also calls attention to the fact that cyanosis as such is not a necessity, for the color may be purple-red, occasionally the fingers are clubbed, the skin may be bronzed and the enlargement of the spleen may precede for a long time the onset of the change in color; the urine may contain albumen and casts and even an excess of urobilin; erythromelagia may be also present.

Pericarditis.

S. West (British Medical Journal, October 26, 1907) states that in pericarditis pain may be due to friction or be of cardiac origin. Cardiac pain is rare, and is met with only with acute cardiac dilatation. Friction is the most characteristic sign, and when present is conclusive. Cardiac dullness is always increased. One of the earliest signs is said to be such increase toward the left base. The writer considers this due, not to effusion, but to dilatation of the left auricle. The difficulty of diagnosis, even by the most competent diagnosticians, between pericardial effusion and cardiac dilatation is proved by the experience of paracentesis. Systolic recession of the apex-beat is pathognomic of adherent pericardium when present, but the converse is not true. Effusion muffles the heart sounds, but they may be equally weak from dilatation only. A perverted pulse-respiration ratio is often as marked in acute pericarditis as in acute pneumonia. True pulsus paradoxus is very rare except with mediastino-pericarditis; however interesting, it is of no practical use in diagnosis. When effusion is large there may be bulging or prominence of the epigastric region, with pulsation that can be seen and felt, also displacement of the left lobe of the liver.

The writer cannot understand the objection to opium in heart affections. He has used it largely, and has never seen

anything but good follow its judicious administration. Paracentesis is rarely

necessary in necessary in pericardial effusions of rheumatic origin, which are always serious. When effusion is purulent further procedure will be necessary, but paracentesis must precede incision, for there is no other way of ascertaining the nature of the effusion.—The Monthly Cyclopædia of Practical Medicine, January, 1908.

Growth in the Course Chanan (These de of Typhoid Fever. Paris, 1907). The abnormal energy of growth in the course of infectious diseases has been known for a long time past. There is no other disease in which it is as well and as universally marked as in typhoid fever, where the patient may grow several centimetres within a few weeks. This increase in size-practically limited to the long bones of the lower extremitiesmay be interpreted as the result of the medullary irritation caused by the Eberth bacillus or its toxins, which is expressed by a hyperemia of the diaphyso-epiphyseal zone. This congestion represents merely the first stage of the bony affections following in the train of typhoid fever (osteitis, osteomyelitis), many instances of which have come under observation.

From the clinical point of view this exaggerated rate of growth is associated with certain signs, notably the presence of pain. These pains may alone constitute almost the entire symptomatology. They are either vague, diffuse and transitory, or they may be more severe, giving rise to constant complaints on the part of the child. There is lassitude and fatigue, with a bruised feeling in the muscles at the level of the joints suggestive of rheumatic or neuritic manifestations. The pain may be severe enough to force the

patient to absolute immobility; when it becomes generalized at the articular extremities the result may be a complete loss of function. As a rule, however, neither heat nor local swelling can be demonstrated, while pressure at the level of the articular ends may serve to increase the pain. The joints are intact, signs of true observations being absent.

These observations lead to a practical conclusion, to the effect that these phenomena of exaggerated growth in the course of infectious diseases, notably typhoid fever, should not be regarded as a matter of indifference. It is a pathological manifestation, which may be simply the first stage of a formidable complication. It follows that the painful regions should be immobilized, even in the mildest forms. Gentle counter-irritation may be combined with these measures. In those cases, however, where the pain persists, or is increased by the pressure, this treatment should be supplemented by blisters and the actual cautery, for the purpose of preventing the development of osteomyelitis. F. R.

The Serum Diagnosis Chautemesse (Bulof Typhoid Fever by letin Médical, No. the Eye.

57, 1907). Following

the example of Pirquet and Vallie, who produced local reactions in the skin of tuberculous individuals by means of local applications of tuberculin to the skin, and of Wolff-Eisner and Cahnette, who succeeded in obtaining a similar reaction in the eye, the author prepared a typhoid toxin, soluble in water, 1-50 mgs. of which in a drop of water was instilled into the lower eyelid of the patient. Individuals free from typhoid fever presented redness and lachrymation at the end of two or three hours, these phenomena subsiding four or five hours later, so that nothing could be seen in the eye by the next following day. In typhoid fever cases, on the other hand, the reaction is far more violent, actually leading to a serofibrinous exudate. It reaches its maximum degree in six to twelve hours, subsiding very gradually, so that the symptoms of irritation are still visible at the end of 24 hours, or even two and three days later. The reaction is regarded by the author as perfectly harmless and reliable. F. R.

M.D., of New York, Professor of Surgery in the New York Post-Graduate Medical School, reports the following case in the Annals of Surgery for February, 1908:

Miss H. L. F., 22 years of age, came under my care at the Post-Graduate Hospital in New York on November 22, 1995. Figure 1, from a photograph taken before operation, gives a general idea of the fa

The left superior maxilla was hypertropic, and the right superior maxilla was atrophic. Teeth irregularly disposed.

them about double normal breadth and thickness. Teeth irregularly disposed. The tip of the large nose was fairly below the right orbit, and the tip of the bulky chin was fairly below the left orbit. The external ears consisted of little more than concha, antihelix and lobe, and they stood out at right angles to the head.

First Operation.-Preliminary tracheotomy, for anæsthesia, and to allow packing of the pharynx. Incision within the mouth along alveolar border. Soft parts separated from the superior maxillæ, with

swung into the space previously occupied by the left maxillary sinus, and held in place with compresses. One week later it was thought best to remove a little more of the orbital plate (operating through the mouth). Healing of the extensive wound surfaces occurred without special incident.

Second Operation.-A segment of mandible fully three inches in length and carrying several teeth was excised. The segment included the symphysis menti, and considerable more of the right body

of the chin to the middle line of the face and in good line with the nose. The ponderous mass of soft tissues composing the chin and lower lip did not contract enough to give symmetry of contour to the face, and about six months later I cut out the superflous soft parts and managed to shape the lip and chin rather prettily. At the same time the protruding ears were set back by the method which we commonly employ for protuberant A segment of skin and cartilage was removed from the posterior part of

ears.

Aneurisms of the Sub- Maréchal (Thése de clavian Artery. Lyon, 1907). Aneurisms of the subclavian artery are not common. They are principally located upon the third portion of the artery, rarely upon the first portion. They are more frequently met with in the artery of the right side. Left untreated, these aneurisms constitute an almost certainly fatal disease by hæmorrhage and by gangrene of the upper extremity. Spontaneous recoveries are exceptional. The aneurisms of the first portion of the artery are amen

able only to treatment by ligature, according to the method of Brasdor. For the aneurisms of the third portion of the artery, the treatment of election consists in the extirpation of the sac, according to

Purmann's method.

Ten cases treated with extirpation of the sac yielded nine cures or very considerable improvements. Even the tenth case might be counted as another triumph of this method, since the patient's death was not referable to the operation or its sequelæ. The extirpation of the sac constitutes, as it were, the radical treatment of aneurisms of the third portion of the subclavian artery. It causes the disappearance of the functional disturbances of the upper extremity, and guards against the recurrences and the postoperative complications, following upon the older methods of treatment.

The extirpation of the sac in aneurisms. of the subclavian artery has yielded results never before obtained, this treatment has only been adopted since the last 201 years or so for the disease under consideration. The author was unable to find more than 10 illustrative cases in the literature.

F. R.

Treatment of Aneur- Cranwell (Revista isms of the External de la Soc. Med., Iliac Artery. Argentina, Vol. XIV, 1907, No. 81). After a discussion of the symptomatology and pathology of aneurisms of the external iliac artery, upon the basis of the cases reported in the literature, the author contributes a recent personal observation upon a patient 48 years of age.

Disturbances in the right inguinal region had existed for about 30 years, and 15 years ago a slowly-growing tumor had made its appearance. This tumor began to increase in size very rapidly after an

injury which it sustained three years before the patient came under treatment. At the time of his admission to the hospital, the tumor had reached the size of a child's head, and the diagnosis was rendered without difficulty. It was decided to perform a laparotomy, in the course of which the very large aneurism was found to consist of three sacs, and to reach from the common iliac as far as the femoral artery. The common iliac was tied at its point of origin. Gangrene of the leg followed at the end of two days, and the leg had to be amputated. The patient, whose general condition had been unfavorable prior to the operation, failed to recuperate, and died one month later.

With special reference to the advisability of ligating the common iliac artery, the author advocates ligature as an emergency procedure only. In all other cases extirpation of the sac is to be preferred as invariably yielding more favorable results. It is the method of election in the treatment of aneurisms of the external iliac artery. F. R.

The Treatment of Ar- Cranwell (Contributerio-Venous Aneurism. tion à l'étude du traitement de l'anéorisme artério-veineux. Revue de Chir., XXVI année, No. 12, Vol. 34, 1906-7). The ideal treatment of arterio-venous aneurisms by lateral or circular suture will prove feasible in exceptional cases only.

A pre-conceived plan of operation is hardly possible. For the smaller arteries, such as the radial, no other method than quadruple ligature enters into consideration. The author in confirmation of these statements reports two cases of aneurism, one an arterio-venous aneurism of the popliteal, with a very narrow communication, permitting lateral ligature, but not suture, and one an arterio-venous aneurism of the carotid and jugular, with in