beyond the skin. They are very common, and doctors are often consulted about their presence on the face.

As examples may be found on the skin of nearly everybody, these three varieties may be regarded as almost normal structures.

When the punctiform or spider angiomata increase greatly in numbers they are very disfiguring. In one case the skin of the face was peppered with them, and at a distance the patient looked disfigured with a bright, fresh acne rash. In another they had also proved a source of danger, as he had bled from them repeatedly. An individual spider angioma may increase in size, or, as in the cases here related, they may become very numerous.

Angiomata have a curious relationship with affections of the liver. In cirrhosis, in cancer, in chronic jaundice from gall stones, spider angiomata may appear on the face and other parts. They may be of ordinary stellate variety, like the stars of Verheyen on the surface of the kidney, or the entire area of the star may become diffusely vascularized, so that there is a circular or ovoid territory of skin looking pink or purple, owing to the small dilated venules. A dozen or more of these may appear on the trunk, or even large ones may disappear. And lastly, in a few cases of disease of the liver he has seen large, mat-like telangiectases or angioma involving an inch or two of skin, looking like a very light birth-mark, but which had appeared during the illness. The skin was not uniformly occupied with the blood vessels, but they were abundant enough on the deeper layers apparently to give a deep change in color and to form very striking objects. The dilated venules on the nose, and the chaplet of dilated veins along the attachment of the diaphragm, are not infrequently accompaniments of the spider angiomata in cases of disease of the liver.

Osler has recently seen the spider angiomata appear in the face in a case of catarrhal jaundice.

Character, like porcelain ware, must be printed before it is glazed. There can be no change after it is burned in.-Beecher.

SURGERY.

UNDER CHARGE OF W. B. ROGERS, M.D.

Professor of the Principles and Practice of Surgery and Clinical Surgery,
Memphis Hospital Medical College.

A Case of Suture of a Stab Wound of the Heart, with Remarks on, and a Table of, Cases Previously Reported.

G. T. Vaughan (Med. News, vol. 79, no. 23) reports a case of stab wound of the heart operated upon by him, in which, however, the outcome had been fatal.

The entire literature reveals reports of 26 cases sutured, with a mortality of 76.93 per cent.

Without doubt the greatest immediate danger is from hemmorrhage, next from shock and entrance of air into the heart. Then comes the danger from pericarditis, empyema and pneumonia. Of the 26 cases, 1 had pericarditis; 2 empyema; 2 empyema and pericarditis; 1 empyema and abscess of right lung, and 1 bronchopneumonia-7 cases with infection, all of which were fatal except the 2 cases of empyema only.

The urgency of the symptoms and the necessity for prompt. and rapid action often prevent the observance of proper aseptic precautions-a fact which probably accounts for the frequency of infection.

The author feels that a review of these cases justifies the following conclusions:

1. The time has arrived when a wound of the heart should be operated on with as little hesitation as a wound of the brain, with the expectation under corresponding conditions of getting equally good results. The mortality must inevitably be high -not from the operation but from the injury-especially if all cases including desperate ones be undertaken. Selection of cases who have survived five or more hours after receiving the wound would give a good percentage of recoveries, but such selection is not to be recommended.

2. In all cases of wounds in the region of the heart, with symptoms threatening life, an exploratory operation should be done by making an osteoplastic flap by dividing the fourth and fifth costal cartilages at their attachments to the sternum and the ribs about one inch external to their attachment to

the cartilage, somewhat according to the method of Roberts. This flap turned up as a door on a hinge gives a good view of the pericardium and can easily be enlarged upward if more room is required.

3. While early and speedy operation is often essential to success, yet the importance of asepsis cannot be too strongly emphasized on account of the great danger of pericarditis and empyema. If there has been much hemorrhage a quantity of physiological salt solution, approximately equal in amount to the blood lost, should be injected into a vein while the surgeon is operating on the heart, if it has not been done sooner.

The Treatment of Aortic Aneurism by Means of Silver Wire and Electricity.

L. Freeman (Amer. Jour. Med. Sc., vol. 27, no. 7) says:

1. Considering the inefficiency of medical treatment, and the comparative efficiency of the use of silver wire and electricity, it is probably better to proceed to the latter at once without wasting valuable time upon the former. This seems all the more desirable when we consider that wiring is not a very dangerous process, and that it is in the carly stages of an aneurism, when the sac is still firm and the patient is in good condition, that the best prospect of cure exists.

2. Soft, undrawn, unalloyed silver wire devoid of springwire just as it comes from the shop-is preferable to the hard, highly drawn wire alloyed with copper and full of spring. It is hardly necessary to previously coil the wire.

3. It is still an open question as to which is preferable, a large amount of wire or a small amount, with the theoretical advantages in favor of the former.

4. A strong electric current is apparently preferable to a weak one.

5. The canula through which the wire is introduced should be inserted just within the sac, and no further.

6. There is little if any danger of bursting the aneurism from increase of pressure due to coagulation in a portion of the sac only.

NOSE, THROAT AND EAR.

UNDER CHARGE OF RICHMOND MCKINNEY, M.D., MEMPHIS. Laryngologist to East End Dispensary; Laryngologist to Presbyterian Hospital.

Laryngeal Paralyses and their Importance in General Medicine.

J. W. Gleitsman (New York Med. Jour., vol. 74, no. 24) reviews the investigations made concerning the innervation of the larynx. It has been definitely shown that irritation of one of the phonatory areas, which are located on the descending surface of the prefrontal convolution, is always followed by symmetrical bilateral adduction of the vocal cords, phonetic movements which also take place when one phonatory centre has been experimentally removed or destroyed by disease, and a positive indubitable case of unilateral paralysis due to cerebral lesion (hemorrhage, softening, etc.), has not yet been reported. The extirpation of both phonatory centres has no influence on the respiratory office of the larynx. Adduction of the cords can also be elicited from a small area in the bulbus. The centre of respiration is located in the bulbus. Recent investigations have shown that the vagus is the motor nerve of the larynx. As the superior laryngeal nerve is the sensory nerve of the larynx and only sends motor fibres to the cricothyroid muscles, the recurrent is the motor nerve for all the intrinsic muscles of the larynx and innervates adductors as well as abductors. The most important chapter in the pathology of laryngeal paralysis is the discovery by Semon of the proclivity of the abductor fibres to disease. The recurrent is not a homogeneous nerve, but contains separate fibres for the adductors and abductors, this fact making it easier to comprehend the isolated paralysis of one group of muscles in affections of a nerve. It is also not surprising from what was said of the location of the phonatory and respiratory centres in the cortex and medulla, respectively, that laryngeal paralyses based upon central causes or physical disturbances such as hysteria and shock, affect the phonatory, the adductor muscles, and bulbar lesions the respiratory, the abductor muscles. Abductor paralysis is of chief importance from a pathological standpoint, for the fixation of the vocal cords in the median line is productive

of voice alterations and dyspnea and frequently, unless tracheotomy be performed at once, bilateral abductor paralysis may cause death from suffocation. The lesions producing adductor paralysis bear a more or less subordinate character, and in this condition the chief cause of complaint will be more or less interference with tone production. The causes of abductor paralysis may be hysterical, psychical, or reflex in nature. Organic causes chiefly produce abductor paralysis, and these may be hemorrhages, syphilis, tumors, diphtheria, progressive bulbar paralysis, amyotrophic lateral sclerosis, syringomyelia, and locomotor ataxia, which are to be classed among those emanating from the bulbus and spinal column. Peripheral causes are tumors of the neck (cancer of the esophagus), aneurism of the aorta, of the innominate, or of the right subclavian (on account of the greater frequency of the aortic than subclavian aneurism the left recurrent is oftener paralyzed than the right), mediastinal tumors, such as malignant growths, infiltration of the peritracheal or bronchial glands in syphilie, pericarditis, pleuritic adhesions, as in tuberculosis, traumatism and injuries; further, infectious diseases, influenza, scarlet fever, typhoid fever, toxic influences, principally lead, which is apt to produce also adductor paralysis or rheumatism, both causing peripheral neuritis, although the diagnosis of rheumatism ought not to be made hastily and before an earnest and conscientious search for other factors has been made.

Rheumatism as Cause and Effect in Inflammation of the Throat. W. Cheatham (Med. Record, vol. 60, no. 24) says:

1. It is undoubted that a certain number of cases of acute rheumatism are preceded by an angina in a proportion varying from 30 to 80 per cent.

2. Both rheumatism and angina have many etiological points in common-season of year, cold, wet, fatigue, depression, vitiated air, etc.

3. The connection of angina and rheumatism, though undoubted in a number of cases, is not yet clearly established.

4. The tonsil may be the port of entry of the rheumatic virus, although the naked eye appearance of the throat gives no indication of its being affected.