THE COMMONER DISEASES OF THE EYE. How to Detect and How to Treat Them. For Students of Medicine. With 250 illustrations, many of them original, of which seven are colored plates. By CASEY A. WOOD, C.M., M.D., D.C.L. Professor of Clinical Ophthalmology in the University of Illinois; Professor of Ophthalmology in the Post-Graduate School, Chicago; Ophthalmic Surgeon to St. Luke's Hospital, Chicago; and THOMAS A. WCODRUFF, M.D., C.M., L.R.C.P., London; Professor of Ophthalmology in the Post-Graduate Medical School, Chicago; Ophthalmic Sur eon to St. Luke's Hospital and Dispensary and to St. Anthony de Padua Hospital, Chicago. Chicago: G. P. Englehard & Company, 1904.

THIS work of 491 pages is intended to su ceed a short treatise entitled "Lessons in the Diagnosis and Treatment of Eye Diseases," published many years ago by but one of the present authors. This, the later volume, is greatly enlarged upon, and the subject of ophthalmology is considtred solely from the standpoint of th physician in general practice.

The authors have certainly carried out their plan sucessfully, for seldom has there appeared a work on the eye more simply and yet more comprehensively written. It is well printed on good paper, and is made attractive by its compactness and by its neat cover. It is not always an easy matter to simplify a difficult subject like optics and ophthalmology and still make it practical and interesting and profitable reading to those little conversant with the science; yet, it must needs be, certainly, a very stupid or negligent general practiti ner who cannot fully comprehend by a little persistent effort the ommoner diseases of the ye met with in onnection with his general p actice an so well depicted in this work.

The illust a ions, though often not new, are plentiful and to the point, and the table of contents and index are complete and well-arranged for quick r ference.

The newer remedies are fully referred to, and the chapter on the pathogenic bacteria invading the eye is thorough and up to date.

By

A PRACTICAL TREATISE ON NERVOUS DISEASES FOR THE MEDICAL STUDENT AND GENERAL PRACTITIONER. F. SAVARY PEARCE, M.D. New York: D. Appleton & Co., 400 pages, 91 illustrations, many in colors. THE object of this book, the author tells us in his preface, is to furnish the general practitioner and student with a textbook in which doubtful points in neurology are curtailed and practical facts are presented in small compass. In the judgment of the reviewer, the object has not been attained. It is particularly in the chapters that offer opportunity for some originality of presentation, those in which diseases of the nervous system are delineated, that the shortcomings are most striking, for the introduction devoted to anatomy, physiology, and chemistry is admittedly compilation, and that not well done. For instance, on page 17, is a paragraph entitled "Pons Varolii," etc.: "This is situated between the medulla and the crura cerebri. It is a white body in the form of a half ring. Its size depends upon the size of the hemisphere with which it has to do. It weighs about 250 grains. It has six faces. The anterior face rests upon the basilar process f the occipital bone, and presents a median groove for the basilar artery. The posterior surface forms a part of the door of the fourth ventricle." Not another word of its topography or connections: To what the "et cetera" in the title refers is not apparent. "The hemisphere with which it has to do" refers probably to the cerebral hemisphere projections from which form constituents of the pons, but why the size of the pons depends upon it, is not apparent. To be told that the pons has six faces, even though it had, cannot possibly convey anything worth while to him who is seeking to learn something of the pons, its connections or functions. "Irritation of the pons will cause convulsions; therefore it contains a convulsive center." Breathing upon the skin of individuals in certain pathological conditions will cause convulsions, but it does not follow that the skin contains a convulsive center. No more does it follow that the pons contains one for the reasons stated. In his chapter on "Symptoms and Methods of Examination" the author says the sense of the application of weight is determined by the piesmeter. This by way of simplifying matters for the student who cannot find bricks or stones to test the sense of weight. Neither "Foster's Medical Dictionary" nor the catalogues of popular instrument-makers mention piesmeters. In the chapter on "Treatment and Prevention of Nervous Diseases" the author says "Consanguinity should be avoided, nor should intermarriage take place between families of highly nervous temperaments." We do not favor one family's marrying another in any event, even though they have lymphatic temperaments. The prevalent method of two individuals marrying seems best adapted to our present needs, and inasmuch as Congress

now investigates the legality of one individual marrying more than one individual, so it is likely that if one family attempted to marry another, considerable agitation would result.

"The overuse of tea, coffee, tobacco, and alcohol must be remembered as causes of various functional or organic nervous diseases, such as optic atrophy or chronic neuritis." Which of these is the functional and which the organic nervous disease, the author does not tell us. "Alcoholic abuse stands next to syphilis as a cause of a legion of diseases of the nervous system." As there are only about two score nervous diseases all told, and as in only one of them, multiple neuritis, has it been shown positively that alcohol is the cause, it may truthfully be said that the author permits himself some latitude. He may have had arterial sclerosis and its sequelæ in mind, then there would have been two-on the way to legionbut then that is not a nervous disease.

We cannot pass without protest the statement "in cases of atrophic dry skin, I have so often seen in women at the climacteric suffering from general nervousness, Turkish bathing does a great good," because it isn't clear who has the nervousness. Perhaps the writer is speaking "metamorphorically,' as he accuses "Kraft-Ebing" of having done (page 362).

The following may be taken to represent the writer's understanding of nervous diseases. "By Myasthenia gravis is meant the peculiar condition in which the patient loses power periodically and sudd nly, in the muscles without any definite neurological symptoms. It is closely allied if not identical with periodic paralysis." Now we maintain there is not a word of truth in that statement. But enough. We do not often permit ourselves to say all that an unworthy book deserves, and this shall be no exception to the rule. Every page reveals amateurishness and incompetency. Not one feature has the reviewer been able to find that commends it to favorable notice.

BURDETT'S HOSPITALS AND CHARITIES. Being the Year Book of Philanthropy and the Hospital Annual, 1904. By SIR HENRY BURDETT, K.C.B. Author of "Hospitals and Asylums of the World;" "Hospitals and the State;" "Pay Hospitals of the World" "Burdett's Official Nursing Directory," etc. 12mo, 1131 pages. London: The Scientific Press, Ltd. THE present volume shows careful editing and is up to date. In the preliminary chapters will be found some new information and an exhaustive review of the chief questions which are engaging the attention of the managers of every group of institutions, which collectively constitute the field of charity. The book contains a review of the position and requirements, and chapters on the management, revenue, and cost of the charities. A record of Hospital work for the year. A guide to British, American, and Colonial Hospitals and Asylums, Medical Schools and Colleges, Nursing and Convalescent Institutions, Consumption Sanatoria, Religious and Benevolent Institutions and Dispensaries. The section on American Hospitals comprises about 50 pages, and that on American Hospitals for the Insane, 12 pages. Information is given on the following points concerning each institution: Date of Incorporation; Name of President; Governing Body: Superintendent; Secretary; Medical Staff; Resident Medical Staff; Nursing Staff; Beds; Income; Expenditure; Special Features.

DISEASES OF THE INTESTINES. A Textbook for Practitioners and Students of Medicine. By MAX EINHORN, M.D., Professor of Medicine at the New York PostGraduate Medical School and Hospital, and Visiting Physician at the German Hospital, New York. Second revised edition. New York: William Wood & Company, 1904.

THIS work has undergone the necessary revision, but due to the recent appearance of the first edition, little has been added.

The book is divided into chapters, the first of which gives the anatomy and physiology of the digestive tract with the exception of those already described in the author's work on "Diseases of the Stomach." The methods of examination and general treatment compose the second and a most valuable chapter. Acute and chronic intestinal catarrh, dysentery, ulcers of the intestines, neoplasms, hemorrhoids, appendicitis, intestinal obstruction, nervous affections, and intestinal parasites, are the subjects of the remaining chapters.

Throughout the work the author has endeavored to make his volume a practical one, giving the needed instruction on diagnostic points, and going into detail regarding the treatment. He has so balanced his work as to give the main bulk of it to the ordinary diseases, at the same time not ignoring the less important conditions.

Society Reports.

NEW YORK ACADEMY OF MEDICINE.
Stated Meeting, Held April 7, 1904.

DR. ANDREW H. SMITH, M.D., IN THE CHAIR. THIS meeting was held under the auspices of the Section on Pediatrics.

Modes of Infection in Tuberculosis.-Dr. PHILIP S. SABINE read this paper. He considered the modes of infection in the male and in the female, reviewing a great deal of literature upon this subject. He said that many cases had been reported in which tuberculosis was present in children prior to birth, but there was an absence of clinical evidence to prove the infection to be from the male, while maternal infection was an established fact. Baumgarten claimed that the majority of cases of tuberculosis was due to heredity. There was no doubt in the minds of investigators that congenital tuberculosis was very common. Dr. Sabine then considered post-genital types, giving a statistical review of evidences of this disease as it occurred in the uro-genital tract, through coitus, through inoculation, through the air passages, the nasopharynx, the tonsils, etc. He believed that the tonsils were the chief portal of entry.

Infantile Tuberculosis; Its Portal of Entry, Topography, and Clinical Manifestations.-Dr. ROWLAND G. FREEMAN read this paper and said that tuberculosis in young children was fairly common; in 1,448 successive autopsies at the Foundling and Nursery and Child's Hospitals 158, or nearly 1 per cent., showed tuberculous disease, and this was a much lower rate than given by other writers.

Portal of Entry.-The point of infection in most cases was a subject on which the widest difference of opinion existed among the highest authorities, but the assumption that the tubercle bacilli most often gained access to the human body by the respiratory tracts seemed well founded. It was still a question to what extent the tonsil was ordinarily a point of entry of the tubercle bacilli, but the lymph nodes of the neck might be safely considered as frequently the first lesion noted after the third year, and tuberculosis of these lymph nodes often existed when there were no evidences of other tuberculous lesions. Tuberculous bronchial lymph nodes certainly formed the most common lesion found at autopsy, but they were usually associated with tuberculous lesions elsewhere. Regarding the frequency of tuberculosis due to the ingestion of food containing the tubercle bacilli, so far as he knew nobody in New York believed that he had ever seen many cases at autopsy evidently due to intestinal infection, though observers in Europe reported an entirely different experience. He thought this difference might be due to a more careful search for tuberculous lesions or to a different judgment as to what was sufficient evidence of intestinal origin. It was evident that tubercle bacilli which gained access to the body by the intestines were readily carried by the lymph stream to the thoracic duct, into the superior vena cava, the right side of the heart and out into the lungs. Living tubercle bacilli had been found to exist fairly frequently in ordinary milk, and it had been shown by Ravenel and others that bovine tubercle bacilli were pathogenic for man. It had been demonstrated that the tubercle bacilli survived the action of the gastric juice, and the fact that we found lesions of undoubted intestinal origin confirmed the fact that they could pass through the human stomach uninjured.

Topography. The statistics regarding the distribution of tuberculous lesions in children showed that the abdominal organs were fairly frequently involved. After quoting various statistics of Froebelius, Schwer, Carr, and Biedert, he thought that we must conclude that it was impossible to state the original point of invasion. He himself had tabulated the results of 158 autopsies on tuberculous children, and these showed that there were between 1 and 3 months, 4 cases; 3 and 6 months, 21 cases; 6 and

I

9 months, 21 cases; 9 and 12 months, 15 cases, or a total of 61 under one year. Between 12 and 18 months, 18 cases, and between 18 and 24 months, 16 cases, or a total of 34 between the first and second year. The average age at death was later among tuberculous children than among other children, and in infancy the disease was sufficiently acute to cause death very often before marked emaciation took place. The nutrition of the tuberculous cases was not materially worse than that of the non-tuberculous cases. The distribution of lesions in his 158 cases of tuberculosis in young children showed involvement of the bronchial lymph nodes in 126, lungs in 112, spleen in 90, liver in 66, mesenteric lymph nodes in 44, meninges in 30, small intestines in 30, mediastinal lymph nodes in 28, kidneys in 20, cervical lymph nodes in 14, and large intestine in 7. As to the general distribution of the series of 158 cases, 36 had thoracic lesions only, 92 had abdominal lesions and 25 cranial lesions. In another table that showed the distribution of the lesions in 52 cases involving the mesenteric lymph nodes or intestines or both, 6 cases showed thoracic lesions but no other abdominal lesions, while 29 cases showed involvement of other abdominal organs and the thorax and 12 cranial lesions in addition.

Clinical Manifestations.-The tuberculosis of infancy was usually an acute, widely disseminated affection which, in a considerable number of cases, involved the bronchial lymph nodes and lungs. It was usually a most obscure disease for diagnosis and often a definite diagnosis could not be made until the meninges became involved. The lungs usually showed merely râles or slight changes from normal respiration, and it was only in advanced stages that consolidation appeared. The involvement of the meninges gave typical symptoms. The duration of the disease was two to three or four weeks. An unresolved pneumonia, which often it was unnecessary to differentiate from this disease, could usually be distinguished by the marked physical signs, the higher temperature, the slow course, and the much more marked emaciation.

Summary.-Tuberculosis in infancy arose most often from either the respiratory or the alimentary tract, but the comparative frequency of these two modes of infection had not yet been definitely determined. The tuberculosis of early life was most common during the first year when children were on an exclusive milk diet; and much milk contained tubercle bacilli, and bovine tubercle bacilli were pathogenic for man. At this period, owing to the structure of the intestinal wall, bacteria could probably pass through, although it was uninjured. Experiments on animals showed that inhalation tuberculosis caused usually lesions of the bronchial lymph nodes and lungs alone, and wherever the portal of entry might be, these structures became very early involved. Inoculation experiments proved that the mesenteric lymph nodes might be tuberculous without the presence of any gross lesions in them. Mesenteric or intestinal lesions could be detected on gross examination in 26 per cent. of the autopsies which he had done at the Foundling and Nursery and Child's Hospitals. The tuberculosis of infancy, unlike that of later life, was usually an acute, widely disseminated, general disease with moderate temperature and few symptoms and physical signs unless the invasion of the meninges gave rise to symptoms. Tuberculosis of the cervical lymph nodes and of the joints was rarely seen under the third year. The power to overcome a tuberculous infection that had invaded the organs apparently did not exist in infancy. While the tabulated autopsies showed a very wide distribution of the tuberculous disease in these infants, they probably indicated a much less general distribution than really existed; for the data were based on hurried gross examination without microscopical confirmation. A series of autopsies in the same institutions in which the intestines were carefully examined without separation from the mesentery, and with microscopical examination of all suspicious thickenings, he said would probably show a much greater proportion of intestinal

involvements, and a still larger proportion could be found by animal inoculations.

The Influence of Bovine Tuberculosis on Human Health. -Dr. MAZYK P. RAVENEL read this paper, and referred to the correctness of his belief in the intercommunicability of the disease, such as he had advanced for years, and he said that he had established certain facts and conclusions which were irrefutable. The study of the cultures of the tubercle bacilli in man and in animals showed no difference that could aid us in determining the origin of the disease. The tubercle bacilli had greater pathogenic power for all animals except swine. He considered the increased susceptibility in animals, the virulence of the bovine tuberculosis, the effects of bovine tuberculosis on man, etc. He reported cases in which there was great resistance to ordinary methods of treatment and cure only obtained after radical excision of the affected parts. He said that the belief that the dried sputum spread tuberculosis was the commonly accepted one, but this was not supported by clinical evidences. He said it was the bovine tuberculous material taken as food that played a part in causing. human tuberculosis. Experiments had shown that the tubercle bacilli could penetrate the healthy mucous membrane and not leave any track, and the lungs might become affected through infection by way of the intestines. The figures regarding primary lesions were not at all to be relied upon because they were not at all uniform. He thought that no doubt the tonsils was the portal of entry for the tubercle bacilli in many cases, although he greatly believed in infection from the ingestion of tuberculous meat from cows. Bovine tuberculosis was a scourge, especially on farms near large cities.

The Prevention of Tuberculosis in Children.-Dr. HERMAN M. BIGGS read this paper. He thought there could be no question that the factor of so-called heredity in the causation of tuberculosis was largely explained through house infection, and this view most authorities accepted. In a family in which a case of pulmonary tuberculosis existed, an infant was seriously exposed to the danger of infection through breathing the air which might contain the bacilli, through kissing, or through the transfer of food from the mouth of the mother to that of the infant, as was frequently done, especially among the lower classes As the child grew older, it was exposed even to a greater extent because, while crawling on the floor, the hands were likely to be soiled by the expectoration carelessly discharged on the floor, or the dust that was wiped up from the floors and near-by objects, and which was transferred directly to the infant's mouth. There was also the possible infection through the use of infected eating utensils and the taking of milk from tuberculous cows. He said the infant of an infected family was more exposed to the possibility of infection than any other member of the family. There was comparatively little danger that young children would be sufficiently exposed to tuberculous disease to acquire infection until after the child had at least reached the age of four or five years—that was, outside the family. If, then, the preventive measures which had been adopted in recent years for the restriction of tuberculosis had had any considerable value, this should first be indicated in a reduction in the death rate from tuberculosis in children under fifteen years. He said the preventive measures which had been adopted in New York City during the past ten or twelve years and which consisted chiefly in the provision of hospital accommodations for advanced cases of consumption, in the disinfection of apartments, and in the education of consumptives and their families as to the nature of the disease and the proper disposal of the expectoration, should result in a lesser degree of house infection and should be followed by lower death rates from tuberculous disease in the early periods of life. Certain data showed that during the ten-year period ending in 1902 there had been a decrease of more than 40 per cent., and that during a period of twenty years the decrease

had considerably exceeded 50 per cent., in the death rate from pulmonary tuberculosis and tuberculous meningitis in children under fifteen years of age.

With the extension of the regulations which were now being enforced, and a wider dissemination of information for the care of advanced cases, he looked for a still further rapid reduction in the death rate in this early period of life. It seemed to him that these data afforded perhaps greater encouragement in the crusade for the prevention of tuberculous disease than any other which were at command.

Dr. THOMAS DARLINGTON, Commissioner of Health, said there was no question in his mind that the entrance of the tubercle bacilli was by way of the lungs, and illustrated his belief by references to post-mortems that he had made upon those who had died during the construction of the Croton Aqueduct. He found, in the smaller bronchioles and practically all through the lungs, a great many particles of ground rock and dust. He believed that if the dust could so penetrate almost every part of the lungs, certainly the tubercle bacilli could gain ready access in the same way. To show how readily cattle could acquire tuberculosis, he related an instance that occurred in an institution near to New York. Consumptives were allowed to play quoits in a pasture near the hospital, and they then did not use their spit-cups but spat upon the grass. Ten cows grazing in the same pasture were killed, and it was found that nine out of the ten had general tuberculosis. He emphasized the importance of removing children from surroundings which exposed them to tuberculosis. The question of nostalgia should always be considered in such cases. In a recent epidemic of measles at the Foundling Asylum eighteen deaths occurred among the thirty-six children that had just been admitted; these eighteen had constantly fretted and were victims of nostalgia. Therefore, if these children were to be sent away they should not be sent so far that their parents could not see them occasionally. Because it had been proven that tuberculous milk could infect children, he advised that all milk be Pasteurized. The great treatment for these children he believed to be fresh air, good food, and rest. When confined to hospitals they did not do well, but when sent to the country they, as a rule, did very well.

Dr. WILLIAM P. NORTHRUP cited instances to show what the New York Board of Health was doing to prevent the spread of tuberculosis by the dissemination of knowledge regarding this disease. He did not wish them to underestimate the importance of the respiratory tract in the production of tuberculosis. In 125 autopsies on tuberculous patients, the bronchial glands were involved in all and the mesenteric glands in but one. Dr. Bowdich of Boston made 369 autopsies, and in only 1 per cent, were the mesenteric lymph nodes involved.

Dr. CHARLES N. DowD said that among 100 cases of surgical tuberculosis which had been followed for years, it had been noted that only one patient showed evidences of pulmonary tuberculosis. Among these were cases of cervical tuberculosis, tuberculosis of the hip, of the axillary lymph nodes, etc., but in only one was there any pulmonary tuberculosis. Of this series of 100 cases, 87 were infected directly from the tonsils or pharynx. The last 1,000 cases seen at St. Mary's Hospital showed that 212, or 21 per cent., of them had tuberculosis. The distribution of these were as follows: 158 occurred in bones and joints; 40 in the lymph nodes; 5 in the genitourinary tract; 5 were perineal; 2 were lupus and 2 were of tendon sheaths. There had been 10 instances of infection of the iliac and femoral lymph nodes from foot wounds.

Dr. HAMILL of Philadelphia, in discussing the mode of infection, spoke of the possibility of the entrance of tubercle bacilli into the circulation without the development of localized lesions at the portal of entry. That such an occurrence was possible was shown by the frequency of cases of tuberculosis of the bronchial glands without discoverable lesions in the lungs or elsewhere. The same

possibility of cryptogenic infection through the gastrointestinal tract was evidenced by the frequency of tuberculous disease of the mesenteric lymph glands, without the occurrence of intestinal lesions. While this kind of infections had not been shown to be of frequent occurrence, the possibility of their occurrence should be borne in mind in cases of tuberculous disease of deep-seated organs in which the mode of infection seemed obscure. The feeding experiments of Ravenel also aided in enabling us to venture the statement that infection through the alimentary tract might result in lesions far removed from the point of entrance of the infecting microorganism. That tubercu lous lesions of the tonsils with secondary involvement of the deep cervical lymph glands might result from particles of infected food being retained by and absorbed from the tonsillar crypts has been definitely demonstrated. Tuberculous lesions of the intestines, together with tuberculous involvement of the lymphatic glands, as well as tuberculosis of these latter glands, without demonstrable lesions in the intestines, had been proven in like manner. It had been shown definitely by experimenters that tubercle bacilli could penetrate the intestinal tract and pass into the circulation without any evidence of lesions of any nature in the walls of the intestine. The bacilli once in the circulation might produce a generalized tuberculosis or might be deposited at some susceptible point and give rise to a localized tuberculosis. The bronchial glands being more susceptible to tuberculous invasion than the lungs, we might be justified in assuming that the bacilli having gained access to the lymph ducts were borne by them to the bronchial glands and likewise if the bacilli had gained access to the circulation they might be carried through the heart to the lungs and there gain access to the lymphatic channels by which they could be conveyed to the bronchial glands. Another possible mode of infection of the bronchial lymph glands through the medium of the intestinal tract was by the conveyance of the bacilli from the mesenteric glands through the medium of the thoracic duct to its point of junction with the efferent vessels of the bronchial glands, and their conveyance from this point by means of a reverse current to the bronchial glands. In view of these possibilities, we could not deny that many of the generalized or pulmonary tuberculoses which developed as a sequence to the various infectious diseases of infancy and childhood primarily had their origin in the intestinal tract. Bronchial lesions might remain latent for an indefinite period, and new foci might in the meantime become so far advanced as to entirely mask the point of original infection.

Dr. JOHN H. GIRDNER said that he had had occasion to observe people who lived in the mountainous regions of Tennessee and North Carolina, and he had been surprised to find what a large number of the children suffered from cervical tuberculosis, i.e. tuberculosis of the cervical lymph nodes. Young adults could be seen with the characteristic scars which had resulted from the breaking down and discharge of the tuberculous glands. This region was but sparsely settled, and there was but little opportunity for the infection to occur by way of the air passages. They lived upon the dairy products, such as milk, cheese, and butter. The cattle had been bred there for generations, and they were the so-called "scrub-mountain cattle." He believed these children had been infected for years by the milk of these cattle, and he had no doubt but that a large majority of them could be found to be tuberculous

Peculiar Phenomena Accompanying the Growth of Bacteria in Media Containing Serum.-Dr. LIBMAN demonstrated a very marked example of coagulum production by a streptococcus in a medium containing glucose-bouillon with blood.

He also demonstrated some fluid which had been aspirated from the chest of a patient suffering from pneumonia. The fluid on withdrawal was light straw-colored, very slightly turbid, and contained pneumococci and a very

few pus cells. After allowing the fluid to stand twentyfour hours in the thermostat it began to turn green. After forty-eight hours it was decidedly green and showed a very heavy, tenacious albuminous deposit.

Dr. Libman said he believed the observation was of interest in indicating that changes in fluids which are found to occur in the body might occur in a similar fashion by the growth of bacteria outside of the body.

NEW YORK ACADEMY OF MEDICINE.

SECTION ON SURGERY.

Stated Meeting, Held April 1, 1904. DR. ROBERT T. MORRIS IN THE CHAIR. Two Cases of Osteoplastic Craniotomy for Epilepsy.Dr. H. D. COLLINS presented the following cases:

CASE I-An Italian, fifty-seven years old, whose father was an epileptic, giving no specific history, was struck on the head and remained unconscious for several hours. He appeared to recover, but after five years he began to have headaches, which were followed by vertigo and convulsions. Two hours later he had another convulsion. He then had from two to seven convulsions daily, then an intermission of from several days to a week or two. On one occasion he had an unusually severe convulsion, followed by paralysis of the left side. He gradually recovered from the paralysis, and later these attacks of paralyses became more frequent and he showed less tendency to recover from them. It was supposed that there was some lesion at the site of the scar, probable hemorrhage in the deeper portion of the brain. An incision was made at the site of the injury, with the usua! osteoplastic flap over the motor area. An extensive broken-down blood-clot was found, extending one and one-half inches into the brain substance. Since this operation, which was performed ten weeks ago, he had had no convulsions. The leg paralysis had improved.

CASE II-A man who had been treated three years previously for cardiac trouble was taken with convulsions, followed by paralysis, which he attributed to an overdose of medicine. He had constant, dull headache, spasticity of the left leg, disturbance of the reflexes of the right arm, and some optic neuritis, which was supposedly of syphilitic origin. It was anticipated that operation would reveal meningitis or gumma. Some pulp-like substance was found. The interesting point in this operation was that during manipulation the bone flap was torn off, immersed in salt solution for some time, and then replaced. The union was good. It was ten weeks since this operation and there had been no convulsions.

Dr. ROBERT T. MORRIS had seen large pieces of bone replaced which united perfectly. The lymph circulation seemed to retain its vitality to an unusual degree. For the prevention of adhesions of the brain meninges after operation sterilized, chromaticized peritoneum could be used with better results than gutta-percha tissue, silver or gold.

Dr. PECK related the case of a boy who had shot himself through the roof of the mouth eleven years previously, the ball passing out through the frontal bone. He became subject to epileptic fits, and craniotomy was performed over the scar. A cyst was found in the frontal lobe. The epileptic seizures disappeared for about two months and then gradually increased in frequency.

Dr. Collins, in closing, said that he had not claimed cures, as in these cases epilepsy was likely to recur. The points of interest were the large surface of brain exposed and the large piece of bone that was removed and then replaced so successfully.

A Case of Fracture of the Zygomatic Arch.-Dr. WARREN S. BICKHAM said that he had had a collision in which he had sustained such a fracture. In searching literature on the subject of zygomatic fractures he had found very little. Scudder only mentioned the subject once and then only incidentally. In Beck there was only ten lines in regard

to the fracture and nothing as regards its treatment; in Stimson there was one and one-half pages in conjunction with malar fractures and a statement to the effect that it was seldom that they could be replaced. After the accident he was very much stunned, the noise was tremendous, due to the proximity of the middle ear, and he could not move his lower jaw. Dr. Matas gave him one-quarter of a grain of morphine and, on examination, found that he could put his thumb between the fragments. Under a general anesthetic, he cut down on the arch; with a Hagerdorn needle he penetrated one inch above the zygomatic arch and, carrying the needle deeply into the temporal fossa, came out one-half inch below the arch. The needle carried silver wire, and on traction the bones were drawn into place. To keep them in position an ordinary microscopic slide was placed over the malar and temporal bones. A dentist made a vulcanized rubber plate, which was introduced in place of the slide on the following day. In such fractures Dr. Bickham suggested putting a dressing of collodion or rubber adhesive underneath, as this would prevent the deformity that was liable to occur.

Dr. JOHN F. ERDMANN considered this an ingenious device, which ought to be followed by good results.

Dr. MARTIN W. WARE had had two cases of fracture of the zygomatic arch and had only strapped the parts firmly together. His experience had led him to believe that no radical operation was necessary. If there was a marked depression, it might be well to resort to such an operation. Dr. Bickham said that the procedure was so simple that it could easily be employed wherever there was any prospect of deformity, and should certainly be employed in compound fractures.

A Case of Hypertrophic Papillary Colitis; Right Inguinal Colostomy.-Dr. A. A. BERG presented this case. The patient had presented himself for treatment in November last, after suffering for nine months from frequent evacuation of blood and mucus from the bowels; he had lost thirty pounds, and was much weakened. Rectal exam

ination showed a large number of villous growths. The sigmoid flexure and caput coli were distended and there was considerable tenderness. A right ingunial colostomy was performed. The anterior wall of the cæcum was sutured to the peritoneum. The opening made was no larger than for an appendectomy. The results, however, had not been brilliant, the bowel was washed twice daily with silver nitrate solution, and while the patient had gained strength, the bleeding began as soon as the washings were discontinued. A number of the villous growths still persisted, and the question that now presented itself was whether he should resect the entire colon and sigmoid Bexure.

Dr. JAMES P. TUTTLE said the pathology might be interesting, as the growth might be partially epithelial or it might be an adenoma, in which case it might have the same degeneration eventually. If the case was one of papilloma, prospects of cure were remote unless the growth was removed, and in such cases the ascending and transverse colon was usually involved. Washings with silver nitrate, iodine, or astringents might allay the symptoms somewhat, but were not very effectual.

Dr. R. H. DAW BARN asked Dr. Berg if he had any objections to the technique of Dr. Weir-the appendix operation. The condition of the appendix must decide the choice of methods. He irrigated with a glass cannula, and if there was slight inflammation he waited until it subsided before introducing a soft rubber catheter. He secured the best results by that method and would advise its adoption accordingly.

Dr. ROBERT T. MORRIS thought that if we used Weir's method the lymphoid layer might not swell fully. If the appendix was amputated near enough to the cæcum the method might be desirable.

Dr. Berg, in closing, said that the affection was not specific; that there were a number of small papillæ, but we could not decide whether they would become malignant

or not. If we feared malignant disease we should remove the colon. He thought Dr. Weir's use of the appendix • good if that organ was healthy, but it seemed a half-way procedure. In flushing the bowels we wanted an opening large enough to admit a 26 or 28 Fr. catheter. If the caput coli was used there would be no more inconvenience if it became necessary to establish an artificial anus. Regarding the patient's hernia, he had it on getting up, and a pad had been applied to retain the hernia and keep the piece of gauze over the wound.

Dr. Tuttle said that, if the appendix was drawn well up into the wound, it could be readily dilated to such a size as to give admittance to a 28 Fr. catheter.

A Case of Movable Kidney in a Child.-Dr. A. ERNEST GALLANT presented a girl, fourteen years old, who had consulted him in December, 1902. She was very much run down and had lost much in weight. She had attacks of vomiting, severe pains in right side, and had never menstruated. Examination showed a floating right kidney; the pylorus reached to the umbilicus. She had been fitted with a corset; it was just like an ordinary corset except that it was long and had been fitted with the patient in the recumbent position with hips elevated. The lower part was tightly laced and the upper part left loose, giving full liberty to lungs and stomach. Since wearing the corset she had gained twenty pounds in weight, had grown four inches, and the kidney no longer came down and she no longer had the severe attacks of pain. She now menstruated.

Dr. ROBERT H. M. DAWBARN asked why we should take it for granted that a case of nephroptosis was necessarily accompanied by a gastroptosis. It had not been his experience that one was a necessary concomitant of the other.

Dr. ROBERT T. MORRIS said he had observed two classes of cases, in one of which the kidney alone wandered, and in the other, the liver began to descend about as soon as the kidney; the pylorus also descended.

A Case of Tenorrhaphy and Neurorrhaphy of Flexor Tendons and Median and Ulnar Nerves.-Dr. Wm. A. DOWNES presented this case. A girl, twenty-three years old, in falling thrust her hand through a glass door, causing a very extensive injury above the wrist, dividing the flexor tendons and median and ulnal nerves. The wound was so severe that the hospital interne would not attempt its repair and she had waited over night for attention. The tendons and nerves were sutured with chromicized catgut and the wound healed by primary union. In four months she practically regained sensation of th ulnar nerve, in eight months of the median nerve, and, at the end of one year, function was nearly restored and sensation was entirely regained. She could write, sew, and play the piano, though the cosmetic effect was not all that could be desired.

A Case of Fibroma of the Popliteal Nerve.-Dr. Wм. A. DOWNES presented this case. A woman, aged forty-nine years, said that fifteen years ago she began to have pains in the right leg and foot. They would continue for a day or two and then might not recur for four, five, or six weeks. About seven years ago, during pregnancy, the trouble was aggravated, the leg became discolored, and she had difficulty in using it; but it became better after her labor In March he had removed a tumor from the internal popliteal nerve, a fibroma of the nerve sheath; it was centrally situated, and the nerve fibers could be seen stretching over it longitudinally and completely covering It was this that made the case especially interesting. It was peeled out without injury to the nerve. There were no nerve elements in the fibroma. No other evidences of fibroma were found.

it.

Dr. ROBERT H. M. DAWBARN said that he had learned that in tendons and nerves severed by a dirty instrument we should dissect out the ends of the sheaths; a tendon could get along without its sheath. If the dividing force were infected with streptococci we could not depend uopn