finely divided, so that they can pass the pylorus without having to be acted upon by HCl. Nux vomica 3x. was prescribed.

She had been on the above treatment for three weeks, and reported much improvement. Nervousness greatly lessened. Sleeps well. Scarcely any flatulence. Bowel movements normal. Appetite improved. The only thing about which she complains is a sort of tight, suffocating feeling in the throat. Evidently a hystericus globus. Nux vomica was continued, but in the 6x., instead of the 3x. attenuation.

Congenital Syphilis, Syphilitic Iritis, Syphilitic Laryngitis and Pharyngiitis. (City Hospital, Prof. Wm. H. Phillips.

I present to you this morning, three patients typical of the different forms of syphilitic infection. This baby with congenital syphilis, this woman with syphilitic iritis and this young man, showing the ravages of tertiary syphilis in the larynx and pharynx. This youngster was born two or three weeks ago. The emaciation-nothing but skin and bones-the facial appearance, that of an old man—the fissures at the angle of the mouth, the mucous patches upon the lips and tongue and the temperature curve 102-105, are all characteristic of the disease. Congenital syphilis is often fatal. Syphilitic iritis often called "iritis papulosa," is a feature of secondary syphilitis. It occurs most often in the acquired form, although it is occasionally seen in the inherited. When typical it is distinguished by the presence of a small brick red papule on the pupillary or ciliary margin of the iris. It is usually unilateral. In the patient the characteristic appearance is wanting, but the discoloration of the iris, the ciliary injection and the neuralgic pain are all characteristic of iritis. The pupil has already been dilated by atropine so that the characteristic contraction cannot be seen. The syphilitic eruption and the mucous patches together with the history, confirm the diagnosis of syphilis.

This young man came here first, two years ago, and was admitted to the tubercular hospital. He is now 18. At that time it is said, the microscopical analysis of the sputum confirmed the diagnosis of tuberculosis. Two weeks ago he returned with the history of having completely lost his voice some weeks ago. Microscopical examination fails to reveal the bacillus. The chest examination shows some involvement in the sub-clavicular region. Temperature is running sub-normal, pulse about 75. No night sweats; looks pale and anæmic, has not lost greatly in flesh. Examination of the pharynx shows considerable deformity of the soft palate, result of past ulcera

tion. Inspection of the larynx shows a loss of two-thirds of the epiglottis, leaving only a ragged, irregular stump. The left vocal cord has been almost entirely destroyed. There is little or no discharge, no pain-there is some cicatricial contraction. So far as is ascertainable, there is no history of acquired syphilis. The local clinical picture presented here, is that of syphilis, not that of tuberculosis. The extensive destruction of the soft palate and subsequent contraction, the destruction of the epiglottis and the unilateral destruction in the larynx and the fibroid degeneration, are all characteristic of syphilis. The absence of pain, expectoration and rises in temperature, together with the negative sputum examination, favor syphilis. The microscopical analysis made two years ago, and the presence now of pulmonary signs, are complicating features in the diagnosis. We can only conclude that there probably exists here a mixed infection. It is perfectly possible for syphillis and tuberculosis to co-exist. The syphilis is probably inherited.

As regards the treatment of these cases, in the first two, mercury is pre-eminently the remedy. In the baby, the marasmus, the syphilitic fever, the earthy skin and the affection of the mouth, teeth and gums are all indications for the remedy. The choice of the salt of mercury to be preferred is not so easy. The absence of glandular involvement would rule out the iodides. The absence of bowel and liver symptoms would rule out the corrosivus and dulcis. We thus have mercurious solub. as the salt to be chosen. In these severe cases, when the effect is desired as quickly as possible, the remedy may be given by inunction, equal parts of mercurial ointment and lanoline being rubbed into the axilla and inner surfaces of the thigh. In syphilitic iritis, mercurious corrosivus is to be preferred. In this young man's case a large part of the treatment must be hygienic and dietetic, good food and careful living are an absolute necessity. In the absence of special indications, I should give him the iodide of potash in increasing doses and watch him carefully. This remedy produces, occasionally, an acute laryngeal œdema. A few months ago I did a tracheotomy upon a man 45 years of age, for this condition. Penetrating Wound of Eye-ball-Enucleation. (City Hospital, Prof. Wm. H. Phillips.)

This young man was struck in the eye a short time ago by a sharp stone. The result was a complete rupture of the cornea through its greatest diameter, and extending some little distance into the sclera on both sides. The iris became entangled in the wound and the resulting irido cyclitis has completely closed the pupil. The eye is soft. showing that atrophy is occurring. Wounds of the ciliary regions are

peculiarly dangerous, not only in that they are almost sure to destroy the sight of the injured eye, but because the resulting irido cyclitis may be easily transferred to the other eye, with consequent destruction of that eye also. Especially is this true of penetrating wounds of the eye-ball, in which the foreign body remains in the eye. If left alone, this eye-ball will undergo complete atrophy, resulting finally in a shrunken, soft organ. It is often months before this condition obtains. In the meantime, the other eye may become affected at any time.

After complete atrophy has occurred the danger of sympathetic opthalmia has passed. It is far safer and better to enucleate these eyes at once; the danger to the other eye is done away with and the months of suffering, during which the eye is undergoing atrophy, are cut short. The cosmetic effect, too, is better; a well-fitting glass eye being much more sightly than a shrunken, shrivelled stump.

In accordance with this idea, we will now enucleate the eye. Adenitis of Inguinal Glands-Incision and Removal. (College Amphitheater, Prof. Bishop.)

Mr. G., aet. 24. This patient had gonorrhoea three months ago and at the present time has a slight urethral discharge. He presents no other lesions which would constitute an etiolgic factor, such as balanitis, herpes, chancre or inflamed corn, and we are therefore compelled to assume that the infection of the lymphatics has originated from the gonorrhoeal infection, although it is unusual for it to do so when the disease has existed for so long. Bubo is usually concomitant with the acute development of a genital infection, though in exceptional cases it may appear even after the genital lesion has entirely disappeared.

The treatment of this case will be operative, incision of the affected area, curetting of the infected glands and packing of the wound. If the case had been seen in its incipiency, suppuration might have been prevented by means of the application of a compression bandage, which would have limited the inflammatory exudation and caused absorption, but it is evident in this case that some of the glands have broken down and that others will follow unless an exit is made for the infectious matter and conditions are secured which are favorable to tissue repair.

The operation is a simple one and consists of first an infiltration of the parts to be incised with a 1 per cent. solution of cocaine. After the skin incision is made, the tissues are opened by blunt dissection with the handle of the knife and the broken down glands removed by

the use of a curette. The most important point of the treatment of such conditions is the packing of the wound. Usually a light packing is used with the result that within 48 hours the edges of the wound are almost together and it is difficult to keep it open for further treatment. The first packing should be forcibly made, as the parts are not sensitive. The wound should be packed with all the gauze it will contain and the skin incisions should be made to gap widely. This packing should not be removed for 48 hours, after which the wound will remain open and can be easily cleansed. I have found that tincture of iodine is an excellent application to such wounds during the process of active suppuration. As soon as healthy granulations appear the edges of the wound may be allowed to come together, care being taken, however, that the wound be compelled to heal from the bottom. Circumcision. (College Amphitheater, Prof. Bishop.)

This patient has been referred for operation by Prof. Horner. The diagnosis, I believe, has not been made, but it is evident that he is a victim of the habit of masturbation. There are many fancy methods of performing circumcision, but the simplest way is the best. It consists first in grasping the tip of the prepuce on its dorsal aspect before it is retracted, with two artery forceps. This will prevent a greater retraction of the skin aspect than of the mucous membrane aspect of the prepuce, and thus save an extra trimming of the mucous membrane. The assistant mades traction upon the prepuce by means of the attached corceps and with the scissors the operator cuts the prepuce between the two artery corceps up to the point upon the dorsum of the penis, which it has been calculated will leave sufficient prepuce to cover the corona during relaxation of the organ. From this point the prepuce is then trimmed, around the penis to the median line, first one side and then the other, at a distance of 1/4 inch from the corona. Four or perhaps eight catgut sutures are inserted through the skin and mucous membrane and a narrow gauze bandage applied. This is discarded at the end of 48 hours and a collodion dressing applied or simply a loose layer of cotton.

Endometritis and Proctitis, of Gonorrhoeal Origin. (City Hospital, Prof. Bishop.)

Mrs. W. Married. Aet. 29. This patient was admitted to the hospital suffering from a profuse bloody discharge from both the vagina and rectum, a condition which had existed for some time. Her history of previous illness is interesting, but has no bearing upon present illness. Examination of the discharges from vagina and rectum shows gonococci in both. Investigation has shown that the

the

primary infection was probably vaginal and that the infection in the rectum has resulted from using the same fountain syringe for douche and enæma.

Gonorrhoeal proctitis is not a condition which will give the patient much trouble and will yield to local applications. It has been treated since the diagnosis was made by means of rectal irrigations of nitrate of silver solution, 1-1000, followed by normal salt solution and has rapidly improved.

The endometritis, however, requires radical treatment on account of the danger of an infection of the tubes. The operation consists of careful curettage of the endometrium, swabbing with tincture of iodine and packing with iodiform gauze. The patient also has an extensive bilateral laceration of the crevix, which is repaired in the usual way.

Salpingitis and Chronic Endometritis, of Gonorrhoeal Origin. (City Hospital, Prof. Bishop.)

Mrs. B. Aet. 24. The history of this patient is the usual one found in women who have had chronic gonorrhoea. She developed a vaginal discharge soon after her marriage, had a febrile condition following pregnancy, and since that time has never been well. From these symptoms, alone, we would be warranted in ascribing the cause of her trouble to the ravages of the gonococcus. She undoubtedly had a puerperal infection which was either due to stoeptococcic infection or to the gonococcus. Had it been the former, it is altogether likely that it would have terminated in abscess formation, which would have probably broken into the rectum or into the vagina. Gonorrheal infections are not so acute and are more likely to terminate in chronic inflammations of the tubes. We are perfectly warranted in resorting to a major operation in these cases, as no method of treatment other than operative, will do more than give temporary relief. The patient cannot escape a condition of chronic invalidism.

We first curette the uterus and swab the endometrium with tincture of iodine. On opening the abdominal cavity we find a mass of adhesions on the left side from which the tube and ovary are separated with some difficulty. The tube alone is removed, as the ovary is not diseased. The right tube is free but is distended and the right ovary is cystic. Both are removed. This patient should make an uninterrupted recovery and will undoubtedly be much benefited by the operation.

Abscess of Liver. Incision and Drainage. Death. (City Hospital, Prof. Nobles.)

This patient is 52 years old. His father, one sister and one