the treatment. The patient may resume his daily occupation without hindrance, for the only reaction is slight swelling and tenderness, which pass away during the course of a week.

It is rarely necessary to excise redundant scrotum, as the natural tonicity of the parts will assert itself after a few weeks and "take up the slack."- Frederic Griffith, M. D., in Am. Jour. of Dermatology, June, 1905.

SOME REMARKS ON CASES INVOLVING OPERATIVE Loss of THE COMMON BILE DUCT.- In the Annals of Surgery, July number, W. J. Mayo gives an account of a case of anastomosis between the hepatic duct and duodenum.

Out of 159 cases of operation on the common duct of the liver, there was a loss of continuity of the duct in seven cases, five intentionally produced in operating for removal of malignant neoplasms, and two accidentally, one of these following an extensive operation for gall-stones, this case forming the basis for the following described operative procedure, the various steps of the latter being neatly and accurately illustrated. Relief of fistula was the occasion for the operation. An incision through the upper rectus exposed a mass of adhesions with the liver and hepatic duct on the one side and the stomach, transverse colon and duodenum on the other. The original drainage opening at the site of the cystic duct was discovered, the hepatic duct found dilated and the common duct obliterated and converted into a fibrous cord, the duodenum overlapping the remains of the latter forming one of the walls of the fistulous tract. The external incision was enlarged and the liver turned and held upward, the duodenum being immobilized. The hepatic duct was then freed from its adhesions and the duodenum fastened to the adhesions about the duct with three catgut sutures placed about three inches from the pylorus. A small elliptical portion of the duodenum was then excised at the point of contact of the latter with the end of the hepatic duct and the latter sutured to the edges of the former openng with throughand-through catgut sutures. The duodenum was still further anchored, laterally and anteriorly, to the under surface of the

liver and to the surrounding scar tissue, thus affording a broad area of attachment of the duodenum to prevent undue traction upon the hepatic duct.

The patient made a rapid and uninterrupted recovery and remained free from trouble, gained thirty-one pounds and resumed her former state of excellent health.

The above report proves two things: First, that drainage is unnecessary in certain instances, and that sutures penetrate all the coats of the duct and duodenum and produce no complications.— E. H., in Lancet-Clinic.

THE IMPORTANCE OF EARLY RECOGNITION OF SUPPURATIVE EAR DISEASE.-A. G. Bryant, in a long article on this subject, contributes a very full discussion of midde ear disease, its etiology, symptomatology and sequelæ, together with the diagnosis and treatment of the various phases of the malady. The disease is so common an accompaniment of the ordinary diseases of childhood that the practitioner should be as familiar with the ear speculum and probe as with the stethoscope, and it should be remembered that it is often the objective examination that gives the first clue as to the existence of middle ear trouble in small children. The following plan of treatment is outlined for early cases: Douche the ear gently every two hours with one or two quarts of a sterile normal salt solution as warm as can be borne, to be followed by a hot water bag or a hot salt bag. Give one grain of calomel in 1-10 grain doses and repeat as necesUse cleansing and astringent washes for the throat and cleansing sprays for the nose. Caution against too forcible blowing of the nose, or blowing both sides of the nose at once. Have the patient remain in bed until the acute symptoms have abated. The bromides or phenacetine may be given, but with caution, and only for a few days. Avoid all opiates, as they mask the symptoms. Early paracentesis is urged, especially in influenza cases, and the technique of the operation and the after treatment are described. Mastoid involvement and the treatment of chronic suppuration are also discussed.- Medical Record, May 13, 1905.

sary.

CLINICAL FEATURES OF THYROID HYPERTROPHY.- Dr. Halsted, at the May meeting of the Johns Hopkins Hospital Medical Society, said that one or more of the symptoms usually known as 'exophthalmic goitre" might occur with various pathological conditions in the thyroid. Cysts, adenomata, carcinomata, and even "normal" thyroids had given such symptoms. No sharp line could, indeed, be drawn between perfectly normal people and those with extreme hypertrophy. The well-known symptomcomplex is sometimes present without hypertrophy of the gland. The condition is more frequent in females (4.6 to 1) though late in life the proportion is smaller. The prognosis is bad and it is doubtful if complete recovery has ever occurred. Twenty-five per cent. of all the patients die within a short time and the rest remain in a state of labile equilibrium. Acute cases occur -one, reported in Nothnagel, appeared in two days and disappeared in eight. The mild form of the disease has been particularly studied by the French; and all observers have noticed that there is no sharp line of demarcation between normal patients and those with mild goitre. In the cystic cases there has usually been no hypertrophy of the non-cystic portions of the thyroid. In the Johns Hopkins Hospital there have been 46 cases of goitre with symptoms operated upon. The majority of these were mild but a few were severe. There was one death in the series. And in this case nearly three fourths of the gland was removed. At present non-operative treatment is being tried, and the X-ray is being used instead. The influence of this agent has been marked in certain of the reported cases but it is not prompt.— Johns Hopkins Bulletin.

ACUTE PNEUMONIA AND ITS MODERN TREATMENT.-L. G. LeBeuf (New Orleans Medical and Surgical Journal, August, 1905) discusses this subject and points out its treatment. Diet is of prime importance, milk fresh or peptonized, peptonoid, panopepton, soft boiled eggs, raw eggs, bouillon, and gruels are applicable. Feed every hour. Give water freely, fruits, grapes, oranges, etc. general diet.

Wait till fever is all gone before returning to
Absolute rest is of great importance. A slow

pulse is a safe pulse; a rapid pulse requires purging, cupping, or blood letting. A soft, rapid, compressible pulse requires digitalis and strychnine. Nitroglycerine is dangerous. Camphor is to be used in two grain powders with sugar or milk. Cyanosis calls for atropine. A fast struggling heart in the early stage may be quieted with a few drops of tr. aconite, veratrum viride, or hyoscyamus.

The fever should be kept below 103° F. by sponging or ice bag to the head. High, cool, rectal enemas are of value. Coaltar products are to be avoided. Pain in the first stage is to be controlled by strapping, mustard plaster, or turpentine stupe. In children redden the skin with the mustard plaster and then apply some of the clay poultices covered with cotton; or apply a flaxseed poultice covered with oiled silk jacket. Dover's powder or codeine may be used to control cough and pain, if necessary.

Elimination must be stimulated. Give a calomel purge and a hot mustard foot bath. Keep covered and give plenty of water, vichy, or seltzer. High rectal saline injections at a temperature of 80° to 98° F. are of value as an eliminator and temperature reducer.

Potassium iodide and the ammonium salts are of service in the third stage. Creosote carbonate may be used as an inhalation and internally. Blood-letting is of value in cyanosis of the second stage. Plenty of fresh air, clean linen, and a careful disposal of the sputum should be insisted upon. The mortality of nearly two hundred cases treated in this plan was 18 per cent.

FRACTURE OF THE PATELLA.— J. B. Cutter, Albuquerque, New Mexico (Jour. A. M. A., August 5), reports a case of fracture of the patella in which the patient refused treatment and precipitately left the hospital as soon as he learned the time and confinement it would require. About three weeks later he returned to obtain a certificate of discharge, having used his leg constantly during the interim, no attempt at treatment or immobilization having been made. There was ligamentous union apparently, the separation of the fragments being three-quarters of an inch.

The functional result was remarkably good, there being almost complete extension and no inconvenience in walking. The separation case suggests to Cutter the question how much or how little advantage is gained by the conventional periods of rest in the recumbent position in cases of fracture of the patella?

RAPID TREATMENT OF VAGINAL GONORRHEA.-C. Daniels thinks that gonorrhea is the most common type of vaginitis. The lesions are located especially in the cul-de-sacs. The writer describes the following method of treatment, which is advocated by Tuffier as being the most rapid: The vagina is first carefully cleansed with a sterilized compress or a soft brush. It is then rinsed with plain boiled water. Injections are then given of six liters of a I to 4,000 solution of permanganate at 35 to 50 degrees. The vagina is then tamponed with five or six large wicks of sterilized gauze, soaked with the same solution of permanganate. After twenty-four hours the wicks are withdrawn. and new ones are inserted. After from twelve to twenty-four hours this treatment is completed. The patient is carefully looked after for about two weeks, although after the second day there are no more gonococci. The cul-de-sacs are painted with tincture of iodine, which is also used to disinfect the cervicouterine cavity. Daniels approves of introducing a stick of nitrate of silver into the urethra. This is immediately withdrawn. Three or four treatments, eight days apart, will effect a complete cure of the urethral infecton.- Revue Francaise de Medecine et de Chirurgie.

SPRAINS. Dr. Britton recommends that the limb be put into a vessel of very hot water immediately, boiling water being added as it can be borne, and kept immersed for twenty minutes, or until the pain ceases. Then put on a pretty tight bandage and order rest. Sometimes the joint can be used in twelve hours. If the trouble is more chronic, apply a silicate of sodium dressing, and let the patient walk with a cane, if the ankle be the joint affected.- Atlanta Journal-Record of Medicine.