intracranial hemorrhage has resulted, causing the bloody tumor, the only chance for prevent g death permanent after effects lies in the early dia sind mediate treatment of the hemorrhage on established su gical principles. So far it is surprising how rarely this very obvious procedure has been resorted to.

See

The author of this paper suggested twenty-three years ago the trephining of the skull for intracranial cephalhematoma. Cincinnati Lancet-Clinic, N. S. Vol. II., p. 322. Also first and second editions of Wood's Reference Handbook of the Medical Sciences.

This unusually interesting subject was called to my attention by the following rare case which was my right good fortune to meet: Multipara, æt 47, married 27 years, and had given birth to thirteen children, six of whom had died, two being still-born. I learned that the membranes had ruptured two hours before my arrival and by vaginal examination I made out a breech presentation. Fetal heart was found and beat 150 per minute. The labor progressed slowly, but delivery was completed with safety to all, the head being quickly delivered and a fine female child was born. Saw the child the next day and found it doing remarkably well. The next day found it somewhat fretful. called late on the third day and found the child dead beside its mother, still warm, and she not aware that life was extinct. She gave the following history: The child began having convulsions on the evening of the second day, had two per hour all night till noon the third day, when it began having three per hour and died, having cried five minutes before my arrival. She said that three of her children had died of convulsions, and she gave this one up to die as soon as they came on. She thought the doctor could do it no good, so did not bother him. She called the minister, however, and had it baptized Lillian May.

Autopsy-Body well nourished, fat. Head presenting externally nothing unusual. Scalp incision from mastoid to mastoid found the skin normal, but between skin and pericranium a large effusion of blood, coagulated, extending over a large part of the left parietal bone and not surrounded by any indurated ridge of bone. On opening the skull found the bones in a perfectly normal condition, the dura mater healthy, but in the cavity of the

arachnoid and corresponding to the outer tumor in position was found a large and extensive clot of blood, causing a depression of the brain in its depest part, which was one inch to the left of the posterior fontanelle. Depression was one-half to three-quarters of an inch deep. Effusion larger than externally, reaching down to the foramen magnum. No ruptured vessels could be discovered. Other parts normal.

The possibility of the child having received a blow, fall or injury be e, during or after delivery was canvassed. The father, nurse were separately and collectively examined ich an event having taken place, but all stoutly tly denied that the child had had any injury of any

ce its birth. The mother said she had had none before very and the opportunity certainly did not present itself during labor. They were given every opportunity to say that the child had accidently or purposely received such an injury. They remained firm, however, even threatenings bringing no confession. The death certificate was signed "Intracranial cephalhematoma."

A case of intracranial cephalhematoma was reported by the late Dr. J. L. Cleveland to the Cincinnati Academy of Medicine (Cincinnati Lancet-Clinic, val. vi., p. 330, 1881). He presented to the Academy a well-nourished child, still-born, died probably five days before birth, weighed I pounds. Discovered external tumor before delivery, but mistook it for bag of water. No unusual amount of pressure during labor. Mother had previously borne two healthy children. No miscarriages. Autopsy performed in presence of the Academy discovered an internal tumor and depression of the brain.

West, writing in 1845, was able to find but eleven cases of the intracranial variety. Ruge (Berliner Klinische Wochenschrift, June 15, 1875), reports two to the Gesellschaft fuer Gynecologie. Jackson (American Journal of the Medical Sciences, 1855), reported a case which he post-mortemed. Tumor on inside of occipital bone, with ossification of the pericranium. No thinning of bone and no disease externally.

There are some evidences of an inherited tendency to the dis

ease, as repeated cases occur in the same mother, and in my case the mother had other children die of convulsions.

IF THE DOCTOR WERE A Czar.

Editor Nashville Journal of Medicine and Surgery:

The editor of Practical Medicine, an Indian medical journal, in commenting on the remark of a correspondent, that he could learn nothing which was of any value regarding the diet which was proper for a Hindoo diabetic patient from English medical literature, emphasizes the need of using judgment and common sense in applying the principles laid down in the English medical text-books, by adapting them to the peculiarities of his patients, He warns his correspondent not to follow the plan of the French doctor, who, when called to see a beggar peddler, covered with filthy rags, and earning only a few pies a day, prescribed for him the following regime: "Avoid fatigue, damp and cold. Clothe very warmly, wear flannel next to the skin. Eat well underdone meat, seven to fifteen ounces a day, to be taken scraped and pounded in cold bouillon, or as balls in powdered sugar. Raw or soft-boiled eggs-four to six, if possible eight or ten a day. Sardines in oil, two daily; butter; watercress, cooked and raw; a large cup of cocoa with milk in the morning. Beer with meals."

This is a very pat illustration of the folly of prescribing a ten thousand dollar course of treatment for a ten dollar patient. It recalls the familiar definition of a physician as "an unfortunate gentleman who is expected to perform a miracle every day;" also the saying that the doctor ought to be a Czar, who could say, and it should be done. (Though even the Czar cannot do this now-adays.)

It is very easy to visit a wealthy patient, worn out with ennui and the great responsibility of doing nothing, and order him to take a trip to Europe, assuring him that he will be a new man when he returns. But how about the poor, worn-out housewife, who is tired of the strenuous life and urgently needs rest and fresh air? The doctor can say it, but how is she to get it? Well

to-do patients may safely be advised to get a trained nurse, or more than one if need be; they are most excellent in their place, but how is it in the little cottage, where one woman does all the work of the family, and she is sick? Here, if ever, a nurse, is needed, but who is to take care of her, let alone doing the work of the house? A friendly neighbor, or an old woman who dares, is worth a dozen trained nurses here. Sometimes the doctor himself has to lend a hand-for he is not a Czar.

So, too, when the doctor goes to a case miles out in the country, and after he has examined the patient with a great deal of care, writes out a prescription to be filled at a distant drugstore. It may be hours or even days before a messenger can be sent and return, and meantime the patient is left to suffer for the needed remedy.

Or again, it may be in the slums of the city, or in the hovel of the very poor-the sources of supply are convenient enough, but the head of the house has no money to avail himself of them. And so again the patient goes without the needed prescription, all because the doctor dealt in uncertain galenics and more uncertain prescriptions, to the patient's hurt. If he were a Czar, such a course might be safe, not otherwise.

But if, instead, the doctor carries the active principles, then in his pocket-case there are the remedies which are needed in this particular case-no need of a distant drugstore-they are prepared by his own hand, the first dose administered to the patient before he leaves the house, and a sufficient supply left to last until his next visit. He knows his patient has got the medicine, knows it is what he wanted him to have, and knows it will have an effect. He can watch its effects and change it as often as he pleases, and that without making demands on an empty pocketbook. In this case he has followed the dictates of common seuse, and he really does not need to be a Czar.

Milford, Miss.

J. M. FRENCH, M. D.

Selected Articles

THE DIAGNOSIS AND TREATMENT OF TUBERCULOSIS OF THE

KIDNEY.

ARTHUR DEAN BEVAN, M.D., CHICAGO.

Although Ammor as early as 1833 pointed out clearly the essential clinical points of kidney tuberculosis, it has only been within the last ten years that the diagnosis and treatment have been placed on a sound working basis, and even today the frequency and importance of the lesion is not generally understood by medical men. To those of us who have been medical students for twenty-five years or more the evolution of this subject during that period furnishes some interesting reading.

Ebstein reviewed the subject and described the process as a cheesy inflammation involving the kidneys and renal pelvis and ureters, as one difficult to diagnose except in the presence of some evident tuberculous lesion; having a bad prognosis; as a condition in which the patient seldom lived more than a year. Ebstein states that all treatment is apparently hopeless. No suggestion of surgical interference is made.

In 1884 Henry Morris described the condition under the two titles of tuberculous disease and scrofulous disease of the kidney. He gives a very good clinical picture and says the treatment consists in alleviating pain and improving the general health. Further, he says, that in tuberculous disease, in which the affection of the kidney is but a local manifestation of a constitutional disorder, nephrectomy would be useless, even if the other kidney were sound. When the scrofulous disease is limited to one kidney, nephrectomy promises much as a means of prolonging life by freeing the individual from a fatal malady.

In 1885 Samuel W. Gross read a paper on the subject of nephrectomy before the American Surgical Association, in which he collected twenty cases from the literature in which nephrectomy